Telemedicine: A New Frontier In Integrative PCOS Care

Jennifer Roelands, MD, ABOIM

Well, thank you so much for having me, Dr. Gersh. It’s an honor, really, to have to get to speak to you today. So I’m really excited to be here. So, you know, I became an ob-gyn and, you know, actually was my mom who said to me that I think that women’s health is your thing. This is I think this is the type of medicine that you should get into. So I actually decided on one because my mom said you enjoyed your labor and delivery rotation. I can see that this is the field for you, that you enjoy seeing women from all these stages that happen in our life and being part of it. Delivery is such a great honor, as, you know, as a doctor and I just was really drawn to working with women in general, and I was in a traditional OB joint office for a year and I started having difficulty with fertility. I struggled to get pregnant with my second son and my personal doctor had told me that, you know, it’s just going to happen. You just got to be patient. You just have to wait. It’ll happen. You’re healthy, you’re young. You shouldn’t have any problems. You’ve already had a child. 

But I, like in my gut, knew and pun intended that I had PCOS. Like I knew that, you know, at the time when I was thinking about what was going on, I had terrible acne and very irregular periods, even though I was lean, I still suffered from a lot of the same symptoms that we know are related to PCOS. And so I actually ran my own labs at the time and my testosterone was in the seventies and my insulin resistance by passing this one was actually very high at the time and I essentially diagnosed myself and after I had gone through quite a long fertility journey, my I started sort of understanding how much that in traditional medicine we see PCOS very differently. We sort of use we talked to women about, you know, if you’re if you have this to you need to be on a birth control pill to control those symptoms, to control your hormones. And I didn’t really want to be on that plan. So here I am as a doctor telling patients, you need to be on this plan. And yet I as a patient and a PCOS patient, didn’t want to be on that plan. I knew that birth control pills kind of made me nuts. 

Like I was not I didn’t do very well from that standpoint. I had I just felt awful, didn’t feel like myself. And so I ended up having to dove into research and figure out what are the other options for women. PCOS It can’t just be the birth control pill. It can’t just be sporadic, active, and it can’t be just metformin. There has to be something else. And so I started taking integrative nutrition classes and really got into integrative medicine and realizing that I could offer my patients so much more if I would just learn for myself how we can look at medicine and really use it from a more preventative medicine state and how to heal someone, as opposed to just continuing to put them on more medication and more medication. So I got I did the two year fellowship with the Andrew Weil program, and now I’m board certified in integrative medicine. And I really try to help patients with lots of different tools to try to solve what’s going on with their PCOS. What are the drivers for their PCOS and how can we give them other solutions besides the birth control pill?

Felice Gersh, MD

Well, it’s so amazing how similar our stories are. I just did it a few decades before you practice. And so and you have started up a medical practice where you focus on a variety of issues involving women’s health care with a focus as well on women who deal with PCOS. But your practice is a little bit different from mine in that you focus more on the virtual clinic experience, so maybe you can explain that because I still have a brick and mortar. I do some telemedicine, but a big percentage of what I do is in person in a in a regular, you know, walls and floor and all that. And you have really taken on this really new kind of approach to health care with a virtual clinic, predominantly virtual clinic. So maybe you can explain to our viewers how can patients utilize a virtual doctor and how can that really be an integral part of their healing journey?

Jennifer Roelands, MD, ABOIM

Yeah, as you and I both know, there’s just not a lot of integrative gynecologists around. So in order to offer this type of medicine to see this to provide root cause medicine, you have to reach more people. And in my mind, telehealth is really I think Kobe kind of all opened our eyes as patients, that telehealth is something that’s attainable and relatively easy to do. And I even have patients who I offer them at the in-person visit and they prefer not to to drive and have to haul their kids or have to worry about work situations and prefer to have a telephone telehealth appointment. And it allows me to really see patients in different states on license in ten states and I can offer patients time. I mean, all of my visits are one hour, so I spend time with patients to hear their story, to hear what’s going on, to hear what is the symptoms that they’re having. Because remember, PCOS patients can have all kinds of different symptoms. They don’t always have irregular periods, acne, hair loss. They can have, you know, poor healing. They can have, you know, anxiety, depression. They can have just other symptoms. So I really set this clinic up to be able to spend time with patients and understand what’s going on with them and have access for them. And I built an integrative team. So in my practice I have a holistic nutritionist. I also have a chef. And I have a psychologist and a trainer, a physical trainer who actually works with PCOS patients specifically. So I like the model of having an integrative team to make sure that we can cover all different aspects of healing for that patient. And so patients can make an appointment with me and they can also make it a point with these other providers to be able to have a better, well-rounded care.

Felice Gersh, MD

Well, it sounds great. And you know that once again, I can see all the parallels between us. That’s why you’re like my kindred spirit, because we both know that it takes a team and I have a similar team. I just have it predominantly in person. So this is really, I think, a wonderful option for people who live in all those different states. Right. And now, in terms of the approach to women with PCOS, if a woman say just heard the diagnosis, they have PCOS and they were told maybe by their a family doctor, okay. So do you think it’s important that they actually see a gynecologist? And what would a gynecologist offer that, say, a family doctor might not?

Jennifer Roelands, MD, ABOIM

So an integrated gynecologist would understand that we need to look at PCOS as a metabolic problem. So your standard OB-GYN or even primary care doctor may just order sex hormones. They may say, okay, here’s testosterone, it’s elevated, so you have a diagnosis, PCOS, but they really will look for metabolic factors. So they’ll really look for inflammation or look for insulin resistance or look for gut health issues. They rarely actually kind of dove deeper into that metabolic aspect. What are those patients at higher risk for diabetes, heart disease, all kinds of long term issues. So we need to look at them from a more metabolic standpoint. So an integrated gynecologist really can offer that aspect is to show women how to take care of themselves now, ten years from now, 20 years from now, 30 years from now, how to really understand their biology, the patient’s biology.

Felice Gersh, MD

Well, certainly it’s finally getting out there that it’s not just a reproduction type of a problem, that it involves, like all the different organ systems. And one of the organ systems that’s really sort of taken like this, the light, you know, the focus, which is the gut, the gut microbiome and so on. And that’s talked about a lot. And people talk about, you know, helping to nurture the gut microbiome. But maybe you can explain what does that actually have to do with women with PCOS because, well, what’s the relationship of the gut? It’s microbial population, the gut microbiome and all the different issues metabolic reproductive that women with PCOS must deal with.

Jennifer Roelands, MD, ABOIM

Yeah, we need our gut to metabolize hormones. We need, you know, there’s a particular portion of the gut microbiome called the extreme alone, which is responsible for estrogen metabolism. So if you have poor gut health or poor microbiome, you certainly don’t even have metabolism of estrogen very well. We know PCOS women struggle anyway with that dysfunction of sex hormones. And so it doesn’t it contributes to their issues by having that gut microbiome different. There’s actually something in your book that I love called Eat to the Beat, which is all about which is all about not only like feeding your gut bacteria, but also paying attention to the timing of when you eat and the importance of the light and how the light can actually promote good gut health. So there’s so many aspects to even growing this great gut microbiome for women with PCOS that we really have to focus on as we treat women.

Felice Gersh, MD

Now, for a woman who has the classic findings of women with PCOS, she has irregular cycles. She has, like you had, you know, excessive production of testosterone and has ultrasound findings of those little follicle cysts and so on. What role do you feel the gut microbiome has played in either like the chicken egg thing? Did these problems create the abnormal gut microbiome or the abnormal gut microbiome came first? And do we even know?

Jennifer Roelands, MD, ABOIM

No, I don’t think we actually know which came first. I do think that the sex hormone dysfunction contributes to the problem with the gut microbiome. And unfortunately, we live in sort of today’s today’s society where we don’t eat really well. So we continue to grow these unhealthy bugs, you know, with lack of a better word. I know bugs is not perfect, but it’s but it’s a word that patients typically use. We continue to grow these unhealthy bacteria in our gut and they sort of make the problem worse. And you continue to have inflammation your gut from the cosmetics you use or the environmental toxins. And so we’re just continuing to add and add and add and add things that are continuing to make that get worse. And so if we make estrogen, we use it and we need to lose it. That last step is really hindered by a poor gut health. So I in my opinion, I think it’s more of sort of the estrogen issue in our gut is making this problem worse. I think this is why you see, I mean, this would be interesting. You probably have more knowledge for sure about sort of this younger and younger puberty that we’re seeing in women and these young and younger women being diagnosed with PCOS. And to me, I’ve been in practice for 15 years, but I’m noticing the changes that are happening even younger and younger and younger. So you have to imagine that some of this is sort of like the hormones are set up and then the gut, what we’re doing and our lifestyles are just kind of like precipitating this disease early.

Felice Gersh, MD

Absolute like I talk about it being a pediatric disorder and most of the pediatricians are not aware that there are things happening even in utero before the that what is to be the woman with PCOS is even born that can actually set the stage for the gut microbiome you know what the environment in the uterus, the endocrine disruptors how a person is delivered. C-section, vaginal, breast fed, bottle fed. Yeah so it is complex this whole gut microbiome. And I was so glad that you brought up the issue of estrogen metabolism and the role of the specific areas of the gut microbial population that’s involved in that. And what about the liver? So the liver is known as the sort of detoxification powerhouse. Is there a relationship between the gut microbiome and the functioning of the liver? Is it bi directional? And, you know, how did the two interplay interact together? Oh.

Jennifer Roelands, MD, ABOIM

Well, our liver has a lot to I mean, has big jobs in particularly during with toxins in my mind. I sort of think of the liver. Well, first of all, liver is involved with estrogen metabolism as well. It’s part of the phases of metabolism. But as far as the liver and gut connection, you know, that liver has to deal with a lot of toxins that we’re exposed to all the time. And the fact that if the liver is sort of overwhelmed by all these environmental toxins, so you get more inflammation in the body, which then causes inflammation issues in the gut and certainly the absorption of nutrients in the absorption of what you eat and all the bacteria, what’s what it has to do to get these vitamins, minerals that we need to make our sex hormones get very disrupted by the liver, sort of being overtaxed, for lack of a better word, for having to be stressed out with what they’re dealing with on a day to day basis. And when you and I know in particular, when you talk about sort of eating to the beat and understanding circadian rhythms and PCOS, the liver is critical, right? If you’re eating all day and all heat and your poor liver has no time to deal with whatever happened all day long, and you’re sitting there having to deal with metabolism for food to midnight or whatever, you’re really taxing the liver and it really can’t do the other job of lowering inflammation in the body.

Felice Gersh, MD

Right. That liver is so critical. And another topic that comes up and I’m sure a lot of the people out there watching this or thinking, what about leaky gut? You know, what is a leaky gut and what’s the relationship of that to the gut microbiome and to women with PCOS?

Jennifer Roelands, MD, ABOIM

Yeah, so there are tight junctions. So between gut cells and parasites, there’s these junctions that should keep them nice and sealed so things don’t pass between in the junction. So you don’t want, you know, viruses or bacteria or food or anything to really pass between these junctions. So when you have inflammation in the body, then you get these gaps that occur and things that normally should not pass, do pass between those cells and our body will react to those. So our immune system kind of go, Hey, this is not supposed to be here. Why, why? Why is this coming through here? And we mount responses to it, which, you know, obviously can contribute to our immune issues. We know that women with PCOS have higher rates of autoimmune issues. In fact, hypothyroid as and which is something I suffer from is higher in women with PCOS as well as other autoimmune issues. I mean, we can talk about diabetes, we can talk about arthritis, we can talk about a lot of other autoimmune that can be connected to PCOS. So when you have a leaky gut from poor nutrition, from environmental toxins, then you constantly are sort of having your immune respond to this and making these the gut honestly that gut health much worse as it continues to get worse and worse. And so you see this in PCOS women because they’ll tell you, yeah, I have constipation issues, my acne is terrible. I’ve done all the stuff over the counter, all those expensive products and nothing’s getting better. And I just go to the bathroom every 3 to 5 days and I’m bloated all the time. And those to me always go, ding, ding, ding. We need to talk a little bit about gut health and we need to talk about, you know, what you’re eating when you’re eating. What kind of nutrients are you actually absorbing in your body? Maybe you’re actually nutrient deficient, which is making this problem worse. So those kind of symptoms definitely scream to me gut health and to address those.

Felice Gersh, MD

So we touched on what you eat of affects your gut microbiome and what time you eat affects it and the environmental toxicants. Now in general, women with PCOS tend to have higher levels of emotional issues, you know, more anxiety or depression. And a lot of the symptoms that you described like constipation and the bloating and all of that are similar to what people describe with irritable bowel syndrome, which is very related to emotion. So what is the role of emotions and women with PCOS and their gut health and gut microbiome and leaky gut.

Jennifer Roelands, MD, ABOIM

So we talked about that inflammation pathway and how inflammation can cause damage in the gut. It can also cause damage in the head, right? Inflammation in the brain. And we and there are a lot of different root causes of anxiety and depression. Certainly trauma can be a factor. Certain medications, certain, you know, receptors that can be causing dopamine issues or other kind of genetic issues. But for PCOS, specifically, inflammation can occur anywhere in the body. So you can have inflammation in the brain and be susceptible to anxiety and depression. But also you need nutrients to make neurotransmitters. You need to make your happy hormones, serotonin and oxytocin and dopamine. You actually need certain nutrients. So if you have a gut issue, then you certainly are going to have a hard time absorbing the proper nutrients to make the right neurotransmitters. So you do see it often. There’s much higher rates of anxiety, depression within the PCOS than women. You do not right now.

Felice Gersh, MD

We were talking before we went on and recorded this a little bit about birth control pills. So do birth control pills help or hinder a healthy gut and a healthy gut microbiome? And is there even any data on that issue?

Jennifer Roelands, MD, ABOIM

Well, so birth control pills do hinder a healthy gut and they can cause nutrient deficiencies. We know that people who are on birth control pills long term have typically have nutrient deficiency issues. But the other thing is that, you know, these artificial hormones also respond to the body. I mean, they’re not kind of mimicking what we have in our body. They’re artificial. So I do think there are people who just don’t do well with birth control pills to from a gut and a mood standpoint, because those artificial hormones don’t respond well to their body like they don’t feel good on them. Does that make sense?

Felice Gersh, MD

Absolutely. I’m so glad that you said all of that because it’s really not well appreciated in the we’ll call it conventional medical world, that birth control pills are not human hormones and that they do have this negative effect on the gut microbiome and can exacerbate certain autoimmune conditions like Crohn’s disease and so on. So we definitely want people to know, I call it informed consent, right? At least know the pluses and the minuses of a very therapeutic modality, whether it’s a procedure or a pharmaceutical. So I really appreciate that you brought that up. Now, we talked about how people can develop in impaired gut barrier, leaky gut and wrong gut microbiome and all the different causes. Now, what are you going to do? You have PCOS, you know, they’re your patient. How can they now take affirmative steps to improve their gut microbiome? Where do you start? It does seem kind of overwhelming.

Jennifer Roelands, MD, ABOIM

Yeah. So I really try to meet patients where they are like, let’s, you know, I’m not a dieting person. I hate the word diet because I’ve been working with women for 15 years and anytime you say diet, everybody runs, including myself. If you tell me I can’t have chocolate, that’s the one thing I want to have because you said I couldn’t have it. So I try to work with women and use something called a healthy plate model or balance plate model and really trying to focus on half your plate, be healthy vegetables. Non-Starchy vegetables, and then you have that fat that sort of makes the veggies taste good on top of that. So olive oil and trying to encourage good, healthy fats, a quarter protein and a quarter of the starchy vegetables stuff that we typically want to make, the entire plate and the potatoes. And so I try to focused on with women to say, let’s just focus every single time you sit down and have a meal is an opportunity to kind of balance that plate so you can still eat with your children, you can still feed, you know, five children and your parents. At the same time, you just have to adjust your plate accordingly to make sure that you’re getting more of a balanced approach to your nutrition. 

And I also discuss with people, again, trying to limit the hours that they eat. It’s important to limit them. It’d be great if they can limit 10 to 12 hours and actually even practice intermittent fasting, but that can be kind of hard for women to start out with. So I usually start with most of my patients talking about a balance plate and talking about that 12 hour window. So if you stop eating at 7 p.m. your dinner, then you don’t eat till 7 a.m.. The next day to allow that microbiome to really reset and kind of get spring clean and get ready for the other. So delivered a spring clean and get rid of the stuff it doesn’t need. And to have a new start the next day. And then I can add those advanced things like intermittent fasting or supplements or getting out in the light first thing in the morning. So I do adds exercise. Ideally we don’t even talk about exercise, but we know for the gut microbiome exercise is critical and I try to encourage women to do the type of exercise that really makes them happy because, you know, hit is not for everybody, yoga’s not for everybody. So finding something that you can move your body every single day is important.

Felice Gersh, MD

Oh, absolutely. And a lot of women with PCOS do struggle with like say, you know, cravings and binge eating. So it’s so easy to think you’ll just time when you eat and when you stop eating. Do you have any, like, tricks that or suggestions for women who say, you know, that bag of chips is just calling my name? I can’t like I can’t stop thinking about it. I mean, these are really challenging real world scenarios.

Jennifer Roelands, MD, ABOIM

Yeah. You know, when I die deeper into what are the cravings, a lot of times there the patient has the answer to what it is. Sometimes it’s because they’re bored and they just they’re thinking about food because they don’t have other things going on. Sometimes they didn’t eat enough at dinner, so therefore they’re hungry. And so having these cravings. So a lot of times that’s really about discussing with a patient like when this happens, what’s going on in your body, like what is happening at the time. I know I’ve had patients who said, Well, we go eat dinner, then we go to a soccer game and I see the kids eating all snack. So I have this sort of like, well, I need to snack too, just because they’re eating a snack. And so it’s trying to sometimes undo some of that mindset changes where you feel like, Oh yeah, I always eat a snack because the kids eat a snack, but was I really hungry? I know. So some of that is a little bit about understanding what’s driving those particular cravings. And she had one patient who she drove home from work and she could smell that fast food restaurant, and that was what triggered her cravings. But then I said, Why don’t we just switch the route, like just go to a different street? And that completely stopped that problem for her. She just had this sort of instinct feeling. When she smelled it, she was like, Oh, I have to stop. I might even I had dinner, I need to stop. So sometimes it’s about just figuring out those obstacles that are causing those particular things. But I find that when most people eat enough fiber, enough protein, enough veggies, they typically don’t have as many cravings as they used to.

Felice Gersh, MD

And all great advice. I mean, like, wow, that’s one powerful smell that comes right into your car as you driving by. Yeah, I certainly find that in airports, you know, they put out these artificial smells that are actually enticing to a lot of people, you know, and we both did the fellowship in Integrative Medicine at the University of Arizona. So I know that you had a similar exposure to mind body medicine. And, you know, we were just talking about, you know, the emotional component of cravings and so on. So what’s your favorite? I mean, I can tell you that I love guided meditations or guided imageries, essential oils. I love body work. What are some of the modalities that you particularly love and find your patients that sort of resonates with them for mind body practice?

Jennifer Roelands, MD, ABOIM

Yeah. You know, I think the most I would see the popular would be breathwork like being able to just sit and I mean even if it’s not for seven, eight like a particular, you know, box breathing, a particular set, but actually stopping, taking these breaths, paid attention to your breath a longer exhale than inhale. Just actually breathwork seems to be fairly easy for patients to do to incorporate you just do it for a couple of minutes in the morning, a couple of minutes at night, or if you find you’re in a stressful meeting and you and you’re in a zoom in the background, you want to take some breaths, you can do it at any location. So I find Breathwork to be really helpful. I also find apps that lead you through a guided meditation to be more helpful patients, often while doing meditation, can be very hard because being in your own head sometimes can be difficult for some people. So I find the app like calm to be very useful for patients to just listen to the little ten minute guided meditation for the day where they can just kind of listen to that voice and follow the prompts and have an easy way to kind of calm their sympathetic system down. And then I really encourage a lot of people to journal because I think a lot of us can benefit from sort of dumping all of our thoughts on a piece of paper and sort of allowing it to come out of us. I know that especially women with PCOS who have difficulty with sleeping, getting to sleep at night and maybe up, it can often be helpful to get that out of your head. So journaling can be very beneficial to just kind of, you know, let go what’s going on inside of you to understand what part you can control, what part you can’t know.

Felice Gersh, MD

Well, I agree. And we both the apps are like, you know, the guided imagery is a guided meditation. I love that, too, because you don’t have to like take a course. You can do that. You really anywhere pretty much any time. So so that that is really wonderful. And in terms of sleep you mentioned, you know, some of the things to relax. Do you have any other little like recommendations to help people who really struggle with sleep because that definitely affects the gut microbiome affects everything as we know.

Jennifer Roelands, MD, ABOIM

Yeah, that’s probably the number one thing you can do with PCOS is just get sleep at night. I mean, I would if you could do anything first, it would be make sure you’re getting adequate sleep. So I encourage people to go to sleep at the same time, wake up at the same time. It doesn’t matter. It’s a weekend, even though people maybe staying up in Netflix, seeing movies all night like you really just need to go to sleep and get up at the same time every single day. That consistency is super, super important. I also encourage people to have like a nighttime routine, like what is sort of the thing to get you to kind of ease you into sleep. So it may be reading a book, it may be journaling, it may be reading the story of your kids. It may be going for a walk. You just need a nighttime routine that sort of you get used to. And I mean, we do this for our children, right? We establish these things for our kids and have them have these routines, but we rarely do it for ourselves, especially as busy moms. So I think it’s really important to have this sort of nighttime routine. And I do sometimes talk to patients about herbal options. I think, you know, herbal teas can be great for calming people down. I particularly love I make this sort of like tumor pick it has to American cinnamon and I just find it like with hot water I just find it calming and it kind of helps me ease into sleep. And sometimes I’ll have Tulsi, which works so some herbal options can be great for kind of easing nicely into sleep.

Felice Gersh, MD

Well, I’m so glad you brought up the teas because they’re medicinal without having a medicinal kind of a quality to them. And and also, not only are they wonderful and and, you know, a lot of women with PCOS have heard about spearmint, but the ones that you mentioned, you know, Holly, Basil or Tulsi and of course, the old standby, you know, Camomile, all these teas are wonderful. And I was going to say maybe that might help. Do you talk about hydration as an issue that helps with the gut microbiome and also just dealing with cravings? So what do you think the role of just general hydration is?

Jennifer Roelands, MD, ABOIM

Yeah, I mean, I think for everybody, PCOS or not PCOS, we typically don’t drink enough water anyway for our I mean, most people are on the go and they don’t think about water. And certainly proper hydration is important for any hormone production as well as your gut microbiome. So I certainly encourage women to drink half their body weight in water and it doesn’t have to be just water. You could have electrolyte water if you wanted to just make sure doesn’t have extra sugar because oftentimes those things kind of add a bunch of sugar in there, which isn’t beneficial. But I sometimes use those. If I’m doing like an intermittent fasting, I’ll use those electrolyte waters to sort of help through. But hydration is critical.

Felice Gersh, MD

Well, that’s wonderful. You are a wealth of knowledge. Thank you so much for joining me. Now, I know you also have a podcast because I was on it and you know, you have this wonderful brand new kind of state of the art virtual practice, which is really a growing phenomenon. And maybe you could tell the audience, how could they reach you? And if they’re in one of the ten states that you have a license in, you know, how can they potentially become your virtual patient? So, you know, tell us, how can they get in touch with you?

Jennifer Roelands, MD, ABOIM

Yeah. So I have a website called wellwomanmd.com. And there you can actually book a 15 minute discovery call if you want to chat with me about if I can help you or not. I also have appointments. Like I said, there are hourlong appointments that I see patients in ten states. So I’m licensing California, Nevada, Washington, Texas, Missouri, Montana, Louisiana and Kansas and Minnesota. Those are my states. So you can actually we can do a virtual appointments and I can order labs to, of course, request the typical labs that are available. I can send in prescriptions so I can do most everything you can do except for the physical exam portion. And I do require all my patients to have had their preventative medicine exam. So it’s important to still have your mammograms and your pap smears and your exams. So that is part of health care. So I really encourage people to do that first before they seek guidance from me for helping them with other options. And then I’m on Instagram, so drjen.md. and you can find they do all kinds of fun roles and all kinds of stuff on there. So and then my podcast is called Ignite Your Power.

Felice Gersh, MD

Well, that’s great. And, you know, congratulations on getting all of this put together to help women with PCOS and, you know, many, many places around the country. And once again, thank you so much for joining me and sharing your wealth of knowledge and, you know, I want you on my Instagram. I’ll invite you over soon. So thanks again and just really appreciate that. There are others that are following. I like it my foot steps, you know, and really taking on this as part of their mission in life to help women with PCOS.

Jennifer Roelands, MD, ABOIM

Thank you again for having me.