The Effects of Anxiety and Stress
Pregnancy is a normal and natural experience of life, but there are so many reason why a mother may be experiencing any degree of stress and anxiety in the months leading up to and during childbirth.
In treating acute and chronic stress and anxiety it is important to first identify the emotional or physical cause. This may include the addition of counseling with a physiologist. Often having a safe environment for women to talk through their fears is all they need.
Fear, Stress and Anxiety all have marked effects on labor progression and pain perception. When people are frightened or stressed the body will activate the flight or flight response. This causes an increased production of catecholamine and adrenaline. The heart begins to beat faster, breathing becomes more rapid, muscles tense, blood pressure rises and blood is diverted from the periphery to vital organs (unfortunately for baby and childbirth, this does not include the uterus).
During labor there can be some signs that show that a mother is not coping well with childbirth, and has begun to panic and become stressed or anxious about the event. This could be restlessness, panic, high pitched vocalizations, increased pain perception due to a decrease in endorphin production, slowing of contractions due to drops in Oxytocin production, and fetal distress.
When a mother has measurable levels of stress and anxiety during her pregnancy, especially in the last months leading up to childbirth, there is an increased chance that it will intensify during childbirth and an increased chance that the mother will need medical interventions such as Pitocin to speed contraction or epidural to help with pain.
Treating Stress and Anxiety with Acupuncture
Anxiety in pregnancy is called Zi Fan, or "child mental restlessness." In pregnancy women are prone to bouts of anxiety, either from an emotional root (worry, fear, or anger), or from a physical imbalance (Qi stagnation, Yin deficiency, or excessive Phlegm from poor diet, which cause excess heat, and the heat causes anxiety). Pregnant women already suffer from excessive heat during pregnancy, so it is very easy for them to become imbalanced and anxious.
When treating Stress and Anxiety with Acupuncture, it is important to differentiate the underlying cause and treat based on the root imbalance.
Acupuncture used in times of high Stress and Anxiety work by...
Treatments may include the needling of auricular points such as Point Zero (directly effects the autonomic nervous system); Shen Men (directly effects the cerebral cortex to increase endorphins); Tranquilizer (facilitates relaxation).
When preparing for Labor and Delivery, it is recommending that a women receive Acupuncture at least 1 time weekly from 36 weeks to delivery. In 1998, a research study compared the duration of labor in women who received Acupuncture from 36 weeks gestation and women who received no Acupuncture. The study concluded that the Acupuncture group had a positive effect on the duration of first stage of labor (time between 3cm cervical dilation and complete dilation). The Acupuncture group had a median duration of 3 hours 26 minutes while the control group (non Acupuncture group) had a median duration of 5 hours and 35 minutes. (Tempfer, 1998)
What is Polycystic Ovarian Syndrome
Polycystic Ovarian Syndrome, or PCOS, is a very common condition characterized by the growth of small cysts on the ovaries. The cysts are benign, but are part of a disruption of the natural hormone balance. Because of these imbalances in hormones there may be any of the following symptoms...
If untreated for an extended period of time, chronic and life threatening condition can arise.
1 in 15 women are diagnosed with some form of PCOS, and in some cases there are no additional symptoms other than irregular menstruation and ovarian cysts, making it difficult to diagnose in some instances. It is also the leading cause of infertility in the US.
PCOS Affects on Hormones
The mystery of PCOS is if the hormone imbalances cause the cysts or if the cysts cause the hormone imbalances. Either way, they go hand in hand, and it doesn't take much to throw off hormones balance. Hormones are complicated and intertwined, often one hormone is needed to release another, and then that hormone is needed again to release another. So, once one hormone are not produced in balance, then they are all off.
In PCOS there is a decrease in Progesterone, and an increase in Estrogen which causes an increase in Testosterone, causing amenorrhea and anovulation. There is also an increased production of Luteinizing Hormone and a decrease in Follicle Stimulating Hormone.
All women produce a small amount of Androgens (male hormones), which are needed to create strong bones, strong muscles, and they play a vital role in sexual function. In the case of PCOS, these hormones are produce in higher than normal quantities. It is important to note, that small cysts in the ovaries are normal, but what is abnormal about PCOS is that when there is an increased production of Androgens, these normal cysts do not release an egg, and build up in the ovaries
Western Diagnosis and Treatments
Often, if PCOS is suspected, your doctor may perform a blood test to check your hormone levels. If those levels seems off balance, they may schedule an ultrasound to confirm the diagnosis. The ultrasound is an important diagnostic tool, as there are Adrenal and Thyroid dysfunctions that can mimic the symptoms of PCOS. I have personally seen several cases where a patient fits several of the symptoms, but blood work did not show a worrisome hormonal imbalance, to only find out years later with ultrasound that they do indeed have PCOS.
There is no cure of PCOS in Western Medicine, but in combination with correct diet and exercise the use of Birth Control and the insulin regulating drug Metformin, can reduce symptoms and prevent long term health problems.
Traditional Chinese Medicine Diagnosis and Treatment
As always, the diagnosis of conditions in TCM can be confusing to those who are not familiar with our way of viewing the body. Within the diagnosis of PCOS there may be several factors involved from the TCM view. But, there is always a Kidney imbalance, as the Kidneys are the controlling organ of reproduction. This can be an imbalance of Qi, Yin, Yang, Jing, or a combination. There is also always a component of Damp and Phlegm accumulation (as seen in the physical cysts). There can also be a stagnation of Qi and Blood causing painful blood clots during menstruation or PMS type symptoms, or a Spleen deficiency component causing weight gain. Treatments are individualized to the patient's presenting symptoms, and often herbal formulas are used in conjunction with Acupuncture, Diet and Lifestyle modification.
Acupuncture can help to restore hormone balance, decrease LH, increase FSH, decrease Testosterone, decrease Estrogen and increase Progesterone. It can also help to decrease excessive weight, shrink ovarian cysts, and benefit ovulation and egg implantation.
Research Study Exercise Vs Acupuncture
One study compared women who exercised and women who received Acupuncture over the course of 13 weeks. At the end of 13 weeks, the women who received Acupuncture had lower androgen hormone levels (estradiol and testosterone) as compared to the group that exercised twice per week. Rates of ovulation were not given, but the women who received Acupuncture had a higher rate of ovulation
Another study compared 84 women with PCOS divided into 3 groups. Those who exercised, women who received Electro-Acupuncture and a group that received no treatment. Electro-Acupuncture group had improved hormone levels (30% decrease in overproduction) and increased menstruation at the end of the 16 weeks.
Unfortunately, there is not enough research on Acupuncture treatments of PCOS, but the little that has been done is promising. What we do know is that Acupuncture stimulates the nervous system and causes the release of neurochemical messengers. These biochemical changes influence the body's homeostatic mechanisms. As with most everything with Acupuncture and trying to describe it in Western terms, we know it works (there are measurable changes), but we just don't know how exactly.
Treatments are based on the flow of a natural cycle. Our main goal is to regulate ovulation and menstruation. Be prepared to receive regular treatments for 3-6 months. While we are trying to regulate hormone production, there may be some months of normal cycling, and months that are still out of balance. Normally women can see increased regulation in ovulation within the first 3 months of treatments. While receiving treatments you will be asked to follow specific diet and lifestyle changes, and also to keep a Basal Body Temperature Chart. The Basal Body Temperature Chart (BBT) is a fantastic diagnostic tool that can help us distinguish diagnostic patterns, hormone imbalances, and if/when you are ovulating. (Often with PCOS, women are ovulating later in their cycle, or not at all.)
The PCOS Diet
A research study done by the Research and Clinical Center for Infertility compared diet and lifestyle modification against common western treatments of Clomid (for ovulation) and Metformin (for insulin resistance). The study took 343 women with symptoms of obesity and infertility with PCOS and assigned them to 4 different treatment groups. 1) Clomid 2) Metformin 3) Clomid + Metformin 4) Lifestyle and Dietary Modification. Results were that those who received the dietary and lifestyle modification had an increased rate of pregnancy as compared to those who only received medical treatments. Clomid group - 12.2%; Metformin froup - 14.4%; Clomid + Metformin group - 14.8%; and Dietary and Lifestyle group - 20%. Lifestyle group also had a significant reduction in waist circumference, total androgen and lipid profile.
I just love this study, not only does it show that symptoms can be managed with diet and exercise, but that they work better than drug therapies.
So, now that we have established that PCOS patients MUST change their diet and add exercise, what kind of diet is it? What if you're not trying to get pregnant, why would you change based on a study that worked with infertility...because its all connected, and many other symptoms were aided in the changing of the diet; weight loss, decreased androgen production, and better lipid profiles, why wouldn't you change for better health!
There are a couple of mainstream dietary lifestyles that will fit into the dietary guidelines that benefit PCOS. Those of the Weston A. Price Foundation, and those of the primitive or paleo diets.
So here are some basic dietary guidelines to follow:
Eat Low Glycemic Foods
One of the biggest issues with PCOS is the high insulin resistance, which is a precursor to Type 2 Diabetes. So it is important to make sure that food choices are on the lower end of the glycemic index. What does that mean? Well, to put it simply foods that are higher in simple carbohydrates and sugars are high on the glycemic index, they break down quickly and are more likely to cause insulin spikes.
Balance Protein and Carbohydrates
By balancing your proteins and carbohydrates you are able to keep insulin levels balanced as well. This will help prevent any yo-yo-ing of insulin levels. Your choice in carbohydrates is very important, making sure that they are low glycemic and high in protein and fiber. It is also important to make sure that your sources of protein are from hormone free organic meat sources, or good complete vegetarian sources.
Eat Small Frequent Meals
By eating several smaller meals throughout the day, your metabolism becomes more balanced and blood sugar is more stable. Each "meal" should be balanced in protein, carbohydrates and vegetables/fruits, and should not exceed daily recommended caloric intake.
Some Examples of Small Balanced Meals/Snacks
Avoid Dairy and other Damp and Phlegm Producing Foods
This is a TCM nutrition guideline. In TCM we believe you are what you eat, and that if you are suffering from conditions such as dampness and phlegm, you should not consume certain foods that are also dampening and phlegmy. Dairy is one of those foods! Have you ever noticed the feeling you get in your mouth after you drink a big glass of milk, that sticky and tacky sensation. In TCM milk has the same effect internally. Other foods that are considered damp and phlegm producing are foods that are extremely cold (they contract and congeal fluids), greasy and fried foods, sugar and processed carbohydrates, and alcohol.
Diet Low in Food Allergies
PCOS is an inflammatory condition, and often times it can be exasperated by eating foods that cause an excessive inflammatory, or allergic reaction. Therefore, I find it important to rule out some level of food allergies. There is a simple blood test that can be ordered by your primary care provider, or, there is also the option of doing elimination diets to determine if you have any reactions to the common food allergens (The BIG 8); Milk, Eggs, Peanuts, Tree Nuts, Fish, Shellfish, Soy, Wheat.
I know everyone hates me now; how dare I tell you to stop that morning cup of coffee that you need to function (I know I need it)! Well, alas in the case of PCOS, it is important in a couple of ways to decrease or eliminate your consumption of caffeine.
Avoid Synthetic and Phyto-Estrogens
These can be found in foods, the environment, and in household products. They have a bad habit of mimicking and disrupting hormone balance in the body, and several studies have linked synthetic estrogens to breast cancer.
Examples of Synthetic and Phyto-Estrogen Sources
As with all conditions treated with TCM, when a patient is seen by a practitioner, often a dietary plan will be suggested. Based on the guidelines above, any known food allergens, etc, we can create a customary diet that will suit you and your symptoms best.
Nutritional Supplements for PCOS
Again, as with diet, choosing supplements is very specific to the individual. Just because a supplement is listed below it may not fit your specific presentation for PCOS. As always, it is recommended that you talk to your practitioner to determine which ones are best for you. Also, there are many other (herbs and supplements) that are not listed below. These are the ones that I personally find to be the most important.
Omega 3 EFA's
I absolutely love everything there is about Omega 3 supplements, and think that everyone (for the most part) should be taking them. In our society, our diets are severely deficient in Omega 3 consumption. We used to be able to get them from our meat sources, but conventional farming has disrupted the natural Omega 6 (inflammatory) with Omega 3 (anti-inflammatory) balance. I also prefer to get Omega 3's in the already converted form, which is found in animal products. (animals eat the plant sources and do the conversion for you) Why? Because, there are some cases where people lack the necessary enzymes to properly convert ALA to DHA and EPA, and then therefore do not get the full benefit of Omega 3's. (Don't worry, this is a subject that is near and dear to me, so I will very shortly be writing on Omega 3's in another blog post, too hard to go into complete detail here. )
In relation to PCOS it can help...
In my opinion the best way to make sure that you are keeping your consumption and conversation of usable Omega 3's at an optimal level is to take supplements and include Omega 3 rich foods into your diet. Some dietary sources include:
I am probably going to get a little flack for what I'm about to say, but I personally find it very odd that we have this Vitamin D deficiency outbreak in the US. I personally think that diet and lifestyle are to blame. By lifestyle I mean this over use of Sun Screen. There needs to be a balance between our use of sun protection (we definitely don't want UV causing skin cancer, but how much skin cancer is also due to the chemicals found in sunscreen products?), and our absorption of sunlight that is necessary for the production of Vitamin D. (You cannot create Vitamin D in the body without sunlight) I do not recommend daily sunscreen use, but do believe that if you are working out in the yard, or planning on being out in the sun for an extended period of time that a natural zinc based sunscreen is beneficial in preventing over-exposure to damaging rays.
Tangent over, why is Vitamin D important when dealing with PCOS? 3 out of 4 women with PCOS have significant Vitamin D deficiencies. A study that was done at the Medical University of Graz in Austria looked at 206 women with PCOS and found that 72.8% had insufficient Vitamin D levels.
Why is Vitamin D important in PCOS?
There are so many other conditions and symptoms not associated with PCOS that can be affected by Vitamin D deficiencies (depression, learning disabilities, childhood asthma, etc...) So, how do you get your Vitamin D levels up to par? This is a combination of lifestyle, diet and supplementation.
Magnesium to me is a supplement that gets forgotten. I know plenty of patients that are on Calcium, Fish Oils, Multi, etc....but never do I hear people mention Magnesium, and its so stinking important to reproduction!!!
Generally speaking, Magnesium is often deficient in women with insulin resistance (which as I've mentioned numerous times, is a big component of PCOS). Magnesium helps the cells absorb glucose, which when found in the blood stream, it signals insulin production in the pancreas. It takes a pretty big spike in insulin to signal the body's natural response to uptake glucose in the blood stream. In those with PCOS or Type 2 Diabetes, this function is unbalanced. Medication used for PCOS and Diabetes insulin resistance (Metformin) increases insulin sensitivity by increasing Magnesium production in the Liver.
Another additional benefit of a Magnesium supplement is that it is a natural muscle relaxant, and if you are suffering from painful periods, or muscle cramping, Magnesium can help to decrease excessive spasming. It can also benefit insomnia, fatigue, irregular heart beat, anxiety and depression.
Again, the best plan is to combine diet, and supplementation to increase magnesium levels. Some sources of Magnesium include:
Another mineral that is often forgotten, Zinc is essential for reproduction. Zinc is also an essential component of genetic material. Deficiencies can cause chromosomal changes in either men or women which decreases fertility and increases the risk of miscarriage. It can also help with Acne symptoms. A study done by Dr. Michaelsson MD compared the use of Zinc and Tetracycline for the treatment of Acne. The study concluded that there was little difference between the two. He gave 135 mg of zinc per day to a group of 19 acne patients and 750 mg of tetracycline daily to a group of 18 patients. He gradually reduced the tetracycline dose during the trial. After 12 weeks, both groups report a mean improvement in the skin of 70%. (This is a very high dose of Zinc, usually no more than 30mg is prescribed.)
Deficiencies can also cause:
As with the other dietary supplement, combining food sources and supplement sources is the best way to make sure that your have sufficient levels of zinc for proper reproductive health.
I love Maca as a fertility supplement because it is a hormonal adaptogen. What does that mean? It means it regulates your progesterone and estrogen no matter which way it is out of whack, so it can be used for both estrogen and progesterone deficiencies, but does not contain phyto-hormones or hormones itself. It contains alkaloids which directly affect the Hypothalamus and Pituitary. So, it doesn't just affect sex hormones but can benefit the adrenals and thyroid (which can also be factors in PCOS).
There are 13 different forms/types of Maca, so it is important to make sure that the Maca you are purchasing is the real deal. There have really been no good studies on Maca for PCOS, but many on menopausal symptoms. Of those only one type has been shown to actually change hormonal levels...Maca-GO. The writers of the book Woman's Bodies Woman's Wisdom Dr. Christiane Northrup MD OBGYN, and Dr. Tori Hudson ND, talk extensively on Maca-GO (commercially known as Femenessence).
There are so many more herbs and supplements that may be beneficial for PCOS depending on your presentation. Again, it is important to consult your practitioner to create a personal plan of attack. Other supplements they may consider include: Vitex, Chromium, Cinnamon, Saw Palmetto, Calcium, Green Tea, etc...
If you have any question, or would like to have a consultation, I am always available to answer question by email or phone.
I am often asked about how Acupuncture can help to stimulate natural labor. This is a newer application of Acupuncture for the Western World, and is beginning to gain some recognition, but it is not new in Traditional Chinese Medicine. Thousands of years ago, Eastern Medicine Doctors had to have ways of stimulating labor in women who either did not spontaneously go into labor, when labor stalled or when labor was not strong enough to successfully delivery the baby. Several Acupuncture points are talked about in the literature as being effective for inducing labor or strengthening contractions. (These points are forbidden during pregnancy, with the exception of stimulating labor).
"If the fruit is not ripe, it will not fall" Proverb
From a Western Medical standpoint, these points work in the body in different ways, but together they are able to stimulate labor. Some cause strong uterine contractions by stimulating the natural production of Oxytocin. Some stimulate dilation of the cervix by increase the natural production of prostaglandins, and some directly affect the sacral plexus to stimulate uterine contractions.
From an Eastern Medical standpoint, these points increase blood flow to the uterus, increase uterine contractions, and are descending and moving.
Acupuncture for Labor Induction is best used when the patient has reached 40 weeks gestation (I never treat anyone who has not reached 40 weeks), and has a healthy pregnancy with no complications.
There are several factor that determine the success of the treatments. These include, dilation of the cervix, effacement, gestation, and station of the baby. There is no progression recipe that will tell me/or other practitioner whether the treatments will work or not because everyone response differently to treatments. A mother may not be ripened, the baby not engaged, but the Uterus responds quickly to treatments.
Most often, mothers call me a day or two before they are scheduled to have a hospital induction. Although I have seen acupuncture inductions work almost immediately, the average time for the treatments to go into affect is 12 hours. According to research studies it can be between 3-48 hours from the beginning of treatments. Because we are stimulating the natural production of these hormones, this takes time. We have to stimulate the acupuncture points to stimulate to corresponding organs/glands to produce the hormones and then give those hormones time to travel to the uterus to stimulate labor. Unfortunately, just like all induction methods, it doesn't work for everyone. Sometimes there are unforeseen reasons that the body will not go into labor...as the quote above says, "if the fruit is not ripe, it will not fall." We cannot force the body to do what it is not naturally ready to do. If mother or baby are not ready then it will not work.
Recently a study was done at the University of North Carolina. The study included 56 women who are 39.5-41 weeks pregnant. Half of the women received 3 acupuncture session, and the other half received western medical induction methods. 70% of the women who received acupuncture went into labor naturally compared to 50% of the women who received standard western care. The women who received Acupuncture were also less likely to deliver via cesarean vs. the standard western care group - 17% vs 39%...that is a 50% decrease in cesarean delivery!!! Research was done by Terry Harper MD
When treating a mother for labor induction, I prefer to see her twice in one day, and I will then attach interdermal needles that can be worn after the treatments to continue to stimulate the acupuncture points. If the mother does go into labor, these tacks can be stimulated to increase contractions and speed the labor process....and some of the points can be used to decrease pain perception during labor as well.
The use of this technique goes beyond just inducing labor in healthy women, who have not gone into spontaneous labor. It can be applied to women who have had a rupture of membranes without the start of labor, women who are in labor but experience weakening, stalling, or irregular contractions.
Although Acupuncture for the induction of labor is safe, with no side effects, or additional risks of natural childbirth complications, there are some cases where is it not applicable. This includes CPD (Cephalopelvic disproportion) or obstructed labor, severe pre-eclampsia, kidney disease, pre-existing heart conditions, diabetes, bleeding during pregnancy, or previous cesarean delivery.