Going Upstream: A truly preventative perspective of Polycystic Ovarian Syndrome (PCOS)

[Average Read Time: 10 minutes]

When I got there, the Townshend’s teahouse was unusually quiet. No line, several open tables near the ambient light, and a background soundtrack that was actually soothing. Perfect.

I was there to meet with Dr. Angela Cortal, a Naturopathic physician specializing in women’s endocrine health and holistic pain management. In February, Dr. Angela will be giving a talk at NUNM’s Food as Medicine Symposium on “Nutritional Interventions for PCOS and Related Hormone Imbalances.”

Between sips of tea, we shared nearly two hours of our day. With this conversation being my first real dive back into the integrative medical perspective on Polycystic Ovarian Syndrome (PCOS), I brought all my questions to the table.

Here are the highlights:
  • Dr. Angela finds patterns in patients testimonies (not labs or ultrasounds) that help her to know they are under the “PCOS umbrella.”
  • Our current social-medical perspective on preventative medicine is incredibly superficial (annual wellness exam, routine labs) and how this can unconsciously limit our mindset to initiate lifestyle changes as patients.
  • PCOS’s origin is NOT in cystic ovaries and likely originates from a hereditary predisposition towards insulin resistance. This triggers the other symptoms we name as PCOS.
  • The danger of PCOS not being treated as multifaceted is that medications are the main go-to & we never get to the root of our body’s messages. This is detrimental to our long-term hormonal and overall health.
  • We tend to have our mother’s or our father’s metabolic constitution. This can be very useful in identifying our own potential metabolic predisposition and compounding conditions.
  • Nutrition and lifestyle changes (i.e., giving time and attention to our own bodies), NOT more money or resources are our biggest challenges in moving towards hormonal balance…and the practice to bring in self-compassion each step of the way.

The edited interview below will dive into these in greater detail. Please find Dr. Angela’s online resource page here. If questions or comments for myself or Dr. Angela, please send me an email at info@leahkwalsh.com. I will make sure the ones for Dr. Angela get to her. Ready? Let’s dive in!


Leah Walsh (LW): Polycystic Ovarian Syndrome (PCOS) affects close to 10% of all women yet is often described as a silent condition with very little public awareness about what it is and how it impacts women. Given this, why did you choose to speak on PCOS and nutritional interventions at NUNM’s upcoming Food as Medicine Symposium?

Dr. Angela Cortal (AC): Well, PCOS is rarely recognized as being as multifaceted or complex as other female sex hormone dysregulations.

LW: Why?

AC: It [PCOS] is easy to suppress with medication and it is not as easy to suppress some of the other female sex hormone dysregulations so they have to be treated more comprehensively.

LW: What would be an example of another hormonal-based diagnosis that is treated with a more integrative lens unlike the typical perspective of PCOS?

AC: Perimenopausal or menopausal conditions. Most practitioners won’t just think that this is just an estrogen condition. They will look at it more broadly. Hypothyroidism would be another condition where a physician, whether it Naturopathic physician or integrative or functional medicine will look at it more broadly. But with PCOS there are like, here is your birth control. Have a nice day. That fixes…uh, well…

LW: (Dr. Angela pauses and I laugh.) I’m wondering, what are you going to say?

AC: Well, in a lot of conventional medicine, if people aren’t complaining to their doctor anymore then the problem is solved. I have a strong endocrine practice but I have a strong pain management- not opioid- but integrative pain management and I talk about that with patients. Saying, “Yeah, you were given that medicine because then you stopped complaining to that doctor about the pain” but now there are all these other issues that are coming up….just like birth control.

LW: Would you be willing to share, what are your lenses for the identifying if a woman might have PCOS?

AC: I know if they are under that umbrella and this will be a piece that may or may not be agreed upon by everyone at the presentation. There are our clinical diagnostic criteria for these specific things and there is everything that is within that same complex. I have just as many patients that meet the clinical criteria of it and can be given that label– whether we want to do that are not– and then there are those who still have multiple or maybe even all of the same endocrine imbalances but they don’t quite meet the clinical criteria but I treat that the same. It is the same dysregulation, it is just often not “bad enough” to be given the label. So, I am going to talk about my perspective on that. The benchmarks for meeting the clinical criteria don’t really do the patients any good.

LW: Yeah. We’ll wait until you get this bad. So you use your intuition and your experience to say, “you are under the umbrella.”

AC: Yes. I hear patterns. And a lot of my patients are not called anything, but if I were to make up a name, I would call it Pre-PCOS. And just like diabetes, I am going to treat someone and not just let them go down the path until you are diabetic and then do something. I am intervening now. Same with Pre-PCOS. I am intervening now.

Labs I do a lot. Ultrasounds I do some, but a lot of my patients elect not to have it and I don’t have any biased opinion about that. It is just a piece of information and that is –depending on the specific organization and their diagnostic criteria- it may or may not even be part of that anyways. So I tell them, if you want to know anatomically, that can give us some information, but if it is negative you are still under the PCOS umbrella. So that may be of interest for someone looking in the near future more toward wanting to assess for fertility but I would say a decent amount of my patients aren’t so…I don’t really care. It is just on the table if they would like it at any point.

LW: Would you say labs then, in addition to how you see someone present, would be your main diagnostic tools?

AC: Um-hum. Yes. Labs can give us that objective data specifically like a benchmark for improvement, but I am not treating someone to improve their labs. And sometimes I see some pretty significant causes there and sometimes the labs don’t quite show the severity of someone’s condition.

LW: With those things set aside- ultrasound, labs– what are the main ways that you gauge whether someone is under the umbrella or not?

AC: What they say. That is it. (Light laugh) The labs are confirming.

LW: I love that. It seems so counter western medicine.

AC: And I would say in your conventional medical realm, labs aren’t run very often unless the woman has a very irregular cycle and is unsuccessful trying to get pregnant and they’ll finally break down and check some estrogen, progesterone, FSH, LH…that is probably about it. Maybe that picture plus a lot of pain– menstrual pain– and then they might do an ultrasound but…

LW: It is all crisis-driven it sounds like.

AC: Yeah. That is kind of par for the course.

LW: Yeah. I’ve gotten used to that by now. At least as a patient in those spaces. Based on a patient’s testimony, where do you normally guide first? Do you start with nutrition? Do you start with herbal supplements? Do you start with lifestyle? Does it totally depend on what that testimony said?

AC: Always nutrition. And then the level of what is going on severity wise and specifically– if I am getting a sense of specific estrogen/progesterone as the top dysregulated hormones, etc. Insulin is nearly always a piece of that so that is where I will start with the nutrition. For some women, there is also hypothyroidism or high testosterone or cortisol. Those are some other hormones that I want to get a sense of if we are going to prioritize what is going on and what needs to be corrected to make the biggest impact in the most dysregulated pieces so I can be the most efficient.

And then I talk about all options with patients, whether that is botanicals or specific nutrients, minerals, amino acids. I talk about if there are any bioidentical hormone medications or interventions and compare so if someone is considering doing a medication or a comparable nutraceutical product then I can tell them what they might plan to expect from each.

LW: So the education sounds like it is a big piece.

AC: Yes. So they can have informed consent as to the treatment plan. And I am not putting all women on medications or hormones or anything like that, but sometimes certain medication can be more efficient in helping correct an imbalance, specifically in the short-term, whereas someone might not stick with something that takes 6-9 months to see an appreciable impact. I am thinking about excessive hair growth and that can be a hard one if it really is about her quality of life and being out in the world. That is where I will sometimes use a medication.

But I have never put any of my PCOS patients on birth control. I can say that much. So I tell patients, “I don’t really have a soapbox about being anti-pharmaceutical but I am pro- smart use of medications,” and there is a lot of not-smart use of medications going on out there.

LW: Bless you. And the educational piece. Telling why, options, and from what I hear you saying, you’re going to recommend something that will match the practicality of a patient’s lifestyle choices and what she’s wanting her outcome to be, and after certain phases being able to look at other long-term options.

AC: Yes. Say, for a woman who is seeing a lot of weight gain, I’ll strategize the elements of the treatment plan slightly different than a woman who has excess hair growth versus a woman with irregular periods and just having a lot of problems and symptoms around the periods. Then my few dozen treatment plan options or the things that I will go to with PCOS umbrella patients will get shuffled up and down in order of what I might use.

LW: You talk about being able to see patterns. I am curious, is there a personality or an energetic feeling or a lifestyle feeling to the types of lives or the core emotional components of women that fall under this umbrella?

AC: The easiest correlation is from Homeopathy and they have different constitutions which are like our base for how we respond to the world and where that drive comes from. Each constitution will be a match for each remedy. I’m not a homeopath by any means but I know some about it. They’ll often listen to patterns, symptoms, and someone’s whole story and put all of that together to match it to a constitutional remedy. There is a remedy called Sepia that that is the closest match that I hear energetically.

LW: Can we transition to talking about food? I am curious, what are your main recommendations for someone that is chilling under this PCOS umbrella?

AC: From the outset, I think of assessing what a someone’s general food sources are and then what their macronutrient intake looks like because if someone meets the PCOS criteria they are going to have insulin resistance. I talk about that a lot from the outset. [Insulin resistance] is not a concept that is known generally. It is not a phrase the vast majority of my patients have ever heard about.

LW: Really? That is surprising to me…good to know.

AC: Yes, I do that to convince them that this is not a disease of your ovaries. (Light laughter) It is a response of your ovaries. That is what we can see not where it starts. That is probably the biggest level around nutritional counseling because our food supply and everything else is hyper-palatable and hyper-processed carbs. This is the biggest challenge I have with any of these patients working with insulin resistance.

LW: So, because humans typically do not to feel the urge or the urgency to engage change until their symptoms are getting into the red zone, does it make it a weird time to work in the field of prevention?

AC: I have multiple conversations that happen each year with patients unpacking how preventative medicine isn’t preventative medicine. Preventative medicine to them (insurance companies) is an annual exam and a couple of labs a year. Our medical model is insurance based and is medical necessity based and apparently means you have to have a medical necessity. You have to be sick. You have to be sick with a diagnosis to have anything to be covered and anything to be treated. So it is not preventative medicine.

LW: Right. I agree with you, which is interesting because the belief is we are moving toward “preventative medicine” and this is still a very close zone to being in the crisis-disaster mode. A crisis derived from the Western medical mindset not being able to see an integrated body, mind, and spirit.

AC: And that the PCOS patient population is not unique in that things have to be bad enough to really prompt someone to take seriously what I am saying and really make those changes. I’ll tell them, “I know I am asking a lot.”

A piece of my upcoming talk is going to be about behavior modification changes around dietary changes because there is a whole psychology around it. I do not have a disordered eating pattern type of psychological background. I don’t have anything like that. But if we’re talking about changing dietary patterns, I want to explore the roadblocks and where do they come from and how can I address those.

LW: Okay, this might be a really hard question. Maybe there is no answer…or maybe there is. What is the origin of PCOS with it being made up of so many layers?

AC: I would say it is a hereditary predisposition towards insulin resistance and that set sets off hypersecretion of insulin and that causes the ovaries to create more testosterone that inhibits your progesterone. So now you have immoderate estrogen, low progesterone, too much testosterone, and way too much insulin. That is the minimum of my endocrine PCOS umbrella. And then from there, it is just plus or minus cortisol or thyroid issues.

LW: Which is why your talk is going to be on nutritional intervention.

AC: Yes.

LW: For the genetic piece with the predisposition to hyperinsulinemia, is that always tracked through the female lineage?

AC: It could be either. And I’ve never seen any hard science to back this up but I am definitely not the only practitioner who I have heard to spontaneously verbalize this. People will metabolically have a similarity to either their father’s side or their mother’s side. It is not like they are a 50/50 mix. Especially, we hear in patients’ testimonies “Yeah, just like my mom…”. Metabolically there is something about people being more like one side more than the other and not that I take that as hard data but definitely as a potential piece of information and listen with a little more care to that side of the family history.

You know, I don’t get referrals specifically from any conventionally trained doctors. The best service I can do is pick up where they left off. A patient may be sick of a medication or they want other options.

That is where I go. In visit #1. We go upstream. I work with the patient to discover what is really going on.



Dr. Angela Cortal is a naturopathic physician who focuses on endocrine health and using Regenerative Injection Therapy (Prolotherapy and Platelet-Rich Plasma Injections) for chronic joint pain and sports medicine injuries. She practices in Portland at Heart Spring Health and Salem, Oregon at Natural Physicians. Her professional memberships include the OANP and the American Osteopathic Association of Prolotherapy Regenerative Medicine. You can find out more details about her practice at www.rosecityhealth.com.