In acknowledgement of PCOS Awareness Month, Dr Gretchen Kubacky speaks to the mental health impacts of PCOS. Dr Gretchen is a health psychologist in private practice in Southern California and author of The PCOS Mood Cure and Moving Through Grief. She is a Certified PCOS Educator, a frequent lecturer on women’s health, and the founder of the popular website, PCOSwellness.com. She is dedicated to education, advocacy, and empowerment for women and girls with PCOS.
Georgie Kovacs 02:03
So tell us your background and what brought you into specializing in mental health and PCOS.
Gretchen Kubacky 02:12
I grew up reading Psychology Today, my mother was a psychology major. And I read everything in the house. And I was always intrigued by it wasn't until I was in my mid 30s though, that I came to realize the lasting effects of suicide in my family. And then at that point, I was also dealing with some health concerns. And I realized that PCOS was a really big deal. It was not the minimal sort of thing that had been described to me by my doctor when I was 20, or whatever. And so I went back to grad school and got a doctorate in psychology and over time evolved from treating infertility and PCOS, specifically, because it's the underlying cause.
Georgie Kovacs 02:56
What I'm excited to talk to you today about is the mental health aspects of PCOS. Because so much of what I've read and seen online is the solution being around diet. Now people do talk about the mental health repercussions of PCOS. But from the solution oriented perspective, it seems very much related to food and taking certain medications. So I'm really excited to have you share this other perspective. So I guess tell us about the mental health repercussions of PCOS. And is it the chicken or the egg, right? Is it the PCOS that causes mental health concerns? Is it mental health concerns and exacerbates it? Or how does all that work?
Just because you have PCOS, doesn't mean you don't have other disorders.
Gretchen Kubacky 03:41
PCOS is the cause of many mental health concerns, or one of the underlying causes. There are many causes. Mental health issues can be caused by a history of trauma, they can be caused by some genetic issues. So for example, bipolar disorder, or schizophrenia have heavy heavily loaded genetic components to them. It's been inaccurately attributed to PCOS that there's depression because women are fat and can't get pregnant. And so that's an inherently misogynistic statement. But more importantly, it's not really accurate. The hormonal imbalance in PCOS is what contributes heavily to increased rates of depression, anxiety, obsessive compulsive disorder, bipolar disorder, and suicide, as well as eating disorders and sleep disorders. So it's really the gamut of mental health issues that can be associated with PCOS or exacerbated by PCOS.
Georgie Kovacs 04:40
Would you say if someone gets their hormone levels under control - and it's really mostly due to PCOS - that their mental health concerns are gone? Minimized?
Gretchen Kubacky 05:10
They're not gone, but they can be. They can recover from depression. So once you have depression, for example, it's not necessarily a lifetime sentence. You can go into remission from it.
Same thing with anxiety. You can go through periods of greater or lesser anxiety, you can be in recovery from an eating disorder. But those are always vulnerabilities.
So if you have had a history of it with depression, for example, once you've had a single episode of major depressive disorder, you have a 50% likelihood of a second episode, two episodes 70% likelihood of a third episode, or episodes 90% likelihood of a fourth episode. So it's something really to keep in mind, healing your body from PCOS, you also don't get rid of the PCOS it is something that can be so dramatically in remission, that tests don't show that you have any indicators of it. And that will almost always improve the mental health symptoms.
The problem, though, is that mental health issues have a lot of different factors. So for example, right now, we are going through a period of tremendous stress in terms of the employment situation, recession, fears around illness, all of that kind of thing. Many, many more people than typically would be depressed are depressed right now. Many more people are anxious. Many people are quarantined at home, and developing eating disorder behavior, or sleep disorders and dysregulation. So all of those things play in everything is multifactorial, and I think the idea that fixing it, you know, getting your hormones in line with pills is also inaccurate.
Even for mental health disorders, antidepressants are maybe 50% effective. Talk therapy is equally, if not more, effective. Sometimes you have severe symptoms, you absolutely need medication to support your well being. But that is never my first line of defense with a mental health disorder.
Georgie Kovacs 06:57
And I know that when we had our introductory call, we definitely hit it off and had so much alignment around the quick fixes. And I think one of the two quotes you said is, There isn't too fast a fix, it simply leads to longer term problems.” And to your point about wanting to have a pill, I often see people saying, “Tell me the diet that worked for you.” And it's, it's so complicated. And again, people talk about the mental health aspects. But you know, it's not always brought up from a solution. So maybe we could jump to how you help these women and the role they play. Because PCOS is so multifactorial, you kind of need a team of different experts.
Gretchen Kubacky 07:44
You definitely need a team, my recommendation is always that you have a primary care provider or general practitioner internist, sometimes a pediatrician, who is kind of the ringleader who's educated, you've got an endocrinologist and a gynecologist, probably a dermatologist, definitely a psychologist or other kind of therapist, then you may also need a reproductive endocrinologist and other doctors along the way.
Keeping in mind also that just because you have PCOS, doesn't mean you don't have other disorders. So it's something where you can focus exclusively on the PCOS, and that will probably improve most inflammatory conditions in the body. But to focus only on the PCOS is not enough.
I just want to back up for a minute, because you said people are really looking for the one pill solution, birth control pills have long been prescribed as the treatment for PCOS. What we have discovered now is, first of all, from a mental health perspective, imbalances and progesterone can often produce a suicidal level of depression in some women. And so one of the treatments is progesterone alone.
For the birth control pills, which are mixed, there's now an attribution of PCOS being caused by the birth control pill. I don't know how much I believe that one. I haven't seen enough science to support that. But the idea that, in fact, it's masking symptoms and not fixing anything, I think is important. So I am not opposed to birth control pills as a treatment method for many women for other reasons that are incredibly necessary. But it is something where there are many possibilities about how you treat.
In terms of what I expect from clients that I'm treating, I expect them to get really informed about the condition. I always say knowledge is power. And I also expect them to be proactive. They cannot just show up in my office, or lately on a Zoom, and expect me to fix them because I've imparted all the wisdom or you know, told them one easy thing to do.
It's always going to come back to a lot of self care.
Reducing dietary elements that are problematic for you
Doing exercise that's vigorous and to be helpful, but not so vigorous as to be an extra stress on the body
Adding in meditation
Doing other stress reduction - things like journaling, continuing with therapy, obviously.
So all of those things, and sometimes I do talk about supplements as a mental health issue, because I think they are relevant. There are a lot of nutritional deficiencies and people with PCOS.
And there are definitely some specific supplements that are helpful for mental health conditions in general, and also specific to PCOS. So we are almost always magnesium deficient. And magnesium and zinc are big players in mental health, we also tend to have a much higher level of IBS, irritable bowel syndrome, or other related stomach and digestive problems. So that inhibits getting all of the nutrients out of your foods. So you could actually be fat and be malnourished, you could be eating enough or eating too much. And to be malnourished, if you've got problems with absorption, all of that is relevant to the brain because the gut brain link is now strongly established about 85% or so of our serotonin, which is one of the feel good hormones or neurotransmitters is produced in our guts, not in our brains or some other part of our bodies. And so if you've got gut dysfunction, you're highly likely to have brain dysfunction.
If you're not getting enough protein, proteins are the building blocks of the neurotransmitters. So when you go on an extreme diet to try to regulate weight, you're probably missing out on a lot of good nutritional stuff. And a lot of protein potentially, also matters more as you age to get that adequate protein source.
Georgie Kovacs 11:50
One thing that I have to just acknowledge is when you were talking about the things that women need to do in the state of COVID, and all the varying dynamics that people feel from being overwhelmed with trying to do many jobs plus children to being bored to missing families. I mean, you name it, everyone's stressed for a different reason, let's just call it that. But what I loved is that when the list you gave about things someone can do and the action that you require of your clients to be successful. I love that you called it self care because it is so true. I think about the 10 years that I spent starting out with my fertility journey, and then just learning so much about health. And once you figure it out and make it like an experiment, it really is self care. Yeah, it's just a really neat journey. I'm sure you would agree that everyone's gonna have a different thing that works for them, like some will need the journaling, I don’t want people to hear, “Oh, my God, all these things I need to do!”
Gretchen Kubacky 13:02
Right. Those are the things all of us should be doing all of the time. But differences with PCOS bodies that have PCOS do not handle stress as well. And so a lot of times we're in a constant state of reactivity and intermittent elevated cortisol, a lot of people talk about cortisol as if it's the be all and end all, almost no one actually has clinically significant elevated cortisol. But we do have elevated cortisol because it is associated with fear, panic, anxiety, which we're all experiencing a lot of lately, and the stress hormones that are unremitting, you know, they were designed to be something that flared when you needed to escape danger and receded when you're out of danger.
The problem with our modern life is that we always have some sense of heightened danger. We are out of sync with our natural rhythms in terms of things like sunlight, and getting to bed and on time, it's become a badge of honor. “I get by on five hours of sleep at night.” No, you don't. Trust me.
And those things, you know, I might assign homework to someone to sleep an extra 15 out of 15 minutes per night, until I see you next week. Those are the sorts of things where it's not a big ask, right? You should probably want to sleep more. There are many other problems, of course, associated with why people are not sleeping, but if you're not sleeping, you are going to exacerbate or potentially cause depression or anxiety. You're also going to aggravate any overeating that's due to hormonal irregularity or imbalance or fatigue.
In general, when you're tired, you make poor choices. Bottom line, and so all of these things that we should all be doing are things like yoga, walking around outside during the day like getting enough sleep, turning off our devices by a couple of hours before bedtime - those are the things that really make a difference for everyone, but especially for PCOS.
Georgie Kovacs 15:05
I'd love to get your thoughts on blue light glasses because I just bought a pair because I'm on a mission to make sure that I get some sleep. And so my routine and I'm sorry for everyone who's listening to the multiple podcasts, I'm gonna keep saying this, but I love the song from Marconi Union. It's called Weightless. And apparently, it's scientifically the most relaxing song. So I listened to that before bed. And when I remember, because some nights I am going to bed at midnight. So I'm sorry, I'm being naughty, but I'm really excited about them. So that's just what happens. But um, I added the blue light glasses, because I am working late. So tell us about them, please.
Gretchen Kubacky 15:37
Sure. So the deal with the blue light is that it is an awake light. It tells your body and your brain to be awake. And what happens then is melatonin gets suppressed, and your body doesn't have a cue that it's time to go to bed. So what's supposed to happen when things are functioning properly. In the morning, you get exposed to sunlight, vitamin D levels rise. Melatonin is suppressed, then as you go through the day, a couple hours before bedtime, your melatonin levels go up your vitamin D levels go down. And then your body knows, “Oh, it's time to go to sleep at say 10pm.
Ten to six is considered probably an optimized sleep schedule. I don't adhere to that one either. But I do try to do 11 to seven or 730. So that I'm really getting that solid seven and a half, eight hours of sleep. So the blue light glasses are definitely helpful. There are also blue light screens that you can get. And there are on Macs, I know there's a nighttime sort of feature that cuts out some of that light as well. I know iPhones also have settings you can do so that it reduces the background lighting, which again kind of contributes to your brain knowing that it's heading towards bedtime. So I recommend using those settings if you have them. And if not the blue light glasses, the blockers, some of them. Or the ones I have are amber. Or getting a screen. If you're on the screen a lot and the glasses are uncomfortable.
Georgie Kovacs 17:10
Thank you for explaining that. Because I wondered, “Are these really working? I'm not 100% sure, but it seems like it cuz some people post on, you know, social media. And they're like, I got my first perfect night's sleep. But there's so many factors.
Gretchen Kubacky 17:24
Sleep is so complicated, literally it is actually in my book, The PCOS Mood Cure, I have two chapters on sleep, because there's so much about sleep. And sleep is fundamental to everything. If there would be one prescription for everyone to get enough sleep. If you're not getting enough, do something to fix it. If your sleep is not quality, sleep, not refreshing and restorative, you've got to work on fixing that. And I can literally spend off 100 recommendations on how to do that. So it is really important, and it is fixable. But you it may take some work.
For some people, it's easy. It's like you stop drinking coffee after 3pm and turn off your device at 10pm. Great you sleep for other people that have really deeply entrenched patterns of poor sleep habits or other things contributing. And it could be anything from medication to supplements that are incorrectly timed. What you're drinking, what you're eating, what the temperature of your room is, how comfortable is your bed, a million things. But if you're having problems, definitely try and do a lot to calm down before bed, do a little yoga for sleep, a little meditation for sleep, something like that.
Georgie Kovacs 18:36
And I saw that on YouTube, you can get yoga routines specifically to aid in sleep. And they're different lengths. It's because the first ones that I was looking at, they're like 20 minutes and like, I'm tired. The last thing I want to do is feel like I'm adding 20 minutes to my going to bed time. So I found the seven minute ones. And that was that was my cup of tea.
Gretchen Kubacky 18:55
That's an important point. I'm a really big fan of brief interventions, because the reality is, there was a study that came out a few years ago that indicated that caring for diabetes takes about two and a half hours a day on average, if you are doing it the right way. So that's counting meal prep food shopping, actual eating of healthy items, testing blood sugars, doing the exercise, factoring in, you know, a 10th of a doctor's appointment. Whatever it is, who's got two and a half hours a day? Yeah, probably in and of itself explains why we have such a problem with diabetes management, which by the way, is a huge component of PCOS.
Most women with PCOS will either be pre-diabetic or go on to develop early onset type two diabetes before the age of 40. And that is something we're also trying to prevent. Poor sleep will contribute to speeding up that process.
It also is something that if you have diabetes, it's another factor in depression, right? So you can start to see how these things all make them also very common. For PCOS patients to be hypothyroid 40% of women over 40 in general are hypothyroid. If you're hypothyroid, it looks like depression. If you're high, or hyper thyroid, it looks like anxiety. All these things mixed up are all problems. So it's like standing on a wobble board and just always trying to get your balance. It does take real focus and consistency. But brief interventions are great.
I tell people who say, “I can't meditate, I can't meditate, I can sit still for 30 seconds.” Alright, fine. There are 30 second meditation recordings out there, find them and do them. I'll usually take them through about a seven to 10 minute meditation in my office and ask them how that was at the end of it and say, “Wow, I feel so relaxed.” I'll say, “You know, that was 10 minutes.” What? And then it's learning. Oh, I actually can sit still for 10 minutes. That was relaxing. I enjoyed it. I feel better. So some of these things. We have a lot of resistance to mentally and it just sounds overwhelming. You think you need all these special tools and trainings and a special cushion and music and incense? No, you can meditate sitting in your car parked on the side while you're waiting for carpool pickup.
Georgie Kovacs 21:23
I will make Brene Brown proud of me for talking about vulnerability. Today's been a stressful day and my brain is racing. It probably didn't help that I was up till midnight. Honestly, no matter what time I go to bed. My son, no matter what time I go to bed, at 6 am he wakes up, it is the weirdest thing. I don't even need an alarm.
Gretchen Kubacky 21:44
Georgie Kovacs 21:46
It is a recent thing. And it's really annoying. But anyways, to your point….
Gretchen Kubacky 21:52
But you work with that right? You need to back it out. Like you've got that getting to sleep by 10. In order to get adequate sleep if you always wake up and say tonight it is 10 o'clock.
Georgie Kovacs 22:01
Okay, because I was stressed, which obviously I'm stressed because I'm not sleeping. And I lay down for seven minutes in the middle of the work day and put on my Marconi Union song and you are right, you don't need an hour.
I know a lot of celebrities are talking about transcendental meditation 20 minutes twice a day. Not happening for me. But in that seven minutes, I literally felt my body just calm down. It was just amazing.
Gretchen Kubacky 22:30
It is amazing the little bits, even five minutes of going outside, walking around the block or sitting on your balcony with a cup of tea makes a huge, huge difference. So it does not have to be that fully ritualized two and a half hours a day. I mean, in an ideal world true would be.
But even with TM (transcendental meditation), I was trained to that about 45 years ago. And people are only talking about it all over the place like now because now there are studies to back up what we've always known about meditation, they have validated it to the extent that they're using it at the VA, for example, with veterans who have Post Traumatic Stress Disorder from combat. And so when we're seeing that kind of success with something really extreme, why wouldn't you have success when you have milder issues than that. And I don't have 40 minutes a day to do meditation either actually meditate for about 27 and a half minutes a day. But when I don't have a lot of time, and I want to just log some in, I'll do a 10 minute meditation, which for me is short. Also take the TM and say, You know what, I've got my mantra, and I'm going to do it for five minutes. Still beneficial.
Georgie Kovacs 23:44
Is the mantra different every time or do you like a mantra and try to stick with it?
Gretchen Kubacky 23:50
Mantras are interesting in transcendental meditation. You are assigned a secret mantra, and it's your age and some other factors, I don't know. My brother was younger than I was when I was trained. And he got a walking mantra because he was hyperactive.
But when you're choosing a mantra for yourself, you can choose anything. What I would choose is something that feels like it's orienting you in the right direction. So you might meditate on peace or freedom or love or calm, doing breath exercises, it might be “breathe out stress, breathe in calm,” or “breathe out anxiety, breathe in peace.” So you can pick words that resonate for you that you pick words that resonate for you. And if you're stuck on them, do a search and you'll find a million recommendations for a mantra.
Georgie Kovacs 24:42