I am so excited to have Melissa Groves Azzaro here talking about hormones, fertility, PCOS, and diet. We’re going to talk about a lot of things that people ask me about every day.
Melissa is an award-winning registered dietitian and nutritionist, her second career after leaving the stress and long hours of advertising. Now, she works with clients to figure out the root cause of their symptoms and create a personalized plan for them that goes far beyond diet so they can finally feel better and balance their hormones.
Melisa also hosts the Hormonally Yours Podcast where she talks about science-based information about PCOS, fertility, and other hormone imbalances, and is the author of the book A Balanced Approach to PCOS.
She’s been featured in places like Healthline, Shape, PopSugar, and VeryWell, and now she’s here to talk with us about balancing hormones, improving PCOS symptoms, and increasing your fertility through a balanced approach to what you eat.
I learned so much from Melissa, and I know you will too. Enjoy this incredibly informative and enlightening conversation!
Dr. Aimee: Welcome, Melissa.
Melissa Groves Azzaro: Thank you so much for having me. I’m excited to chat with you.
Dr. Aimee: I’m super curious. Advertising to nutrition, can you talk to us about that transition?
Melissa: I would say advertising is pretty much exactly like it’s depicted in the media. It’s really long hours, lots of travel, lots of drinks and takeout. I think working in that environment for so long, I really understand what it means to be busy and struggling to take care of your health while you don’t have a lot of control over your work hours or even what you’re eating sometimes, so I definitely bring that to my work with clients.
The bottom line is I was getting burnt out in that field and it was starting to affect my own physical and mental health. I started to think about “what could I possibly do to get out of advertising,” and nutrition was something I was always interested in for years and years. I had tons of books. I thought, “I wonder what it would look like to go back to school,” so that’s what I ended up doing. I went back to school and became an RD (registered dietician) at 40.
Dr. Aimee: That just shows that if you have passion for something, it’s so important for you to pursue that. You now have a new career and you’re helping so many people out there.
You basically described a very stressful lifestyle. I bet it was super fun in the beginning and then took its toll in the end. What does lifestyle have to do with hormones?
Melissa: Lifestyle plays a really important part. I think people are surprised when they are talking to a registered dietitian and they’re expecting us to give them a diet, but we have to consider the whole person. Unfortunately, you could be eating the most balanced diet in the world, getting every nutrient, but if you’re not sleeping, if you’re stressed to the max, if you’re over-exercising or not moving your body at all, you’re not going to have balanced hormones. It’s really complicated. Hormones are affected by much more than just diet.
Dr. Aimee: There must be so many myths that you bust every single day, just like me, literally. No, just because you got pregnant once doesn’t mean you’ll get pregnant easily again. That’s one of the most common myths that I bust. What are some fertility and hormone myths that you bust all the time?
Melissa: I think probably the most common is around PCOS. I’ve actually had many of my PCOS clients tell me that when they were first diagnosed with PCOS their doctor told them, “You can’t get pregnant with PCOS.” I think that’s really an oversimplification because PCOS isn’t really a situation of infertility. It’s more a situation of subfertility. Once we get you ovulating, it’s entirely possible to get pregnant. We can improve chances of ovulation with nutrition and lifestyle factors, or in your line of work with ovulation inducing medications, or a combination of the two, depending on what someone’s timeline looks like.
Another myth, and I feel like I might get a little hate for this, is when people tell people who are trying to get pregnant, “Just relax and it will happen.” Again, that’s a massive oversimplification to say that stress is the only reason why you’re not getting pregnant and that somehow it’s your fault. The bottom line is that hypothalamic pituitary adrenal access does impact our sex hormones and other factors that can improve the odds of successful conception, implantation, and pregnancy. Stress does negatively impact progesterone production and thyroid hormone production, both of which are extremely important in early pregnancy.
I would say those are two of the myths I see the most often.
Dr. Aimee: You’re not going to get any hate from me. Honestly, if you are so stressed out, you’re not going to want to have sex if you’re in a heterosexual relationship. If you have a male partner that is stressed out, his testosterone level is going to be low, his sperm isn’t going to be as strong as it could possibly be. No hate from me at all.
You talk to a lot of patients with PCOS all the time. Do you have a really simple explanation as to what PCOS really is? I’m just curious. What would you say to someone, quick short explanation, what is PCOS?
Melissa: It’s hard. There is no one-size-fits-all diet or one-size-fits-all lifestyle, or supplement, or medication plan even that works for PCOS because it’s a syndrome. It’s a collection of symptoms. I talk about it from a root cause perspective.
We’re looking at insulin resistance, which comes into play in the vast majority of people with PCOS. We’re looking at inflammation. We’re looking at gut imbalances and hormone imbalances. Then you dig down even deeper into the hormone imbalances. Which androgen is high, do you have high testosterone or do you have high DHEA? It’s going to be an entirely different approach depending on which root cause is affecting you. Then we have to talk about lifestyle stuff, like exercise, movement, sleep, stress, and environmental exposures that are contributing to the condition.
No two people are going to present exactly the same way with PCOS. That’s why we really have to take that individualized approach to figure out which of these factors is most important for you to be working on and what we need to focus on first.
Dr. Aimee: That makes sense. You talk about in your book A Balanced Approach to PCOS that knowing what your hormone levels are is important because that plays a role. How do you check hormones, do you work with a doctor, do you check them yourself? Can you talk to us about your work?
Melissa: Both. I use whatever the patient has already. Most of them have had the diagnostic testing. That’s one thing outside of the scope of a registered dietitian: to diagnose. They have to be diagnosed with the condition, so they’ve mostly had that testing.
They’ve had their androgens checked, they’ve had their estradiol checked. Sometimes if they’re going the fertility route, they may have had FSH, LH, AMH checked. I like to see that the other conditions that can also cause similar symptoms to PCOS have been ruled out, so I like to see they’ve had a prolactin test, they’ve had thorough adrenal testing, maybe deeper pituitary testing if there is something off with that, they’ve had thyroid testing because low thyroid levels can also cause irregular cycles and lack of ovulation. So, I do like to see those diagnostic tests.
I’m often running tests in addition to what they’ve already done to get to those hormonal roots. A lot of them have not had testing for those root causes that I mentioned. Most people that I work with have not been tested for insulin resistance, they’ve not been tested to see what their inflammation level is, they’ve not had other hormones looked at, like adrenal and thyroid hormones. Maybe some deeper gut testing if they’re having gut symptoms that may be contributing to that systemic inflammation and the PCOS symptoms.
So, it’s really a combination. We use what they have and then add on top of that.
Dr. Aimee: Is that important for you to have before you start making diet recommendations, or do you start with the diet recommendations from the very beginning?
Melissa: I feel very comfortable making diet recommendations without having the lab work because some of the things that we talk about when it comes to PCOS are so foundational. I always joke we’re going to assume that you’re insulin resistant until proven otherwise. That being said, following a blood sugar balancing diet is not harmful to anyone, whether you have PCOS or not. Following a diet that is anti-inflammatory, including more fruits, vegetables, and omega-3s, those kinds of things are not harmful if you don’t have PCOS.
Where the testing helps inform decisions is more around supplementation. I would never ever recommend a supplement that can actually impact a hormone without having test results in front of me first.
I see a lot of harm out there. I’m sure you see it, too: people taking supplements that they think are beneficial for fertility, but it’s actually the wrong thing for them, or it’s causing them new or different symptoms.
Dr. Aimee: You just mentioned something that now has piqued my curiosity, blood sugar balancing diet. What is something that someone could do today that is listening to this to start following a blood sugar balancing diet?
Melissa: PFF is a simple acronym, protein, fat, and fiber. When we’re thinking about what a blood sugar balancing diet is and we’re consuming social media and doing Google searches, it always comes up to eat a low carb diet. You don’t have to go so low. All of the studies that show benefits with a low carb diet on PCOS and prediabetes and diabetes, low carb is actually defined as 40% of daily calories. It’s definitely lower than the standard American diet, but I consider it much more of a moderate carb approach.
What matters much more to me than the type of carbs that you’re consuming is that you’re pairing them with protein, fat, and fiber. That’s the PFF. I find most people are doing great with protein at dinner. If you were to eat that same amount of protein that you eat with dinner for all three meals of the day, even breakfast, you would be in such a better situation. That high protein breakfast really sets the tone for your blood sugar balance for the whole day.
Fats, we want to make sure that we’re getting enough. We need fats to make hormones. We need fats to support fertility. Fat doesn’t at all impact blood sugar or insulin, so fat is your best friend when you have PCOS or any sort of blood sugar imbalance.
Then fiber, which comes from fruits, veggies, legumes, and whole grains.
Dr. Aimee: I’m sure you get this question a lot. Should I do intermittent fasting if I have PCOS? What do you think?
Melissa: I don’t recommend it for anyone of reproductive age. The reason for that is because women’s hormones are so sensitive to scarcity.
Based on the research that we do have in terms of time restricted eating, it’s actually the opposite of what most people are doing. It’s more beneficial to eat a big breakfast, normal lunch, and then a small dinner. I like to talk about starting eating when the sun comes up, and stopping eating when the sun goes down. Really, no more than around 12 hours for someone who is in that reproductive age category.
I think possibly once we’re past those reproductive years, but I still would want to see that you’re not over-stressed, that your thyroid is functioning well, that you’re sleeping adequately, because it does add stress to the body. I think the majority of the research done on intermittent fasting, unfortunately, has been done in men and postmenopausal women, so really we only pretty much have animal studies to go on when it comes to reproductive age women and those are not good.
Dr. Aimee: What about the keto diet? It was a huge fad not that long ago. I don’t hear patients coming in talking about it as much or asking me about it, but I do see the occasional patient. What about the keto diet as it relates to PCOS?
Melissa: As it relates to PCOS, same thing, we don’t want to stress the adrenals by going too low because the adrenal component is such a strong piece for many people who do have PCOS.
I do know for a fact there are still fertility clinics that are recommending a keto diet for fertility. From a dietitian standpoint, it really worries me because during early pregnancy what the baby actually needs isn’t calories at that point. During the first trimester, the baby needs adequate micronutrients to develop. It’s so difficult to get all of those vitamins and minerals that the baby needs during that first trimester if you’re limiting fruits and vegetables.
I hear people say, “I eat fruits and vegetables on keto,” but it’s the same three or four fruits and vegetables every day. They’re eating lettuce, they’re eating cucumbers, and maybe a few berries here and there. We want the widest variety of antioxidants and nutrients that we can possibly get. It’s really hard to achieve that balance and achieve that adequate nutrition on a keto diet. Again, not really recommending it during the reproductive years for women.
Dr. Aimee: What kind of strategies do you recommend to women with PCOS to improve their symptoms?
Melissa: We start with the basics. The foundation is balancing that blood sugar. The reason we do that is high insulin tells the ovaries to make more testosterone. Testosterone is what is going to result in those symptoms that most women are annoyed with, things like losing their hair, acne, excess facial and body hair, and the weight gain around the middle area. That’s all coming from those androgens. The insulin is indirectly telling the ovaries to make more testosterone.
It’s also telling your liver to make less sex hormone binding globulin, which I always explain as “it does exactly what it sounds like it does.” It gloms onto your sex hormones so they can’t roam around free where they can cause symptoms.
So, we start with balancing blood sugar. We layer on an anti-inflammatory diet. By that, I don’t mean cutting out foods or food groups. We’re working on increasing those antioxidants and increasing omega-3 fatty acids. We are minimizing the things that we all know are not great for our health, things like fried foods, too much added sugars, things like that. We work on supporting gut health with even more of a focus if they already do have gut symptoms. We know IBS and IBD occur more commonly in PCOS.
There are some foods we can add that can help with hormone levels, but we need to know what’s going on with hormone levels for that. Things like ground flax seed can help our androgens and our estrogens go down better pathways. We know spearmint tea can help lower testosterone. So, there are some functional foods we can work in to support it, but with hormones, you have to have all of those other foundational systems in place before we can attempt to balance hormones.
Dr. Aimee: Right. I imagine your book will have a lot more of this information, too. A Balanced Approach to PCOS is your book, and I think I need to recommend it to all of my patients now because I didn’t really know about spearmint tea. I’ll be recommending that for sure. I love tea.
How hard is it to make these changes for people when they meet you?
Melissa: It’s not hard. I think that the changes I recommend are very simple to implement. I like to recommend things that are easy to implement. Ways of getting more protein for breakfast, for example.
What I find that the difficult part can be for some folks is that mindset and motivation play a role in terms of how willing someone is going to be to make the necessary changes. For my clients who are trying to get pregnant, that’s a pretty big motivation. They’re willing to do anything to achieve their goal. If you tell them they need to cut a foot off, they are likely to do that if it means it will result in a healthy pregnancy.
I do find for my clients who are not trying to conceive and are just struggling with symptoms and looking at long term health, it can be hard to maintain motivation. Fear is not a good motivator. For some, there is fear of diabetes, heart disease, cancer, all of the long term risks of PCOS, but that is only going to motivate you for so long. Usually, after you’ve received a not-so-nice lab result and your doctor told you that you need to start working on this.
Ultimately, it really comes down to self-love, believing that you’re worth taking care of. Sometimes it’s not about the food or the lifestyle changes at all or having “willpower.” It’s about believing you’re worth it. If I’m working with someone who has been on multiple diets throughout their life and they’re having trouble sticking with any of them, I highly encourage them to reach out to a mental health professional at that point, because sometimes it’s not about the food.
Sometimes it is about the food, if it’s a super restrictive diet that they can’t follow for the long term. Ultimately, you have to see yourself as worth investing in and learn to see nourishing yourself properly as a form of self-care.
Dr. Aimee: You’re speaking my language. I feel like with what’s going on in the world, so many people don’t think that they’re deserving of receiving love. I get it, as women we tend to be very empathetic. My patients are extremely empathetic people, so they feel other people’s pain and then they feel bad that now they’re going to treat themselves with kindness and respect because there are people out there that are not being treated that way. Thank you for bringing up the mental health piece. I think it is so important right now, more than ever.
I’d love to hear some of your success stories. Can you share some with us?
Melissa: Yes. I think one of my favorite ones was one client where I was her last stop before an ovarian wedge resection surgery, which to be honest, I didn’t realize people were still doing. It sounds really barbaric. For those that don’t know what that is, they actually remove a portion of your ovaries so that, in theory, you would produce less testosterone. This client had secondary infertility, so she had a child who was about 5 or 6 years old.
When she came to me, what didn’t come through at all on the phone call, but finally came through when I was reading all of her paperwork and talking to her about what she was actually eating, was that her gut was a mess. She wasn’t overweight, and she never struggled with her weight, but like most of my clients, she worked a really high stress job and she used food as a reward. It was like, “I have a 9:00 meeting. I’m going to come out and have my little granola bar. After my 10:00 meeting, I’m going to come out and have a handful of fruit and some almonds.” She was eating like 8 or 10 times over the course of the day. Also, the stress piece was really big for her with her job.
Literally, all we did was get her working on having fewer, more balanced, more nutrient dense meals, and she got pregnant naturally before she even got her first period. So, she got to call the doctor and say, “Don’t schedule my surgery, because I don’t need it anymore.”
I have a client on the other end of the spectrum who is similar. Depending on what clinic you’re working with, there are BMI requirements for some patients. They won’t even perform diagnostic testing until your BMI is below a certain level.
I had one of those clients reach out to me for weight loss, of course. I said we’re not going to work on weight loss, we’re going to work on lowering your insulin resistance, lowering your inflammation, and improving your gut health. We got her eating a more blood sugar balancing diet, a gentle calorie restriction, not a 1,200 calorie a day diet, I’m talking like 1,800 or 1,900, and just got her moving her body more, spending more time outside. She was another one who got to call the clinic and say, “I don’t need you because I’m pregnant naturally.”
Dr. Aimee: I can’t imagine being told that I won’t even do diagnostic testing. Thank you for sharing those success stories. Is there anything else you would like to share with us today?
Melissa: Yes. I think another common misperception and something that I hear all the time is, “I’m eating a pretty healthy diet. I don’t understand what I’m doing wrong.” I don’t think I’ve ever had anyone talk to me who said, “I’m not eating a healthy diet.” I think the things that you might think are healthy are different from what is supportive of fertility. That’s what we need to look at and maybe make tweaks based on supporting fertility, and not whatever your current idea of “healthy” is, which might be different from what you actually need to be doing.
Dr. Aimee: I think the biggest mistakes I see are people using a lot of creamer in their coffee, for example. Another thing is the amount of alcohol people consume, they don’t realize how many calories are actually in it. It’s basically just simple sugar.
Melissa: Yes. Even the recommendations are one drink a day for women or no more than one drink a day, but you can’t save that all up for the weekend and have seven on Friday. One would argue if you were really motivated to work on your fertility, seven drinks a week might be something you want to look at because, ultimately, it’s affecting your hormones, it’s affecting your blood sugar balance, and it’s affecting your sleep, and it might not be aligned with your goals to get pregnant and have a healthy pregnancy.
Dr. Aimee: Right. What we think of as a serving is different than what is actually a serving. Four ounces is not a lot of alcohol. I find people are drinking half a bottle or even more than that, thinking that’s their serving. Thank you for sharing that.
If someone is curious about you and wants to find your book, wants to download your next podcast episode, or work with you, where can they find you?
Melissa: My website is TheHormoneDietitian.com. I work with clients virtually, and you can find all of the information about my programs and my online courses there. My podcast is Hormonally Yours with the Hormone Dietitian, and you can find that on my website or anywhere that you listen to podcasts. Then my book is A Balanced Approach to PCOS: 16 Weeks of PCOS-Friendly Recipes, and you can find it anywhere books are sold. The place I spend the most time is on Instagram, @TheHormone.Dietitian.
Dr. Aimee: Thank you, Melissa. Thank you for joining us today. I’m so glad that I got a chance to finally meet you and learn more about your very important approach to PCOS. Thank you again.
Melissa: Thank you for having me.
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