If you’ve landed here, chances are you have been diagnosed with or suspect you or a loved one may have Polycystic Ovarian Syndrome (PCOS).
You may also feel disillusioned with the diagnostic process and care options you’ve been offered OR unsure about what you should do from a diet and lifestyle perspective.
As an integrative functional medicine physician specializing in women’s health, I can tell you that you are not alone in feeling confused.
Although there is much discussion about PCOS and advances in care, there is also loads of misinformation or half-baked information on its symptoms, causes, and effective treatments.
In this article, we’re putting all that to rest with everything you need to know about a no-nonsense functional medicine approach to PCOS, including:
- What is PCOS?
- PCOS symptoms (and lack of symptoms)—beyond facial hair and infertility
- Different types of PCOS
- What causes PCOS
- The connection between PCOS and other conditions like metabolic syndrome and Hashimoto’s
- How to diagnose PCOS
- Is PCOS autoimmune
- A functional medicine approach to PCOS treatment and management, including supplements, nutrition, exercise – and why I do not recommend birth control pills to “treat” PCOS
Even if you feel you’ve lost—or are losing—control of your body, know it is almost always possible to right this ship.
The most important factors are a willingness to do the work to get better, a clear understanding of the cause, and dialing in the right treatment options.
What is PCOS? A common and underdiagnosed condition
Women with PCOS have a hormonal imbalance of excess androgen and may have dysfunctional estrogen receptors (there are other hormones at play here, but this is a high-level view).1
High levels of androgens in women are a problem because they can disrupt ovulation and cause follicles in the ovaries (the tiny, fluid-filled sacs in which eggs grow) to halt development.
This causes them to enlarge, creating multiple cysts, hence the name Poly-cystic Ovarian Syndrome.
PCOS is the most common endocrine disorder of reproductive-aged women. Chances are you know at least one person who has it— and maybe that person is you.
Research shows PCOS affects 6-12% of American women and is one of the most common causes of female infertility.2
Yet, data also indicates that up to 75% of PCOS cases are not known clinically. Which tells us it is highly under- or misdiagnosed.
This is in part because PCOS is a complex and heterogeneous condition, and it can manifest with a wide range of symptoms and hormonal imbalances – this means that women with PCOS can have the same diagnosis but look very different.
Some women with PCOS have hirsutism (male pattern hair growth on face/body), obesity, and insulin resistance.
Other women are thin, athletic, high achievers with a lot of stress and mild acne, irregular periods or fertility issues.
Both sets of women have PCOS which makes the diagnostic criteria a little bit sketchy (and also helps explain why this syndrome is so underdiagnosed).
PCOS Symptoms—Beyond Facial Hair and Infertility
- Irregular menstrual cycles — This could look like an absence of menstruation, menses longer than 35 days apart, or less than eight periods a year.
- Hyperandrogenism – excess androgens or male dominant hormones like DHEA and testosterone
- Excess facial and body hair – especially above the upper lip, chin, chest, and abdomen
- Hair thinning
- Oily skin
- High blood sugar and/or insulin resistance
- Weight gain (although PCOS is also common in lean women)
- Increased body odor
These symptoms can vary from woman to woman and change as life progresses.
Most of the symptoms of PCOS are caused by higher-than-normal levels of androgens, such as testosterone and DHEA.5
You may also have no symptoms of PCOS. Many women have no idea there’s a problem until they try to get pregnant and encounter fertility issues.
Given the array and varying presentation of PCOS symptoms, it is essential that women be heard and offered a range of diagnostic tools and treatment options, which we’ll discuss in the upcoming sections.
It’s also essential that women pay close attention to their menses and track the timing and overall experience. Consider this your monthly insight into your hormonal health.
If your periods change in regularity, be sure to talk to your healthcare provider.
What Causes PCOS?
Unfortunately, the exact cause of this syndrome is not entirely understood, but it is believed to result from a combination of genetic, hormonal, and lifestyle factors which could be explained by one or more of the following:
- Genetics: There is evidence to suggest there may be a genetic predisposition to PCOS. If you have close family members with PCOS, you may be at an increased risk of developing the condition.
But as I always say, genes load the gun, and the environment pulls the trigger. This means, you may not develop PCOS—or any other syndrome—based on genetics alone. Environment plays a significant role.
- Hormonal Imbalances: As we touched on earlier, PCOS is characterized by hormonal imbalances, particularly elevated levels of androgens (male hormones) such as testosterone.
These hormonal imbalances can disrupt the normal function of the ovaries and lead to the development of cysts, irregular menstrual cycles, and other symptoms.
Some studies suggest that the primary defect is in the hypothalamic-pituitary axis, with high levels of luteinizing hormone (LH), which we believe results from increased gonadotropin-releasing hormone pulses from the hypothalamus.
Other studies show that the ovaries themselves have an intrinsic problem leading to androgen overproduction.
- Insulin Resistance: Many individuals with PCOS have insulin resistance, where the body’s cells do not respond efficiently to insulin.
This can lead to elevated insulin levels in the blood, which in turn can stimulate the ovaries to produce more androgens.
High insulin levels may also suppress the production of sex hormone-binding globulin (SHBG) in the liver, exacerbating the hormonal imbalance caused by free circulating androgens.
Insulin resistance is also associated with an increased risk of type 2 diabetes.
- Excessive Chronic Stress: Stress can lead to an increase in the production of stress hormones such as cortisol. Chronic stress and elevated cortisol levels may disrupt the balance of reproductive hormones, including those involved in PCOS, such as insulin and androgens (male hormones).
This disruption can contribute to irregular menstrual cycles, exacerbate insulin resistance, and potentially worsen PCOS symptoms.
- Environmental Factors: Newer research indicates that environmental exposure to estrogen-mimicking chemicals, such as pesticides, dioxins, phthalates, bisphenol A, and diethylstilbestrol, may also play a role in the development or exacerbation of PCOS.6
These estrogen-mimicking chemicals, also known as endocrine disruptors, are a big problem because they create hormonal imbalances, which can negatively impact ovarian function.7
According to a recent research article entitled: “Estrogen Receptors in Polycystic Ovary Syndrome”published the journal Cells:
“Research on women with PCOS indicates elevated production of LH (lutenizing hormone) and free testosterone. Under the influence of endocrine-disrupting chemicals (phytoestrogens or synthetic estrogenic compounds), hormone secretion is also further affected, resulting in the PCOS disease.”
As you can see, there are many possible causal factors involved in PCOS.
Therefore, addressing and treating the root cause requires an individual approach.
How to Diagnose PCOS
Diagnosing PCOS correctly requires awareness of the symptoms, risk factors, and any pre-existing conditions.
The standard criteria for diagnosing PCOS is called The Modified Rotterdam Criteria.
This criterion requires two of the following three findings to be present:8
- High androgens – this may show up on bloodwork or clinically.
- This means elevated levels of total or free testosterone.
- Elevated dehydroepiandrosterone sulfate (DHEA-S) and androstenedione (ANSD) can also be considered.
- Clinical hyperandrogenism is known as hirsutism, defined as male pattern hair growth in women, such as hair above the upper lip or chin.9
- Irregular cycles or anovulation.
- This means menstrual cycles longer than 35 days apart or less than eight periods a year.
- Polycystic appearing ovaries on ultrasound.
- This means an ultrasound revealed multiple cysts on the ovaries.
- Note an ultrasound will not always show ovarian cysts in women who are on birth control pills.
The Modified Rotterdam Criteria was established as part of the 2018 International PCOS Guideline, which integrated multidisciplinary and consumer perspectives from six continents and is now used in 196 countries.
Recent updates to The Modified Rotterdam Criteria
In October 2023, Monash University (on behalf of the NHMRC Centre for Research Excellence in Women’s Health in Reproductive Life) published updated recommendations for the assessment and management of PCOS as part of an ongoing commitment to better understand and diagnose the condition.
The new recommendations10 in 2023 still recognize the Rotterdam criteria but state that anti-Müllerian hormone (AMH) levels can now be used instead of ultrasound in adults (not adolescents).
Additionally, the new recommendations included updated and expanded definitions for irregular cycles or anovulation:
- Cycles <21 or >35 days or <8 cycles per year in women who started their period at least 3 years ago and are not in menopause
- Any cycle that is >90 days for women who started their period at least 1 year ago (having irregular cycles in the first year after menarche is considered normal)
- No onset of period (primary amenorrhoea) by age 15 or >3 years after breast development)
Blood Tests for PCOS
Bloodwork gives us much information we need to diagnose PCOS under this criteria.
I typically run labs to test the following:11
- Free and Total testosterone—elevated in women with PCOS.
- DHEA-S—elevated in women with PCOS.
- Androstenedione (ANSD)—elevated in women with PCOS.
- Fasting insulin level—helps confirm or rule out insulin resistance which is thought to play a role in the hormonal imbalances seen in PCOS.
- HbA1c—helps confirm or rule out metabolic disorders.
- Fasting Lipid Panel—tells us the risk of cardiovascular disease, which may be elevated with long-term PCOS.
- Luteinizing hormone (LH) and Follicle-stimulating hormone FSH— LH/FSH ratio is sometimes elevated in women with PCOS (mostly in lean women). This should be drawn on day 3-5 of a cycle.
- Progesterone— should be measured in the luteal phase (2nd half of the cycle), and an elevated level suggests that ovulation has occurred. Timing is important!
- Prolactin and 17-hydroxyprogesterone—to rule out other conditions that might mimic PCOS.
- Complete Thyroid Panel—to check for thyroid disorders, including Hashimoto’s.
I may also suggest testing for Vitamin D levels, homocysteine levels (a marker that can directly test for the deficiency of B12, B6, and Folic Acid) and other nutritional merkers.
I also test for sex hormones using the DUTCH test (which stands for Dried Urine Test For Comprehensive Hormones). The DUTCH test is unique because it measures a broader range of reproductive hormones and helps us understand hormone metabolism as well.
Imaging Test for PCOS
A pelvic ultrasound is also typically recommended to look for ovarian cysts.
However, it’s important to note that an ultrasound may not show ovarian cysts in women with PCOS taking birth control pills.
Different Types of PCOS
- Mild PCOS (accounts for 16% of affected women): characterized by irregular periods, polycystic ovaries on ultrasound, mildly elevated androgens, normal insulin levels
- Ovulatory PCOS (accounts for 16% of affected women): characterized by normal periods, polycystic ovaries on ultrasound, elevated androgens, increased insulin
- Hyperandrogenism and chronic anovulation (accounts for 7% of affected women): characterized by irregular periods, normal ovaries on ultrasound, elevated androgens, increased insulin
- Severe PCOS (accounts for 61% of affected women): characterized by irregular periods, polycystic ovaries on ultrasound, elevated androgens, increased insulin
This helps explain some of the heterogeneity of this syndrome which I have also observed in clinical practice.
Is PCOS Autoimmune?
It is possible PCOS is an autoimmune condition.
This new theory is based on evidence of specific antibodies documented in PCOS patients, including anti-nuclear (ANA), anti-thyroid, anti-spermatic, anti-SM, anti-histone, anti-carbonic anhydrase, anti-ovarian, and anti-islet cell antibodies.14
In addition, there is an association between PCOS and other autoimmune diseases such as Hashimoto’s Disease. More research is needed.
The Connection Between PCOS and Hashimoto’s Disease
Hashimoto’s is an autoimmune disease affecting the thyroid and one of the most common conditions I treat in practice.
Interestingly, Hashimoto’s is three times more common in women with PCOS than in women without it.
In women with both Hashimoto’s and PCOS, high testosterone is less common, but they have an elevated risk of insulin resistance. This makes sense since thyroid disorders tend to exacerbate issues with weight and metabolism.15
Thyroid issues also significantly affect fertility problems if not mitigated by proper treatment.
The bottom line is anyone diagnosed with Hashimoto’s should pay attention to additional symptoms of PCOS – and vice versa.
A Functional Medicine Approach to PCOS
Now that you understand what PCOS is and the hormones involved let’s look at an integrative approach to PCOS treatment and management.
When I treat women with PCOS, we address it on multiple levels, including getting a handle on insulin resistance and using various diet, supplements, and lifestyle changes to address hormonal imbalances.
Research has shown that we address PCOS from an integrative functional medicine approach that focuses on lifestyle factors. It can reduce or eliminate symptoms, complications, and other co-infections or health conditions associated with PCOS.16, 17, 18
Let’s talk about the best diet for PCOS
As I always say and firmly believe, there is no one-size-fits-all perfect diet for everyone.
Even in women with PCOS, there will be variations depending on other factors such as food sensitivities, co-infections or other conditions, the type of PCOS we’re dealing with, your health history, and more.
As a general rule, we focus on balancing blood-sugar!
In a nutshell, this means focusing on high-quality protein, fat, and fiber.
Here’s what this looks like:
- Significantly reducing or eliminating processed foods
- Significantly reducing or eliminating refined sugars
- Eliminating any foods that cause sensitivity. Dairy, for example, is a trigger for many women. A trial of a gluten-free diet is also a good idea – but be careful not to replace foods with gluten with high sugar gluten-free alternatives.
- Focusing on high-quality protein at every meal and snack
- Focusing on healthy fats such as extra virgin olive oil, coconut oil, avocado oil, nuts, seeds, and fatty fish
- Eating plenty of colorful vegetables
- Eating moderate amounts of fruits
One of the tools we use most often in our practice is a Continuous Glucometer (CGM).
This gives you immediate feedback and data to better understand how your body responds to certain foods.
Some examples include, which foods spike and/or causes rebound hypoglycemia, and how different foods/food combinations affect blood sugar, energy, and sleep.
Again, this is a very general description of dietary principles for PCOS, which will vary from person to person.
The main goal is to focus on whole, unprocessed foods emphasizing blood-sugar-balancing protein, anti-inflammatory, high-fiber vegetables, and healthy fats.
Best supplements for PCOS
Once again, this is not a one-size-fits-all. The best supplement regimen for PCOS depends on lab work, blood sugar, co-infections, lifestyle, etc.
However, here are some of my go-to supplements for different types of PCOS.
This one is critical for anyone dealing with PCOS and fertility issues because it helps with insulin resistance, which can help restore ovarian function.19, 20, It’s also been shown to help enhance embryo quality and improve pregnancy rates.21
As an added bonus, Inositol has been shown to improve thyroid antibodies associated with Hashimoto’s when taken with selenium.22
I recommend Biotics Research Balanced-B8 (Myo-inositol and D-chiro-inositol powder)
You’ve probably heard about all the incredible health benefits of taking fish oil. However, it’s especially beneficial for PCOS, with studies showing fish oil can improve ovulation, ovarian reserves, and fertility.23 It’s also been shown to help improve insulin resistance and has anti-inflammatory properties.24
I commonly recommend Metagenics OmegaGenics.
Vitex (Chaste tree berry)
Vitex, also known as Chastetree or Agnus Castus, is an herb known for its beneficial effects on female hormonal balance, especially progesterone.25
Research has also found Vitex may help enhance fertility in women with PCOS.26
I use Citex in combination with other herbs, and sometimes by itself. One product we like is Vitex: Progesterone Support from Gaia Herbs/Professional Solutions.
Saw Palmetto is typically considered an herb for male hormone imbalances and prostate problems. However, research has shown phytochemicals in saw palmetto may reduce androgen activity and balance estrogen levels.27, 28I often recommend Saw Palmetto for women with PCOS who have acne and undesirable hair growth.
I recommend Saw Palmetto from Gaia Herbs/Professional Solutions.
Berberine is a component of certain herbs (Goldenseal, Oregon Grape, Barberry, California Poppy) known to support immunity, inflammatory response, endocrine function, and help with metabolic conditions.29, 30
One of my most recommended products is Berberine from Thorne.
Chromium is a trace mineral that supports normal insulin function. It’s also been shown to help lower blood sugar and insulin levels in women with PCOS.33
Chromium can be found in many metabolic support formulas, such as Metabolic Xtra from Pure Encapsulations, which also contains Berberine.
N-acetyl-cysteine (NAC) is a type of amino acid involved in building antioxidants that help prevent cell damage.
Research has shown NAC can help reduce insulin sensitivity, regulate ovulation, boost fertility, and lower testosterone levels. For women with PCOS, NAC can help to reduce insulin sensitivity (as well as metformin in some studies), lower testosterone levels, regulate ovulation, and improve fertility.34, 35
One of my favorites is N-Acetyl Cysteine from Designs for Health
Acetyl L-Carnitine (ALC) is an antioxidant that helps your body transform fat into energy. Research suggests that non-obese women with PCOS have significantly lower L-carnitine levels than women without PCOS.36
In some cases, low levels of L-carnitine go hand-in-hand with excess androgen production and insulin resistance.
A favorite is L-Carnitine from Ortho Molecular Products
Vitamin B2 (riboflavin), B12 and folate can be especially helpful for women with high homocysteine levels. High homocysteine is common in PCOS patients and is associated with various aspects of infertility and pregnancy.37
Women who are trying to conceive should be on a high quality prenatal vitamin with methylated Bs. Outside of that, I often recommend Metagenics MethylCare.
Magnesium is an essential mineral in glucose metabolism and over 300 enzyme reactions. It’s also a mineral that’s lacking in the standard American diet.
Research has shown that women with PCOS are 19 times more likely to be magnesium deficient than the general population.40 Research has shown magnesium supplementation may improve insulin resistance, reduce inflammation, and ease PMS symptoms in women with PCOS.41
One of my most recommended products is Seeking Health Optimal Magnesium
Zinc is an essential mineral with antioxidant properties that support cell growth, hormone function, immunity, inflammatory response, and reproductive health.42
Research suggests zinc deficiency may be associated with symptoms of PCOS, such as insulin resistance and abnormal cholesterol levels.43
Zinc should only be used after a full meal as it can cause nausea on an empty stomach.
I often recommend often is Zinc Picolinate 30mg from Thorne
Vitamin D deficiency is not uncommon, with up to 85% of women with PCOS suffering from a lack of vitamin D.46
Studies have shown that sub-optimal vitamin D levels can exacerbate PCOS symptoms such as irregular periods, insulin resistance, excess androgen production, weight gain and obesity, and ovulation problems.
Vitamin D3 + K2 gets recommended to most of my patients, and one high quality option comes from Seeking Health.
Do you have to take all these supplements?
Absolutely not! I recommend different combinations of these supplements based on the individual patient, and sometimes a combination product that nails two birds with one stone.
Check out Restorative Formulas PCO Px, Douglas Labs TestoQuench (for women with high androgens), and Thorne Ovarian Care (for women with PCOS who are trying to conceive or who have irregular cycles).
All of the products mentioned above, and dozens of other high-quality, pharmaceutical-grade supplements, are available to you at a discount from my online dispensary.
What About Medication and Birth Control Pills for PCOS?
Although I typically prefer supplements vs. drugs, I sometimes prescribe metformin, depending on the case. It’s always a risk vs benefits decision with me.
I do not, however, recommend birth control pills for treating PCOS (gasp!).
Although they are part of the standard of care and may be appropriate for other reasons, they create a fake menstrual cycle versus “regulating your cycle,” potentially leading to more hormonal trouble down the road. They do nothing to treat the underlying cause(s) of PCOS.
Since people with PCOS are already more susceptible to nutrient deficiencies and thyroid trouble, birth control pills may do more harm than good.
Exercise is Critical for Managing PCOS
Exercise is critical in treating and managing PCOS because of its broad-spectrum benefits for lowering insulin, balancing blood sugar, promoting sleep, elevating mood, and helping with hormonal imbalance.
Any exercise is good for PCOS.50 However, interval-style exercise, yoga, and weight lifting are especially helpful for lowering insulin levels.
I recommend everyone work up to at least 30 minutes of moderate to vigorous exercise most days.
If you’re reading this and thinking, “I have zero energy right now, how am I supposed to exercise?” Do not despair.
Chronic diseases, like PCOS, can take such a toll, and the point is to start somewhere.
Can you take the stairs, do some rebounding, or do a few couch squats? As your health improves, you’ll naturally gain more energy to devote to exercise.
This isn’t about training for a marathon! The goal is to move your body every single day and gain more muscle.
Stress Management for PCOS
I’ve written about this extensively in What I Wish I’d Known About Stress and Autoimmune Disease and Why HPA Axis Dysfunction May Be More Important Than Gut Health. Still, you cannot fully treat the root cause of any chronic health condition without addressing chronic stress and trauma.
The easiest way to start getting a handle on stress is to begin practicing some basic self-care. Some of my favorites for PCOS include:
- Quit intermittent fasting and instead focus on “you time” and protein in the mornings.
- This may mean waking up ahead of your children, but it’s worth it just to have 15-30 minutes to devote to meditation or prayer, preparing a healthy meal, and getting some morning sunlight.
- Make meditation a part of your routine.
- Prioritize connections and community.
- Did you know the effects of loneliness or social isolation have been compared to smoking a pack of cigarettes daily? In other words, being and feeling surrounded by people who care is equally important as eating right and exercising for healing and long-term health.
- Exercise, see the previous section.
- Consider Heart Rate Variability (HRV) training to help create a calm state of mind.
- HRV training is a form of biofeedback that activates and calms our autonomic nervous system. HeartMath is my favorite.
- Sleep at least 8-10 hours a night while you’re healing
- Getting optimal sleep is essential to resetting your stress response and controlling insulin levels.
- I like the Oura ring for tracking quantity and sleep quality (P.S. Try this link and you might get $50 off). Click here for more tips on what to do if you have trouble sleeping.
This is a very short list of basic self-care practices that can benefit women with PCOS or anyone looking to reduce chronic stress.
I discuss more options in What I Wish I’d Known About Stress and Autoimmune Disease and Why HPA Axis Dysfunction May Be More Important Than Gut Health.
Create a Hostile Environment for PCOS by Ridding your Home of Endocrine-Disruptive Toxins
As discussed previously, environmental factors such as endocrine-disrupting toxins, especially those that mimic estrogen, have been linked to PCOS.
However, did you know you have tremendous control over your exposure level to many of these chemicals?
Here are some simple ways to reduce estrogen-mimicking chemicals at home:
- Avoid plastics in favor of glass or stainless steel. This reduces your exposure to various plastic chemicals such as BPA, BPB, BPS, and phthalates.
- Buy organic and/or naturally-grown foods as much as possible. At the very least, avoid produce on the Dirty Dozen list, opt for the Clean Fifteen, and prioritize organic, pasture-raised meats.
- Choose non-toxic cleaning and laundry products. Branch Basics is my favorite non-toxic branch because just one concentrate replaces every cleaner in your home. It’s super economical too. Use the Environmental Working Group’s handy “Guide To Healthy Cleaning” product database to easily vet products for safety.
- Choose natural and non-toxic beauty and personal care products. Learn more here.
- Clean often. Various toxins ride on dust, and regular dusting and vacuuming can go a long way in reducing toxins at home.
- Filter your water. This alone can drastically reduce exposure to dozens of chemicals, including chlorine, fluoride, pesticides, pharmaceuticals, and PFASs (aka: “forever chemicals”). I like the Berkey or Aquasana.
- Get rid of fragranced products. These contain a toxic soup of endocrine-disrupting ingredients, such as phthalates, so ditch all plug-ins, fragranced cleaning products, personal care products, and laundry products. Note: Switching to fragrance-free isn’t always better. Believe it or not, many synthetic fragrance-free products, such as laundry detergents, used added scent-masking chemicals, which are no bueno!
- Open your windows. Bringing fresh air into the home is one of the best ways to improve indoor air quality.
- Opt for fluoride-free, non-toxic toothpaste and oral care products with hydroxyapatite.
The point here is not to drive yourself nuts eliminating everything potentially toxic.
Rather, to do you best to mitigate everyday exposures where you have the most control, which is usually in your home.
Download my free Guide 12 Ways To Detox Your Home for more tips on reducing chemical exposure at home, and the Trusted Products page of our website for links & discount codes to the trusted healthy home products we use at home and recommend to patients.
Finally, Don’t Ignore your Symptoms
For far too long, women have suffered through irregular periods, conception and pregnancy problems, and various other PCOS-related symptoms with no answers from their doctors.
Or worse, have been told this “was normal,” “there’s nothing medically wrong with you,” or “welcome to being a woman,” which belittles a person’s symptoms, concerns, and innate intuition.
There’s nothing normal about skipping periods, having pain, not getting pregnant, being unable to lose weight, having excess body or facial hair, or suffering any other symptoms of PCOS.
PCOS may sound like a scary diagnosis, but I can assure you it is very manageable once we know what we’re dealing with.
Plus, it’s far better to start treating PCOS early—especially if you plan on having children some day
So do the work now, if you can. The sooner you get the right tests and find the right doctor, the better.
Interested in a Functional Medicine Approach to PCOS?
Working with women on hormonal health issues like PCOS and preconception preparation is one of my greatest joys and specialties.
If this article has inspired you to look deeper into your symptoms or diagnosis, we’d love to get to know you better!
For those in my tri-state area of practice (Colorado, Michigan, and Texas), click here to learn more about our functional medicine approach and how to apply to become a patient.