PCOS Awareness Month
September 9, 2021
By Rebecca Kawagoe, DO
Editor’s Note: This is a fascinating interview with Dr. Lynn Keenan, a board-certified internal medicine and sleep medicine physician in Fresno, California. She is the director of the UCSF Fresno Sleep Medicine Fellowship Training Program and a leader within the growing field of fertility awareness, having served as president of the California Association of Natural Family Planning for nine years. She is the current treasurer of the International Institute for Restorative Reproductive Medicine. We are grateful for Dr. Keenan’s gracious gift of time and her willingness to be interviewed by Dr. Rebecca Kawagoe as part of the FACTS elective.
During a medical school elective about using fertility awareness-based methods (FABMs) for restorative women’s health, I had the opportunity to interview Lynn Keenan, MD, a physician specialized in sleep medicine who incorporates FABMs into her practice. Motivated by both faith and science, Dr. Keenan has embraced FABMs for their many benefits throughout her professional life in Fresno, California.
Dr. Keenan completed medical school at Temple University School of Medicine in 1989. She then completed residency in internal medicine at the University of California San Francisco in Fresno. Later, she assumed her current role as the program director of the sleep medicine fellowship at UCSF Fresno.
She is trained in several fertility awareness-based methods and embraces the science that supports FABMs as natural alternatives to the potential side effects of hormonal birth control options. Twenty years ago, she completed training in the Creighton Model and began providing this method to her patients. In 2018, she trained in NeoFertility and now teaches her patients how to use the Chart Neo app.
FABM Applications in Clinical Medicine
Dr. Keenan has found multiple ways to apply FABMs to her practice. The most striking example that came up during our conversation centered around the association between polycystic ovary syndrome (PCOS) and obstructive sleep apnea (OSA). In a 2001 study, Vgontzas et al found that women with PCOS were 30 times more likely to have OSA than controls, even after controlling for body mass index (BMI).[i] A 2002 small cohort study reported a 70% prevalence of OSA among women with PCOS, with no correlation found between obesity and severity of OSA.[ii] This association may exist due to the elevated androgen levels found in some PCOS phenotypes, as testosterone has been shown to have adverse effects on breathing during sleep and to predispose patients to OSA. Alternatively, the association could be related to lower progesterone levels, as progesterone is a respiratory stimulant. Although the high prevalence of OSA in PCOS does not seem to be due simply to an elevated BMI, there may be an increased risk with elevated levels of visceral adipose tissue.[iii]
In her clinical practice, Dr. Keenan has found that if women with OSA are tracking their charts, they can see significant improvement in their bleeding patterns once the OSA is treated. Other conditions she has managed with FABMs include postpartum psychosis, premenstrual migraines, and infertility with low post-peak progesterone.
Another striking example we discussed involved a patient diagnosed with bipolar disorder who developed renal failure after starting lithium therapy. Dr. Keenan’s evaluation elicited evidence of severe premenstrual syndrome. She prescribed post-peak progesterone to normalize the patient’s cycle, effectively controlling many of her symptoms.
Empowering Women Through Education
Dr. Keenan supports the use of FABMs not just to manage diagnoses but as a way to empower and educate women. Although she acknowledges learning these methods takes time and dedication, she loves that they provide “a lifetime of knowledge,” enabling women to apply learned concepts throughout their reproductive lives.
We also discussed the low cost and environmentally conscientious benefits of these methods. When I asked about disadvantages of FABMs, Dr. Keenan acknowledged there is still stigma against natural family planning. Patients in her practice have reported feeling mocked or misunderstood by the medical community. Dr. Keenan is encouraged to see medical students and residents learning more about FABMs, and provided me with resources in the Fresno area to build a network of medical professionals trained in FABMs.
Another disadvantage we discussed is the slow progress in the world of research, mainly because there is very little money to be made in this field. We shared the hope that my generation of medical professionals will see the value in FABMs and continue to support research in this area.
I am so privileged that I could spend an afternoon talking to Dr. Keenan, who is an example of a physician in my native Fresno who embraces FABMs for their diverse applications. Interviewing her was one of the highlights of my FACTS elective, and I am so grateful to Dr. Duane and the FACTS team for the opportunity to gain insight from this expert in FABMs.
Editor’s Note: Dr. Lynn Keenan recently completed the FACTS Speaker training and is now available to give our CME-approved presentations. Follow the link to invite her to speak at your institution or event.
[i] Polycystic ovary syndrome is associated with obstructive sleep apnea and daytime sleepiness: role of insulin resistance. Vgontzas AN, Legro RS, Bixler EO, Grayev A, Kales A, Chrousos GP. J Clin Endocrinol Metab. 2001 Feb; 86(2):517-20.
[ii] The role of obesity in the increased prevalence of obstructive sleep apnea syndrome in patients with polycystic ovarian syndrome. Gopal M, Duntley S, Uhles M, Attarian H. Sleep Med. 2002 Sep; 3(5):401-4.
[iii] Tasali, E., Van Cauter, E., & Ehrmann, D. A. (2008). Polycystic Ovary Syndrome and Obstructive Sleep Apnea. Sleep medicine clinics, 3(1), 37–46. https://doi.org/10.1016/j.jsmc.2007.11.001.
ABOUT THE AUTHOR
Rebecca Kawagoe, DO
Rebecca Kawagoe, DO is a first-year family medicine resident physician in Visalia, CA. After residency, she plans on staying local to practice in the Central Valley of California. She participated in the FACTS elective during her fourth year of medical school and is looking forward to applying fertility awareness-based methods to restorative women’s health care in her practice.