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S1E9 Living With PCOS: Symptoms, Fertility & What You Need to Know — Transcript

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0:00Hello everyone. Welcome back to the Push
0:02podcast.
0:03>> Hi everybody.
0:04>> I'm Sydney. I am a labor and delivery
0:07nurse and a online educator, content
0:10creator in the birthing postpartum
0:12world.
0:13>> And I'm Megan. I'm an OBGYN,
0:16a clinical researcher, and a new mom
0:18myself. So I'm navigating a lot of the
0:20postpartum experiences for the first
0:23time in real practice.
0:25>> Yeah, which has been such a good
0:27conversation starter with a lot of our
0:29topics on the podcast. So,
0:32um today we are talking about a very
0:34special episode for polycystic ovarian
0:38syndrome awareness month, which is
0:40September. So we are going to dive in
0:42and talk about PCOS.
0:49>> [music]
0:53[music]
0:55>> Perfect. We're we're trying to keep up
0:57on all of the different highlight months
0:59throughout the year. If we miss one
1:01that's particularly relevant to you guys
1:03and to our audience in general, please
1:05know we will circle back to these
1:07topics.
1:08>> Of course.
1:08>> Um realizing there's a lot of highlight
1:10months throughout the year, which is
1:12which is listen, it's great. So many of
1:13these conditions need to be talked about
1:16and we need to kind of enhance awareness
1:18of what these things are.
1:19>> Absolutely.
1:20>> Um but your girls are struggling to keep
1:21up a little bit.
1:22>> a lot. [laughter]
1:23>> There's a lot, but we felt like PCOS was
1:25like a good topic to talk about for
1:27sure. It's particularly relevant right
1:28now, right?
1:29>> I think a lot of people are talking
1:30about hormone health in general online.
1:32>> Yes.
1:33>> And PCOS being a predominantly
1:35hormonally driven disorder
1:38is something that invariably comes up, I
1:40think.
1:40>> Yeah, yeah, for sure. Well, before we
1:43get into it, I have to [clears throat]
1:44say you're looking great in your in your
1:46scrubs.
1:47>> Thank you, nurse Sydney. So are you in
1:50your
1:51>> custom monogrammed scrubs.
1:52>> Yes, so thank you Geddes Mallette. They
1:54sent us these beautiful embroidered
1:57scrubs.
1:58Um we love them. If you guys haven't
2:00checked out um Garma Lab before, they
2:03are a Canadian Montreal-based
2:05women-owned business or women-founded
2:08business, I should say. And I've been
2:10wearing their scrubs for years and
2:12they're super comfy, super stretchy,
2:14breathable, um and they come in the
2:16cutest colors, which I love.
2:19>> told you this a few times I think
2:20actually offline, but I have tried out
2:20scrubs from lots of different companies
2:21before and I have to say these are very
2:22lightweight. They're very lightweight,
2:22they're very stretchy. They I don't feel
2:23encumbered, I don't feel sweaty in them,
2:23um which is really really great. I'm
2:24running around clinic so fast half the
2:25time that I I can't be held back by my
2:26scrubs, so Garma Lab, thank you so much.
2:27We are a little bit biased being that
2:27both of us have roots in Montreal
2:29>> Yes.
2:31>> and we we have got lots of family there
2:33and we um are super keen to support
2:36Canadian businesses in
2:38>> Yeah.
2:38>> Um but we we really objectively like
2:42>> Yeah. Yes. We wouldn't be talking about
2:44it if we didn't.
2:45>> Exactly. So thank you again. Go check
2:47them out if you haven't already.
2:50Um and also, you guys might notice we're
2:53in a little [laughter] bit of a
2:53different environment.
2:55This new pink pink walls. I love it. I
2:59love it. This was Dr. Megan's
3:01uh office new office in Vision or
3:04Vision, I should say. Dream office
3:07space. Oh, I think as we've alluded to
3:08before, we moved recently, so that's
3:10part of why August was so bananas
3:13>> Yeah.
3:13>> right here at The Push Podcast because
3:15we had between Sydney and I a lot going
3:17on in our personal lives. Um but with
3:19the move allowed us to do too is kind of
3:22reimagine an office space
3:25with honestly some of our Push Podcast
3:27branding in mind. So
3:29aside from that too, I I you know, I
3:31think
3:50>> Casper ending in mine, so
3:51>> Oh, yeah.
3:52>> But aside from that, too, I I, you know,
3:54I think in this chapter of my career,
3:56I've really been feeling
3:58um hard into like recapture some of my
4:01own femininity in a professional sense
4:03and a professional context.
4:05>> Yeah.
4:05>> I think a lot in, you know,
4:08I'm sure a lot of people would say this
4:09in a variety of different careers,
4:11especially those that have been, you
4:13know, traditionally more male-dominated
4:14like surgery.
4:15>> Yeah.
4:15>> There's a little bit of a pressure to
4:18dampen that some of that down,
4:19especially when you're in training. And
4:21now that I'm a staff, I'm kind of
4:22celebrating those feminine aspects a
4:25little bit more, so
4:25>> pink back.
4:27>> Listen, if you can't have a pink office
4:28as an adult, when can you?
4:30>> Yeah. Right?
4:31>> Yeah.
4:31>> That's the best part of growing up. You
4:32can paint your office whatever damn
4:33color you want.
4:34>> Oh, yeah. And it's so cute, and we're
4:36going to get it like a nice little couch
4:39for in here, so we can be cozy.
4:41>> So, pin in this for now. This This our
4:43set is going to change over the next
4:45little while.
4:46>> [laughter]
4:46>> Yeah, but I'm so excited.
4:47>> But uh it's a lovely lovely new space,
4:50so we hope you guys like it, too, on
4:52YouTube. You can see it and
4:54>> Exactly.
4:54>> Let us know how we should decorate
4:56because we're really just getting into
4:58it. But without further ado, all all
5:01home decor aside,
5:03>> [laughter]
5:03>> Yes.
5:03>> let's get into PCOS for PCOS Awareness
5:06Month.
5:07>> Yeah. Yeah. So, um let's go over exact
5:10Well, actually, let me give you like a
5:12little rundown of what we're actually
5:13going to be talking about today just so
5:15that you know, if you don't have much
5:16time and you want to stick around or
5:18save this for later, you'll actually
5:20know what we're going to talk about. So,
5:22we're going to give an actual one
5:23rundown of what is PCOS, um how common
5:27it is, and why it happens. And then
5:30we're also going to talk about like
5:32signs and symptoms, health implications
5:34of this diagnosis, um how diagnosis
5:37happens, how you actually get diagnosed,
5:39and then we're going to go over um
5:41management, treatment options, and then
5:43also debunking some myths,
5:45misconceptions, and social media trends
5:48that you might see online because PCOS
5:51gets a lot of um
5:53online attention, I feel like.
5:54>> I think so, too. I mean, I think so, you
5:55know.
5:56>> Yeah. Yeah, and you know, we'll go we'll
5:57get into why that is and how common it
6:00is of a diagnosis, and maybe that's why.
6:03Um and then just some tips on living
6:05with uh PCOS. So, make sure you stick
6:08around, listen to the whole episode. Um
6:10and I hope I hope it helps some of you
6:12guys out there who may have been
6:14diagnosed with PCOS or think that this
6:16is a condition that you might have.
6:17>> suspect you have it, right?
6:19>> Yeah.
6:19>> Already. Well, listen, let's get into
6:21it. I think before we talk about any of
6:23the fun details any of the I mean, fun
6:25for somebody who's a little bit of like
6:27a science nerd like me. I don't suggest
6:29that it's fun to be living with PCOS.
6:30>> living with it, yeah.
6:31>> Um especially if it's untreated and
6:33undiagnosed and not taken seriously,
6:35right? Um
6:36but generally speaking, at the baseline,
6:39PCOS is a hormonal disorder that affects
6:43um ovarian function.
6:45Um so, basically, it's one of the most
6:47common endocrine disorders or hormonal
6:49system disorders um
6:51particularly that affects people with
6:53ovaries of reproductive age.
6:55Um
6:56and in order, I think, to understand
6:58why PCOS does the things it does, right?
7:01And why it causes this like hormonal
7:03imbalance as is the like oft, you know,
7:05referenced term, especially in social
7:07media, I think we have to rewind a
7:09little bit to understand again a bit
7:11more about the menstrual cycle in
7:13general. Now, if you have not listened
7:15to our episode, This Is Your Body on the
7:17Pill, please go back and listen to at
7:20least our menstrual cycle briefer in
7:22that episode.
7:23>> episode, you guys. It's one of my
7:25favorite episodes. I have to say. It's
7:26so good. And I feel like, you know, as a
7:29woman with with a reproductive with the,
7:31you know, reproductive organs, the the
7:34Oh my god, why couldn't I think of the
7:35word uterus? I'm sorry, I'm still
7:36warming up, you guys. Apparently, I need
7:38to wake up. But with a as a woman with a
7:40uterus, I think like every woman needs
7:42to know what their body does and how it
7:45works. Yeah. Yeah.
7:47>> So, go back to that episode. Just listen
7:49to the the menstrual cycle part if you
7:52want to kind of give you a quick sense
7:54of what we're talking about, but I will
7:55try to like
7:57contextualize as much of this as
7:58possible.
7:59>> Yeah. Yeah.
8:00>> Um so, basically, part of how our
8:03menstrual cycle works is that our brain
8:05has to tell our ovaries, which then tell
8:07our uterus to produce different hormones
8:10and get parts ready so that an egg can
8:12be released and ultimately a um
8:16baby could be conceived, right?
8:18>> Yeah.
8:18>> And again, that starts kind of at the
8:20brain level. So, the brain talks to the
8:22ovaries using two predominant hormones.
8:26FSH or follicle-stimulating hormone and
8:28LH or luteinizing hormone. And this is a
8:31like
8:32broad simplification.
8:34>> Yeah.
8:34>> Um but basically, FSH helps to grow an
8:37egg each month. And [snorts] LH helps to
8:40to trigger the release of that egg. Uh
8:42and that is ovulation, right? It's the
8:44release of an egg. Um at [snorts] the
8:46same time, those ovaries are also
8:47producing estrogen and a little bit of
8:50androgens or what we would think of as
8:52like male hormones like testosterone.
8:55Now, in PCOS, the balance of these
8:58signals gets a little bit mixed up for
8:59some reasons that we understand and some
9:01reasons that we're still continuing to
9:03elucidate a little bit better.
9:04>> Mhm.
9:04>> Um but basically,
9:06in PCOS, the brain produces too much LH
9:10compared to FSH.
9:12>> Okay.
9:12>> Right? And also the way the pattern that
9:15the brain is sending out LH is a little
9:17bit discoordinated.
9:18>> Okay.
9:19>> Um and what that means practically is
9:22that we get tons of little tiny
9:23follicles starting to grow, um but none
9:26really get the full push to mature to
9:29become a dominant follicle and a mature
9:31egg that would then get released with
9:32ovulation.
9:33>> Right.
9:34>> So, because [snorts] the eggs don't
9:35mature properly, ovulation doesn't occur
9:37and periods can become very irregular or
9:40stop entirely.
9:41>> Okay.
9:42>> Um
9:45Now, again, luteinizing hormone
9:47they it doesn't just cause release of
9:51the egg.
9:51>> Yeah.
9:52>> It also acts on a different set of cells
9:54within the ovary called theca cells and
9:57stimulates them to produce androgens,
9:59right? Again, those male pattern
10:01hormones like testosterone. And in a
10:03normal menstrual cycle, we want those
10:05because they are part of the same kind
10:07of biochemical pathway as things like
10:09estrogen, right?
10:10>> Yeah.
10:10>> And so that testosterone is usually
10:12converted into estrogen by the follicles
10:15under the influence of FSH.
10:17>> Mhm.
10:18>> So if you're following me, we kind of
10:19have this like this one pattern that
10:21starts to become a little bit
10:22discoordinated and it has all of these
10:24downstream effects, right?
10:26>> Yeah.
10:26>> That impact the way the hormones are
10:27circulating in our bodies.
10:30So again, in summary, in PCOS, the brain
10:32makes more LH than FSH.
10:35Um
10:36tons of tiny follicles start to develop
10:38but never get the signal to ovulate, and
10:40the theca cells get overstimulated by
10:42LH, which means they're pumping out more
10:45androgens and there isn't enough FSH
10:47present to fully mature the follicles,
10:50so we get less conversion of the
10:51androgens into estrogen.
10:53>> Mhm.
10:53>> What this second part of PCOS results in
10:56is androgen buildup, right? And that's
10:58what causes symptoms like acne, hair
11:01growth on the face or body, and scalp
11:03hair thinning to name a few.
11:05>> Okay. So that's kind of the background
11:07of this picture of constellations of
11:09symptoms that are symptoms that we'll
11:11talk about in a little bit more detail
11:13later.
11:13>> Yeah. Yeah.
11:14>> Now, there's kind of a secondary thing
11:16going on with PCOS as well.
11:19For reasons, again, that some of them we
11:20are starting to understand, some of them
11:22we are continuing to elucidate a little
11:23bit better,
11:24many people with PCOS also have cells
11:27that don't respond quite as well as we
11:29would like or expect to insulin.
11:31>> Mhm.
11:32>> Now, insulin I'm sure people are
11:33familiar with as a major chemical that
11:36is important in the context of diabetes,
11:38right? Or processing sugar. So,
11:40basically, insulin allows our body to
11:42take in circulating sugar in our
11:45bloodstream from the meals that we eat
11:47and to store it into cells to be used
11:48for energy later on.
11:50Um and what that means when people are a
11:52bit insulin resistant, right? Or they
11:55don't respond well to insulin, is that
11:58the body has to make more and more
12:00insulin in order to get the same effect,
12:02right? That is essentially what insulin
12:04resistance means.
12:06High insulin levels can, number one,
12:08tell the ovaries to produce even more
12:10androgens, like testosterone, which
12:13exacerbates some of those symptoms that
12:15we are experiencing.
12:17It also can make it easier to gain
12:18weight over time and harder to lose it.
12:21And again, over time can raise the risk
12:23of type 2 diabetes.
12:25Um so, PCOS and insulin resistance are
12:28inextricably linked in many ways, right?
12:31Um and we'll talk about some of the
12:33reasons why that may be later. Um but
12:35again, the extra androgens in PCOS make
12:38insulin work less effectively, and then
12:40the higher insulin, in turn, drives up
12:42androgen production, which creates this
12:44like vicious cycle of exacerbation of
12:46symptoms. So, again,
12:48I think it's important to start to talk
12:50about some of these things in a little
12:51bit more detail, right? And in a way
12:53that is easily understandable, because
12:56it's not enough for us to just say, "Oh,
12:58hormonal imbalance." Right? Cuz it isn't
13:01always even like the levels of the
13:03hormones, right? Sometimes it's it's a
13:05bigger problem about the way that those
13:06hormones are interacting with each other
13:09and the way that they're interacting
13:10with different parts of our bodies,
13:12right?
13:13Now, for diagnosis of PCOS, we use
13:16what's called the Rotterdam criteria.
13:18And to be diagnosed, you only need two
13:20of
13:21two out of three of the following. So,
13:22the first would be irregular or absent
13:25ovulation. Again, we've got those
13:27follicles that are developing into tiny
13:29little premature follicles in response
13:31to some FSH but never get quite enough
13:33to develop into a mature follicle that
13:36would then release an egg leading to
13:38anovulation or lack of ovulation and
13:40often times subsequently, we don't get
13:43the signal to have a period, right?
13:46>> Um the second one would be elevated
13:48androgens and that can be in either the
13:50form of symptoms, right? So again,
13:52significant acne, hair growth in places
13:54that it wouldn't typically grow for
13:56women. Um
13:58and it also can be present in the form
14:00of abnormal lab results, right? So we
14:02can test for testosterone
14:04um and to see whether or not that is in
14:07fact elevated beyond the levels that we
14:08would expect.
14:10>> [snorts]
14:10>> Um now the last thing is polycystic
14:12ovaries on ultrasound.
14:14>> Mhm.
14:14>> I think it's a little bit of a misnomer
14:15to call them polycystic ovaries. Even
14:17the whole naming of it is a little bit
14:18of a misnomer cuz they're not true
14:20ovarian cysts, right?
14:22>> Or like the water balloons uh that can
14:24develop within the ovary um that have a
14:26whole other ideology and a whole other
14:29kind of
14:30um diagnostic criteria to figure out
14:32like what the underlying cause is and
14:33whether we should be concerned or not.
14:35>> should have been called something with
14:37hormonal imbalance
14:38>> polyfollicular like ovary I don't know.
14:40And you know what again like the cysts
14:41on the ovary are a symptom of the
14:43underlying issue, right? As opposed to
14:46like the major feature themselves.
14:48>> Yeah.
14:48>> Um but in any case, polycystic when we
14:51say polycystic ovaries on ultrasound,
14:52what we mean again is not big cysts but
14:55lots of small immature follicles that we
14:58see.
14:58>> Mhm.
14:59>> And sometimes what this is called called
15:01on the ultrasound reports is a string of
15:03pearls appearance. So you can see kind
15:04of like this little string of tiny
15:07little circles all around the ovary when
15:08we look at it under the ultrasound.
15:10>> Interesting.
15:11>> Um and again, key point is you only need
15:12two out of three.
15:13>> Okay.
15:13>> And I could talk about PCOS all day cuz
15:15I think it's so cool but I'll just
15:17briefly drop here and we can talk more
15:19about it in the comments if you guys are
15:20interested that there's all sorts of
15:23emerging evidence and research into the
15:25different phenotypes of PCOS, or like
15:27why some people can meet this criteria
15:30and have some features but not others.
15:32>> Right.
15:32>> So then again, I think as we continue
15:34exploring this, there's likely a few
15:35subtypes of PCOS.
15:37>> Mhm.
15:37>> And why some people develop one subtype
15:40and not another is a really interesting
15:41area of research. Not to mention like
15:43what that means for people's overall
15:45health.
15:45>> Yeah, so just to be clear, you you
15:47technically can be diagnosed with PCOS
15:49without even having had an ultrasound
15:51then.
15:52>> Yeah, yeah, absolutely. Absolutely you
15:53can. Although typically we recommend
15:55sending the ultrasound just for
15:57confirmation of the the study, right? So
15:59of the investigation.
16:00>> work,
16:01>> ultrasound,
16:02>> ultrasound, and then just looking at
16:03your signs and symptoms.
16:04>> symptoms. Exactly. Exactly. Yep.
16:07I think the other thing too is that
16:09people can have polycystic ovaries,
16:11right? And not have polycystic ovarian
16:14syndrome.
16:15>> Mhm.
16:15>> Right?
16:16>> Okay.
16:16>> Polycystic ovaries are actually a really
16:18common finding on ultrasound, especially
16:20in young women.
16:22>> Okay.
16:22>> the absence of elevated testoster- or
16:24elevated androgens, right? Or irregular
16:28periods,
16:28>> Mhm.
16:29>> that person would not necessarily meet
16:31the criteria for PCOS. So if you have
16:33had an ultrasound investigating
16:34something else at some point and you saw
16:36a notation of polycystic ovaries, but
16:38you're having a period every month and
16:40you have no signs of high androgens,
16:42then you probably don't meet the
16:44criteria for PCOS.
16:46>> and think, "Oh, I have PCOS and I was
16:47never told."
16:48>> I have seen many referrals uh coming
16:50from our colleagues, you know, out in
16:52the community, um saying that somebody
16:55has PCOS and then I chat with them and
16:57actually they don't meet the other
16:58diagnostic criteria, right?
16:59>> Okay. Okay, that makes sense. Now, um
17:02let's kind of talk about how common PCOS
17:05is, because I think probably everyone
17:08listening either knows someone with PCOS
17:10or has
17:11a PCOS diagnosis themselves. Like I feel
17:13like it's become
17:15more talked about online nowadays. I I
17:18hear all the time like I'm scrolling and
17:19then it's like I have PCOS and these are
17:21my signs and symptoms. Like I I see a
17:23lot of people talking about it online.
17:24So how does this mean that it is a super
17:27common diagnosis?
17:28>> common diagnosis, right? And and again
17:30as with so many thing that things that
17:32affect women, it is probably under
17:34diagnosed, right? Um but when we begin
17:37to try and estimate the prevalence, we
17:39are seeing rates of around 10 to 13%
17:42worldwide wide. Depending on the region,
17:44this can be higher or lower as well.
17:46Okay.
17:47>> Okay.
17:47>> Um it is also one of the leading causes
17:49of infertility or subfertility, right?
17:51So challenges getting pregnant. And
17:53again this leads back to the lack of
17:54ovulation, right? In order to get
17:57pregnant, we have to release an egg so
17:59that egg and sperm can meet, the genetic
18:01material can combine, and an embryo and
18:03ultimately a fetus can start to develop,
18:05right?
18:06If you're not ovulating, it doesn't
18:08necessarily mean that there's something
18:09inherently wrong with your ovaries or
18:11your eggs themselves, right? But you
18:14have to release the egg in order to be
18:16able to have egg and sperm meet, right?
18:17And so if you're not ovulating, that
18:19that can obviously present a challenge
18:21to spontaneous conception, right? Or
18:23just
18:24conceiving a pregnancy just from like
18:27sex at home with your partner.
18:29>> Yeah. It's
18:30You're bringing up infertility as well
18:32and I I have seen a lot of stuff online
18:34where someone says, "I was diagnosed
18:36with PCOS. I was told it would be very
18:38difficult to get pregnant or I was
18:40infertile." Oh my god, I hate it so
18:42much. I hear that a lot and then they're
18:44like so went off of birth control
18:46because I didn't think I could get
18:47pregnant and then I got pregnant right
18:48away, which isn't the case for everyone,
18:50but I've seen that a lot online.
18:53>> So classically with PCOS, too, right?
18:56Like people often don't just have no
18:58period. Some people can, right? Have
19:01anovulation and and
19:03amenorrhea, right? No periods. But very
19:06frequently people have oligomenorrhea,
19:09which means less frequent periods, which
19:12>> really means that it's it's harder to
19:14time intercourse, right? Because you
19:16don't necessarily know when you're going
19:18to be ovulating. You ovulate a little
19:19bit more unpredictably than other
19:21people.
19:22>> Yeah.
19:22>> But that certainly means that for many
19:24of these people they still ovulate, just
19:27not in the kind of coordinated schedule
19:28that we would expect. And so it makes it
19:31again, it makes it hard if you're
19:33actively trying to conceive to plan for
19:36sex around the time of ovulation or at
19:38least like presence of sperm around the
19:40time of ovulation, right? But it
19:42certainly does not mean that you cannot
19:44get pregnant.
19:44>> Okay.
19:45>> And I have seen many people like that as
19:47well who've been told that they're
19:48infertile. I find I'm like walking that
19:50diagnosis back a lot in my clinic when I
19:53see patients with PCOS because you're
19:54right. I think that was kind of the like
19:57old school way to think of PCOS.
19:59>> Yeah.
19:59>> Was that people couldn't get pregnant,
20:00right? But we we just know that that is
20:02not true.
20:03>> Yeah.
20:03>> Yeah.
20:04>> Interesting. Okay, good to know. So if
20:06you do have a PCOS diagnosis and you
20:08were told you you're infertile
20:10>> is not a method of contraception.
20:11>> No, no. It
20:12>> If you do not want to be pregnant, you
20:14should still be using something for
20:15contraception.
20:16>> Yes. And then if you do want to get
20:18pregnant and you're having trouble
20:19timing that, there are things that
20:22that we can do to help with your
20:24ovulation, regulating it and and
20:27hopefully conceiving as well. So it's
20:28not doesn't mean you'll never be able to
20:30get pregnant at all. It just means you
20:32might need a little bit of extra
20:34assistance
20:34>> Yeah.
20:35>> with timing and all of that kind of
20:36stuff. But
20:38I've definitely seen a lot of patients
20:40who have a diagnosis of PCOS who have
20:42had multiple multiple pregnancies. So
20:45>> Yeah, I'm sure you've seen patients like
20:46roll up in triage to Sydney and you're
20:48starting to take the history and you
20:50hear PCOS and then they'll say something
20:51like, "Oh, you know, it's funny. My you
20:54know, doctor when I was a teenager and
20:57was diagnosed with this told me I could
20:58never get pregnant and here I am, right?
21:00>> am on baby number three.
21:01>> So [laughter] again, I I don't I don't
21:02want that to take away from the
21:03experience of people who have struggled
21:05with their fertility due to PCOS, right?
21:07>> Yeah, cuz that is a real thing, too.
21:09>> 100% and still very hard. But it is
21:12certainly not a reason in and of itself
21:15to carry the burden of a diagnosis of
21:17infertility or subfertility before
21:19you've even started trying to get
21:21pregnant.
21:22>> Yeah.
21:22>> Um and definitely definitely again,
21:25especially to our younger listeners who
21:27perhaps do not want to get pregnant
21:29right away,
21:30>> Yeah.
21:30>> do not count on your PCOS to prevent
21:32pregnancy, especially if you're having
21:34somewhat regular unprotected
21:35intercourse.
21:36>> Yes, yeah. And you know, that kind of
21:38highlights
21:39the difficulties that people with PCOS
21:41experience with with infertility, but
21:44also just the the symptoms. The symptoms
21:46that they experience like um can be very
21:49difficult, too. So,
21:51um you know, it could be frustrating
21:53when you don't know when your period's
21:54going to come.
21:55>> I could imagine that that would be
21:56>> Yeah.
21:57That would that would cause me a lot of
21:58stress if I if I couldn't keep track of
22:01that at all. And you know, the emotional
22:05toll of the symptoms as well, um the
22:07hair thinning,
22:08>> Yeah.
22:08>> the
22:10What are What are some of the other ones
22:11you were saying? The irregular hair
22:13pattern growths as well. So,
22:15>> Yeah, so people can get growth on the
22:16face like hair growth on their face, on
22:18their chest.
22:19>> Kind of more of a male pattern
22:21typically.
22:21>> Okay.
22:22>> Sometimes because of insulin resistance,
22:24people can find that again that they are
22:26putting on weight when they're not
22:27trying to put on weight, right? Or that
22:29they're finding it really really
22:30difficult or impossible to take it off.
22:32>> Yeah, yeah.
22:33>> Um sometimes people can develop what's
22:35called acanthosis nigricans, which is um
22:37like a darkening of the skin
22:39particularly in like flexural areas. So,
22:41like creases of our body, like
22:44>> elbow like the inside of your elbow,
22:46around your neck, things like that.
22:47That's also associated with insulin
22:49resistance.
22:50>> Gotcha, yeah.
22:51>> Um and uh irregular periods, right?
22:53>> Okay. And what are some things that you
22:56as the doctor can do to help with these
22:59symptoms and help with the underlying
23:02diagnosis of PCOS. How do we manage this
23:04diagnosis?
23:05>> Oh my gosh, in so many cool different
23:07ways. But if I can redirect us for one
23:09moment before Sydney takes me down the
23:11management, and I know you guys want to
23:12hear about the management, and I want to
23:14talk about the management. But if you'll
23:16entertain me for 1 second.
23:17>> Yeah, of course.
23:18>> Let me talk about a little bit about the
23:19genetics of PCOS because I think that
23:22this is really interesting, and again,
23:23is a really like emerging area.
23:26>> Absolutely. So,
23:27>> Oh.
23:28>> that there's a genetic link with PCOS
23:30for quite some time. And part of that
23:32comes back to twin studies where we have
23:33looked at like do siblings, do twins, do
23:37families
23:39develop diseases at a higher rate than
23:41other families. And that
23:42>> Yeah.
23:43>> I think you know, bench scientists,
23:44correct me if if you feel that this is
23:47like way off base, but I find that
23:48that's often times where these like
23:50hypotheses begin, right?
23:52>> Is in finding an association in family
23:55studies,
23:55>> Yeah.
23:56>> and then having to say, "Okay, what
23:58genes could be implicating implicated in
24:00this? Why is this happening in families
24:03more so than in non-related
24:05populations?" So, we've known for a
24:07while that the prevalence of PCOS is
24:09higher
24:10um in mothers and sisters and daughters
24:12of PCOS women than in unrelated women.
24:15>> Okay.
24:16>> So, in families where PCOS is present,
24:18the prevalence is more like 20 to 40%
24:20>> Oh, wow.
24:20>> as opposed to that kind of 10% baseline.
24:23>> Wow.
24:23>> Which is is a significant difference,
24:26right?
24:26>> Yeah.
24:27>> Um
24:27and how we're kind of coming to
24:29understand it, there are certainly some
24:31genes that we're seeing associated with
24:33PCOS, but we're also finding that there
24:35is an epigenetic component to PCOS as
24:38well. Which in brief kind of talks about
24:40the way that our environment um which
24:42includes things like lifestyle and diet
24:44and exposures
24:46um affect whether or not a gene that we
24:49possess is expressed. So, whether or not
24:52we experience symptoms, side effects,
24:54disease development or not. So,
24:58epigenetics again in brief kind of means
25:00whether our genes are turned off or
25:02turned on without actually changing the
25:05code.
25:06And so, it's like if you imagine like
25:08the wiring in your house for lights. You
25:10can turn on or off those lights, but
25:12that doesn't actually change how the
25:14house is wired, right?
25:16Epigenetics are the same, right? The
25:18brightness can change depending on
25:20outside factors, but the wiring may
25:22remain the same. So, again we think that
25:23there is some wiring associated with
25:25PCOS. There are some genes that are
25:27associated with PCOS. But whether or not
25:30they turn get turned on depends on other
25:33factors that again we're beginning to
25:34kind of suss out.
25:35>> Okay.
25:36>> Um
25:37and
25:38this is kind of why we think that this
25:40condition can develop and run in
25:42families and also can present really
25:43differently in different families and in
25:45different people.
25:46>> Yeah.
25:46>> Um the DNA itself doesn't explain it
25:49all, right?
25:50>> Interesting.
25:50>> Um and so, there's a few different
25:51things that we think are impacted here.
25:54One is the DNA methylation, um which
25:56kind of acts like a dimmer switch for
25:58>> Yeah.
25:59>> genes.
25:59>> Yeah.
26:00>> Um
26:01and this is potentially what is
26:02impacting like the the unbalance I
26:05suppose if you will of um the hormones
26:08and their impact on metabolism as a
26:10whole.
26:10>> Mhm.
26:11>> Um we also think that there may be an
26:13issue with histones, which are kind of
26:15the packaging of DNA. It's like a
26:17proteins that the DNA wraps around. And
26:19if they're packed too loosely or too
26:21tightly, the wrong genes may get
26:23switched on or off.
26:24>> Yeah.
26:25>> Um and then the last thing is something
26:26called microRNA, which are small
26:28molecules that basically block certain
26:30genes from making proteins.
26:31>> Yeah.
26:32>> Um and in PCOS we think that microRNAs
26:35can potentially make hormones and
26:36metabolism problems worse.
26:38>> Mhm.
26:38>> Um so, these changes may begin before
26:41birth, but they also can be influenced
26:43by things like environment and
26:44lifestyle.
26:45>> Okay.
26:46>> Um so, again that's why PCOS certainly
26:48seems to run in families, but also can
26:50look different person to person within a
26:53family, and certainly can look different
26:54family to family.
26:55>> Yeah.
26:57Interesting.
26:57>> I think it's cool.
26:58>> No, it is cool.
26:59>> it's interesting. [clears throat]
27:00>> So, what you're saying is potentially
27:03also like
27:04some people might
27:07might be overweight and some people
27:09might not be.
27:10>> 100% and we are seeing that in PCOS
27:13phenotypes.
27:14>> Yeah.
27:14>> So, we are certainly seeing some
27:16phenotypes where people have, for
27:17instance, irregular ovulation and weight
27:21gain, but maybe perhaps not other
27:23features. Or we see that very frequently
27:25with like a normal BMI PCOS picture,
27:27right? Like we certainly see people who
27:29don't meet that phenotypic but
27:31phenotype, by the way, is like the way
27:32that people the way that uh genes
27:35express visually, right? That we can
27:37see. So, um as like a as as
27:39oversimplification, but um that's why we
27:42can see some people that, again, are
27:44normal BMI when we perhaps would expect
27:46a higher proportion of people to have
27:48higher BMI or to be in larger bodies. Um
27:51but have all the same dysfunction,
27:53right? From the hormonal perspective.
27:55>> Interesting. And then when you're saying
27:57environmental factors, so is
28:00you know, diet changes and lifestyle
28:02changes, is that part of your management
28:04plan when
28:05um dealing with
28:07people with PCOS? Like does that help
28:09everyone or is it very individualized?
28:11>> So, absolutely, lifestyle factors are
28:14mainstay of like first-line PCOS
28:16management. Um and I think what we
28:19choose with respect to management kind
28:22of depends on like what we're targeting
28:24and why, right? Because as we've
28:25discussed, PCOS has implications that
28:28run downstream. It's not just the
28:31hormones themselves.
28:32>> Yeah.
28:32>> Um
28:33and again, just as a brief summary
28:35before we get into it, some of the
28:37things that people experience are,
28:39again, absent or irregular periods,
28:41right? And that's caused by a lack of
28:43ovulation or irregular ovulation. Cycles
28:46can be long, unpredictable, skipped
28:48altogether, right?
28:49>> Mhm.
28:50>> Um they uh we also can have
28:52androgen-related symptoms, right? Caused
28:54by that excess of testosterone and other
28:56androgens within the body.
28:57>> Yeah.
28:58>> Um that can present like acne,
28:59especially persisting beyond teenage
29:01years.
29:02>> Okay.
29:02>> Something we call hirsutism, which is
29:04extra coarse hair growth, particularly
29:06in places like the chin, on the chest,
29:09the upper lip, shoulders, stomach, back.
29:11>> Mhm.
29:12>> Um scalp hair thinning or even male
29:14pattern hair loss can be one as well.
29:17Um infertility, as we've discussed. And
29:20again, the main issue with infertility
29:22is is anovulation. It's not releasing an
29:24egg.
29:24>> Yeah, the whole timing of it, you can't
29:26quite get right.
29:27>> Exactly.
29:28>> Mhm.
29:28>> And then there are some long-term risks
29:30associated with PCOS as well.
29:32>> Okay.
29:33>> So, we know that when we are not
29:35shedding we are when we are not
29:37ovulating, we are often not receiving
29:38the signal then as well to shed our
29:40endometrial lining, right?
29:42>> Okay.
29:44>> uh when we ovulate, uh again, go back
29:46and listen to the This is Your Body on
29:48the Pill episode.
29:49>> It'll make more sense.
29:50>> proud of that explanation.
29:52>> complex. [laughter]
29:53I have to say, like, even learning about
29:55about the menstrual cycle in school, I
29:57remember almost being in tears trying to
29:59understand it truly because it was just
30:02so complex, but I do find the way you
30:05explained it was one of the first times
30:07I feel like it really made sense.
30:08Sydney, I'm so glad
30:10it made sense. It's true. It's true. Cuz
30:11it is a it's a tough one. I have to say.
30:13>> Even Dan understood it.
30:14>> Even Dan understood it.
30:15>> You guys can see that off camera, but
30:17Sydney's husband
30:18>> Yeah, now my now husband.
30:20>> husband, [laughter] Dan, is always just
30:22off camera managing our sound. And uh
30:24and he afterwards, too, was like, "Wow,
30:26that's so cool."
30:27>> Exactly.
30:28>> And I'm joking, guys. I'll explain it as
30:30many times as you want. But But briefly,
30:32um when we release that egg,
30:35>> Yeah.
30:35>> right? From the dominant follicle, kind
30:37of the shell of the egg, if you will,
30:39>> Yeah.
30:39>> remains kind of hormonally active. And
30:42it start It's called the corpus luteum.
30:44And it starts producing a hormone called
30:46progesterone.
30:47>> Yeah.
30:47>> Which helps to stabilize the endometrial
30:49lining or the inner lining of the
30:51uterus, which has grown nice and thick
30:52and plush in order to be a soft place to
30:55land for a fertilized egg to develop.
30:57>> Yeah.
30:58>> So, the the corpus luteum produces that
31:00progesterone, stabilizing that lining,
31:02but if no implantation occurs, it kind
31:04of can't sustain things all on its own,
31:07right? And so, it involutes, the
31:09progesterone level drops, and it's that
31:11drop that signals to your uterus to
31:13start contracting to shed the lining.
31:15>> gives you your period.
31:16>> Exactly. So, if we don't get that corpus
31:18luteum cyst,
31:19>> Yeah.
31:19>> we don't get that progesterone drop,
31:21which means we don't receive the signal
31:22to shed our lining.
31:23>> Mhm.
31:24>> And an endometrial lining that builds up
31:26over time is what we would call
31:28unopposed um
31:30uh estrogen, right? We are still
31:32producing some estrogen during PCOS, but
31:34it's not
31:35countered by that progesterone, and then
31:37the progesterone withdrawal to cause the
31:40lining to shed.
31:41>> Mhm.
31:41>> And we know that processes that are left
31:43unchecked over time
31:45>> Mhm.
31:45>> are um particularly vulnerable to
31:47mutations, right? And cancer very
31:50frequently is caused by mutations,
31:52right?
31:53>> Yeah.
31:53>> So, PCOS in the long run does carry with
31:56it an elevated risk of endometrial
31:58cancer, so cancer of that inner lining
32:00of the uterus. But specifically again,
32:02when it's not managed.
32:05>> Okay.
32:05>> Right? So, this is if people are not
32:06having periods
32:07>> Mhm.
32:08>> for many, many years, over a long period
32:10of time, right? And and not having
32:12periods like for longer than 3 months at
32:15a time.
32:15>> Right.
32:16>> Now, so where my brain goes is I have an
32:19IUD right now, and my body doesn't, you
32:22know, I don't usually have a period or
32:24I'll have a small period.
32:25>> yeah.
32:25>> Um however, I know that IUDs prevent
32:29that endometrial lining from becoming
32:32thick and needing to necessarily shed.
32:35So,
32:37my my not doctor brain is thinking,
32:39well, wouldn't IUD be helpful for these
32:41patients then?
32:41>> Absolutely. An IUD is definitely helpful
32:44for protection of the endometrium,
32:46right? In the context of PCOS.
32:48But, it doesn't tackle everything we
32:50might want to tackle. I'm going to get
32:51into that in a second. I realize I'm
32:53like ruining Sydney's flow so much in
32:55this
32:55>> No, [laughter] you're not. I'm I'm
32:56literally No, no, no, you're not. I'm
32:57just thinking about these things. I'm
32:58like, "Ooh, I feel like an IUD would fix
33:00this."
33:00>> You're right. An IUD does. An IUD
33:02totally addresses that. An IUD totally
33:05addresses that. Guys, I like these gynny
33:07episodes. Sydney's just going to like
33:09kill me through them because [laughter]
33:11I'm such a huge geek about it and I love
33:13talking about it. And so, I feel like
33:15I'm just like a woman on a mission every
33:17time we we have a gynny episode.
33:19>> No, I'm not even following the the our
33:20little layout right now. I'm just like I
33:22genuinely thought [laughter] an IUD
33:24would be cool. Like it would fix it.
33:26>> It is. It is. It totally is. Put a pin
33:28in that for us. We're coming back to it.
33:30>> [laughter and gasps]
33:31>> So, the other long-term risks associated
33:32with PCOS are metabolic risks, right?
33:35And what I mean by that is the risk of
33:38greater um
33:40endocrine issues due to things like the
33:42elevated rather the insulin resistance,
33:45right?
33:45>> Yeah.
33:46>> So, many people with PCOS, as we've
33:48discussed, have higher levels of insulin
33:50and increased insulin resistance, which
33:52eventually can progress to diabetes.
33:54>> Mhm.
33:54>> And so, people with PCOS do have a
33:56three- to four-fold
33:57higher risk of type 2 diabetes over
33:59their lifetime. That's independent of
34:01age and BMI.
34:02>> Yeah.
34:03>> But, I think it's it's
34:05important to note as well that that risk
34:07is actually strongly modified um by
34:10adiposity in favor of increasing the
34:12risk.
34:13>> Mhm.
34:13>> Um adiposity, what I mean by that is
34:15having just greater fat stores on the
34:16body, right?
34:18>> Um so, for people who are in larger
34:20bodies, who have greater fat stores,
34:22>> Yeah.
34:22>> the risk, depending on size, can be up
34:25to eight times higher.
34:26>> Wow.
34:26>> Right?
34:27Um the other thing is cardiovascular
34:29risk as well. PCOS is linked with higher
34:32rates of high blood pressure, abnormal
34:34cholesterol, and heart disease later in
34:36life. Now, the effect of PCOS on those
34:38things is less pronounced. It's about 1
34:40and 1/4 to 2 and 1/2 times higher.
34:43>> Yeah.
34:43>> Um but I think what's important to note
34:44as well, like I think most of our
34:46audience is fairly young, right? And the
34:49absolute risk, right? So, the baseline
34:51risk of those things happening
34:53>> Yeah.
34:53>> Um is very low in young women, right?
34:57So, even a like 1.25 increase is still
35:00going to give you a number that is a
35:02very low risk of having heart disease.
35:04>> freak out.
35:04>> Especially if you're you're in your like
35:0620s or 30s, right?
35:07>> Yeah. Yeah. Yeah. Yeah.
35:08>> But as age increases, right?
35:10>> Then your risk increases.
35:11>> Especially with things like weight gain
35:13and other comorbidities like development
35:15of diabetes,
35:16>> Mhm.
35:16>> that rate does go up.
35:18>> Okay. Okay. So, now Sydney, we're going
35:19to get into what we can do about it.
35:20[laughter]
35:21I'm like, I just want I just want you to
35:23tell people how to fix it.
35:24>> Like, Sydney, I have a plan. I'm getting
35:26there. Give me a second.
35:28>> ahead. I'm jumping ahead.
35:30>> [laughter]
35:30>> Okay. Well, what what is your first-line
35:32treatment? What what do you do?
35:33>> So, first and foremost, lifestyle
35:36modification is is really really healthy
35:38helpful, right?
35:39>> Helpful and healthy.
35:40>> Helpful and healthy. So, healthy eating,
35:42weight management, and physical activity
35:44are all things that have really good
35:45positive impacts on PCOS as well as
35:47mitigating the risk of those long-term
35:49consequences, right?
35:50>> Okay. Yeah.
35:51>> Um so, these changes improve our
35:53metabolism and our reproductive hormones
35:55as well as inflammation within our
35:56bodies.
35:57Um
36:00And uh and there is some Like I like
36:03hesitate to to frame this for a second
36:05because I think there's a lot of of
36:09companies and groups out there who are
36:11really trying to like profit from women
36:14off of women and this diagnosis in
36:16general.
36:17>> Mhm.
36:18>> There is some beginning evidence that
36:20perhaps diet and lifestyle modifications
36:22can start to reverse some of the
36:24epigenetic effects of PCOS, right?
36:27>> So, cuz a lot of the things we're going
36:29to talk about with treatment are really
36:30like managing the downstream things,
36:32right? Not necessarily that like that LH
36:35FSH dysfunction to begin with. Um but
36:38there is some evidence that in diet, in
36:40lifestyle, we can perhaps begin to turn
36:43off those gene signals.
36:45>> Interesting.
36:45>> Now, there is no good study that shows
36:48that like one diet or one lifestyle
36:51modification is going to like do that
36:53entirely for every single person, right?
36:55Because like anything, this is
36:57multifactorial, which means that there's
36:59a bunch of genes associated with PCOS.
37:01There's a bunch of different epigenetic
37:04effects, right? Like the histones, the
37:06methylation, the micro RNA, all of those
37:09things are not necessarily going to
37:10respond to the same treatments, right?
37:13>> yeah.
37:13>> Um but this is very much a watch this
37:15space, and I think further kind of onus
37:18for diet lifestyle modifications to be a
37:21focus in anyone's PCOS management,
37:23right?
37:23>> Okay. Okay.
37:24>> Now, medical options as well.
37:26>> Mhm.
37:27>> Um so,
37:28one of the mainstays of medical option
37:31is a combined oral contraceptive or a
37:33birth control pill, right? Now, for many
37:36people, we might not be necessarily
37:38using this for contraception, right?
37:40>> have patients certainly who've like
37:42had a salpingectomy, right? Had their
37:44tubes out, who have no plans to get
37:46pregnant, right?
37:48>> Um and or who don't even need
37:50contraception, right? But the reason
37:52that an oral birth control pill is
37:54helpful in this case, a combined oral
37:56contraceptive specifically, is because a
37:59combined oral contraceptive contains
38:01both estrogen and progesterone, right?
38:04The estrogen component to the birth
38:06control pill increases something called
38:08sex hormone-binding globulin.
38:10>> Mhm.
38:11>> And it kind of is like pretty aptly
38:13named. I like to think of sex
38:15hormone-binding globulin as a bus that
38:17just like drives around our bodies, and
38:18it just mops up excess hormone that's
38:21hanging out. And so, what that does is
38:23it binds up free testosterone to make it
38:26less active.
38:27>> Uh progestins also keep the endometrial
38:29lining nice and thin, which is going to
38:31decrease that risk of endometrial cancer
38:33in the long run.
38:34>> Okay.
38:35>> Um so, I think the thing that is nice
38:37about the combined oral contraceptive is
38:40that it kind of does twofold action,
38:42right? Progestins alone do decrease some
38:45of the production of androgens
38:46>> Yeah.
38:47>> based on decreasing that LH production
38:49or that I LH um
38:51release.
38:52>> Release, yeah.
38:53>> Um but it's not quite as strong as like
38:55driving that bus around to collect all
38:57of the free testosterone and androgens
38:59that are already circulating in your
39:00bloodstream.
39:01>> Okay.
39:01>> Uh which we can do by giving estrogen
39:04and which in turn as we discussed
39:06increases sex hormone binding globulin.
39:08>> Yeah.
39:08>> By the way, this is like the bus analogy
39:10is something I've thought about for a
39:11really long time. Like literally, I
39:12remember studying for my board exams.
39:14>> Yeah.
39:15>> Uh Royal College exams in Canada for the
39:17Americans. I sometimes refer to them as
39:18board exams in an international kind of
39:20setting.
39:21>> makes sense.
39:22>> Um but it's called the Royal College
39:23here in Canada.
39:24Um
39:25But yeah, that's how I remembered the
39:27details around sex hormone binding
39:28globulin. I just like thought of a
39:30little bus driving around and picking up
39:32different uh
39:33>> [laughter]
39:33>> different sex hormones as it went.
39:35>> Yeah, it's totally cute. Sometimes you
39:37got to be creative with
39:39>> You got to
39:40whatever works,
39:41right? Whatever works.
39:42>> Yeah.
39:43>> As you mentioned, these processes can be
39:44really complicated.
39:45>> Yeah.
39:46>> And I'm sure not to like toot my own
39:48horn a little bit, but
39:50>> it was so esoteric. It was so detailed
39:53on the Royal College exam.
39:55>> Yeah. Yeah.
39:56>> Uh the level of detail I needed to know
39:57just like made my brain hurt. And so, uh
40:00so
40:01>> You have to do it, yeah.
40:02>> Got to do what you got to do.
40:03>> Listen, it's coming in handy now.
40:04>> I hope the bus works for you guys, too,
40:06[laughter] cuz that's what I think about
40:07when I when I think about sex hormone
40:09binding globulin.
40:10>> Yeah.
40:11>> Anyway, progestin-only methods also
40:12great, right? And again, like I I will
40:14prescribe those to patients, especially
40:16for those for whom an estrogen may be
40:18contraindicated or maybe they're
40:20particularly sensitive to estrogens.
40:22>> Like a history of
40:24>> Like blood clot for instance, right?
40:26>> Yes.
40:27>> um
40:27>> Or migraines.
40:28>> Migraine headache with aura, right?
40:30Would be contraindications to
40:31estrogen-containing combined oral
40:33contraceptives.
40:34>> Yeah.
40:34>> Um again, we talk about all of that in
40:36our our [laughter] episode on Your Body
40:38on the Pill.
40:39>> We're really heavy-handed, I think, with
40:40this promotional push for a
40:42>> No, but it is such a
40:43>> [laughter]
40:43>> good I just feel like it goes so hand in
40:45hand. It's such a good intro to this
40:47episode.
40:47>> It is a really good intro to this
40:48episode.
40:49>> keep going.
40:50>> You're right, you're right. Now, so
40:52that's what we can do for decreasing
40:54that LH release and also kind of mopping
40:57up the androgens that are already there
40:59that are causing like the acne and the
41:01hair growth and the like male pattern
41:03like hair loss.
41:04>> Okay.
41:05>> Um but what we can we do for the insulin
41:07component, right? What can we do to
41:08decrease our risk of um diabetes in the
41:11long run, to help manage weight loss,
41:13that kind of thing?
41:14>> Yeah.
41:15>> Well, there's good evidence actually for
41:17metformin, which is a very common
41:19medication used in diabetes in general,
41:22right? In type 2 diabetes.
41:24>> Um so metformin basically makes the
41:26body's cells more sensitive to insulin.
41:29That way they can take up the sugar more
41:31effectively.
41:32>> Mhm.
41:32>> Um and this then lowers circulating
41:34insulin levels, which in turn reduces
41:36the ovaries' drive to make
41:38uh excess androgens, right?
41:40>> Yeah.
41:40>> Um and sometimes that helps improve
41:42cycles um and even provide a more
41:45regular ovulation pattern with PCOS. So
41:47metformin has actually really good
41:49evidence for it.
41:50>> Yeah.
41:51>> Um now increasingly as well, we are
41:53seeing some evidence with GLP-1 receptor
41:55agonists, so more commonly known as
41:57things like Ozempic or Wegovy.
41:59>> Mhm.
41:59>> Um they also improve insulin resistance
42:01in PCOS and some other metabolic issues
42:04associated with the syndrome as well.
42:06>> Yeah.
42:06>> Um there's some early lab research as
42:08well to suggest that both of these
42:09medications may also help to reset some
42:12of those epigenetic changes.
42:14>> Yeah.
42:14>> Although again, this hasn't been shown
42:15clearly in human trials. We are not like
42:17counseling patients that they can turn
42:19back the clock on their PCOS with
42:22Metformin and Ozempic.
42:23>> Ozempic, yeah.
42:24>> But it is a but but there certainly is
42:27good evidence that is well supported in
42:29all guidelines for the metabolic
42:30benefits of both of those medications.
42:33Um I think just with respect to the
42:35epigenetics, it's an evolving area, but
42:37something that's really cool to think
42:38about and and a really promising area of
42:40study I think for PCOS in general.
42:42>> Yeah, that maybe we can do also future
42:45episode on
42:46>> Totally.
42:46>> once evidence gets a little bit more.
42:48>> We'll update you as we go, guys.
42:50>> Yeah.
42:50>> So listen,
42:51let's say we're on a birth control pill,
42:54right? We maybe have even added some
42:56Metformin. So we're improving our
42:59metabolic health, we're able to lose
43:01some weight perhaps. We are our
43:04endometrium is protected. We've mopped
43:06up the excess androgen, but what if
43:07we're still experiencing those symptoms
43:10of acne, of hair loss, of abnormal
43:13patterns of hair growth?
43:14>> Mhm.
43:15>> Um well, that's when an anti-androgen
43:17come can come into play. And something
43:19like a spironolactone is a really nice
43:21choice for that.
43:22>> Mhm.
43:23>> So basically, what that does is it binds
43:24androgen receptors in the skin.
43:27So testosterone and other androgen
43:29derivatives can't bind and trigger
43:31things like acne or excess facial hair,
43:33right?
43:34>> Mhm.
43:35>> It also reduces androgen production in
43:37the ovaries uh to a smaller extent.
43:40>> Okay.
43:40>> So basically, if we can't if we're
43:42driving the bus around and we can't grab
43:44enough of it, right? And decreasing the
43:46production isn't really enough,
43:48>> Yeah.
43:49>> then what we can also do to help
43:50people's symptoms is to
43:52cover those block those receptors in the
43:55skin and tissues that would be otherwise
43:57responsive to the testosterone that
43:58would be causing the acne.
44:00>> Yeah.
44:00>> So again, it's a little bit more of a
44:01downstream effect, but it certainly is
44:04something that can be a really nice
44:05adjunct therapy, especially when people
44:07are experiencing the acne, the hirsutism
44:10in a higher amount, okay? Now, what
44:13about uh patients who are are wanting to
44:16get pregnant, but are having trouble
44:18timing that ovulation because they don't
44:20know when they're going to ovulate. Is
44:21there something that can help with
44:24um inducing ovulation, I guess?
44:27>> Absolutely.
44:28>> Yeah.
44:28>> Um and I'll I'll say just before we get
44:30into that part as well that if you are
44:32looking to get pregnant, something like
44:33a spironolactone is actually not a good
44:35option.
44:36>> Okay. It's contraindicated for Okay.
44:38>> is. So, number one, it doesn't It
44:40doesn't fix the underlying issues with
44:42PCOS, so it's never kind of like our
44:44only our best management when used in
44:46all of its own. It's usually paired with
44:48something to to manage those other side
44:50effects of PCOS.
44:52>> Um [snorts] but it also can
44:54um
44:55cause problems, especially for male
44:57fetuses being developed, right? Because
44:59it blocks androgen.
45:01>> That's right.
45:02>> usually don't recommend
45:03not usually, we don't recommend
45:05spironolactone in the context of trying
45:08to conceive.
45:09>> Yep.
45:09>> Um and certainly, we actually typically
45:10recommend also using contraception,
45:13right?
45:13>> Yeah. Yeah.
45:14>> Again, number one because the combined
45:15oral contraceptive has all the benefits
45:17we've listed already for PCOS, but also
45:19because it prevents pregnancy in that
45:21context.
45:21>> Yeah. Yeah.
45:22>> Now, fertility treatments are available
45:24for PCOS.
45:26And I won't get into too many of the
45:28details. Number one, because I'm not a
45:30reproductive endocrinologist and
45:32infertility specialist. I'm not an REI.
45:34That was not the fellowship that I did.
45:36>> Yeah.
45:36>> Fertility can be multifactorial,
45:38>> Yeah.
45:39>> and can get very complicated very
45:41quickly. To hear some of my colleagues
45:42talk about and like get into the weeds
45:44of of fertility treatments,
45:46>> Yeah.
45:46>> it's so cool. The medicine is so cool in
45:49that area. I will just be the first to
45:51say that I with respect to understanding
45:53of fertility, I'm a generalist in that
45:55area, and I I I won't uh I won't claim
45:59to know even a fraction of what my REI
46:01colleagues do.
46:02>> a fertility specialist on here though.
46:03>> Oh, for sure. We will in the future.
46:06For sure.
46:07Um but there in brief, we with
46:11perspective fertility related to
46:12anovulation, I do kind of want to talk
46:14about that because I think again people
46:16really worry about their fertility when
46:18they've been diagnosed with PCOS.
46:20And there are medications we can use to
46:23make you ovulate, right? If anovulation
46:26or lack of ovulation is the main problem
46:28with PCO, there actually are medications
46:31that we can use to prompt ovulation,
46:34right? And one of those would be
46:35letrozole.
46:36Uh so letrozole is an aromatase
46:37inhibitor, and basically what it does is
46:39it lowers estrogen briefly which tricks
46:41the brain into releasing more FSH.
46:44The FSH then stimulates the ovary to
46:46mature and to release an egg.
46:49Um and it is shown in multiple trials to
46:52be quite effective. Now, we used to use
46:53a medication called Clomid. Um it's also
46:56not available anymore in Canada or at
46:57least
46:58at the time I wrote my Royal College
47:00exam, it was not available in Canada. Um
47:03but in some studies the letrozole has
47:05been shown to be more effective in any
47:07case. And And further into the weeds I
47:09will not go because I'm sure my REI
47:12colleagues would be very quick to say,
47:13"Well, in this case or in that case."
47:15And they'd be totally totally right. Um
47:18but I think again like it's important to
47:20know that there are options for
47:22fertility associated with PCOS,
47:24particularly if the only problem we're
47:26dealing with is ovulation, right? That's
47:29a thing that has some really good
47:31evidence for it and good solutions
47:33available. Um practically speaking, I
47:36would refer a lot of my patients who are
47:38trying to conceive with PCOS to a
47:41fertility clinic. Um I realize that's
47:43not always an option everywhere, either
47:45because of lack of access to fertility
47:47clinics or perhaps because of financial
47:49costs in areas where the visits
47:51themselves, you know, we're very lucky
47:53in Canada the visits to fertility
47:55themselves are covered under um our our
47:58health care.
47:59>> Yeah.
47:59>> Um our universal health care, although
48:01IVF for instance and some of the
48:03treatments are not necessarily always
48:05covered in every province. But in other
48:08places, of course, fertility clinics are
48:09much more private, stand-alone and and
48:11there's costs associated with that. I
48:13know that there are some general OBGYNs
48:15who do do dabble in some of this initial
48:18fertility management, especially for
48:20conditions like PCOS. Um and so seeking
48:23out a provider that feels comfortable
48:24navigating that with you, whether it be
48:26through a referral to fertility clinics
48:29or through, you know, seeking a provider
48:31or referral to a provider that is able
48:33to start some of that management, I
48:35think can be really, really helpful. Um
48:37now, as we stand with PCOS,
48:40there isn't necessarily like a cure,
48:42right?
48:42>> Yeah.
48:43>> Cuz this is again, it's multifactorial,
48:44it's genetic, it's epigenetic.
48:46>> Yeah.
48:47>> Um but I think what's should be
48:49heartening, I hope, for people listening
48:51is that there are lots of management
48:52options that can be really effective.
48:54>> Yeah.
48:55>> Finding the right one for you can be a
48:56challenge because there's so many
48:58different variations of it, as we've
48:59talked about, right? But there are
49:02solutions available, there are ways that
49:04we can improve the symptoms that you're
49:05experiencing at the very least.
49:07>> Yeah, that makes sense.
49:08>> Now, Sydney, I know that you've done
49:09some reading and some looking online
49:11about kind of what the the the
49:14sentiments are out there. What are
49:15people saying about PCOS?
49:17>> Yeah, which I
49:18you know, this is kind of where I want
49:19you to come in and and
49:21fact-check
49:23all of these things because, you know, I
49:25think with anything you see online, you
49:27know, take it with a grain of salt.
49:29It's probably not true, but that's why
49:32we, again, created the Push Podcast to
49:34hopefully decrease some of that
49:35misinformation online, but um
49:38so much on
49:41um diet changes and how, you know, well,
49:44if I I try I cut out gluten from my diet
49:47and you know, my acne got so much
49:49better, my um my symptoms completely
49:52disappeared or I cut out sugar
49:54completely. That was a huge one. Sugar
49:56and gluten were like everywhere.
49:59>> What what is the evidence like I know
50:01you said earlier in the episode diet
50:04diet does play a role. So um but does
50:07that necessarily mean that you need to
50:09go gluten-free and sugar-free or does it
50:11just mean from a generalized perspective
50:13of just making sure you're having a war
50:15well well-balanced well-rounded diet?
50:17>> I mean definitely well-rounded
50:19well-balanced diet is a great mainstay.
50:23And I think irrespective of specific
50:24dietary approach, we do have lots of
50:27evidence that especially for people in
50:29larger bodies even modest weight loss.
50:31So even like 5% of your body weight can
50:33improve insulin resistance and your
50:35hormone balance and ovulation in
50:37general. Now there have been some
50:39studies that have looked at different
50:40diets like the Mediterranean diet, a low
50:42glycemic index diets, even the keto
50:45diet. And there are lots of studies that
50:47have shown benefit with different
50:49dietary interventions. However, I think
50:51what makes it challenging as we sit back
50:53here as providers to like give cart
50:55blanche advice to anybody is that when
50:58we've looked at these diets in
50:59comparison to one another, right now it
51:02doesn't look like there's one that's
51:03superior, right? So certainly having a
51:06well-rounded healthy diet is helpful. Um
51:10some specific diets have shown good
51:12effect with PCOS for like things like
51:14return of ovulation and insulin
51:15resistance.
51:17Um but right now we don't have enough
51:18evidence to say that like one is
51:20obviously better than the other for
51:21everybody. And it's possible that we may
51:24not have good evidence at least for a
51:26while on that, right? In part because as
51:28we've like discussed ad nauseam in this
51:31episode, PCOS is really really different
51:35amongst different people even within the
51:36same family, right? So it kind of makes
51:39sense intuitively that what works for
51:40one person might not work for another
51:42person. But my advice with all, you
51:44know, lifestyle modifications, diets,
51:46things like that for my patients. Um and
51:49I get this question a lot with other
51:51disorders, too, right?
51:52>> Yeah. Yeah, yeah, yeah.
51:53>> Is if there's something that you want to
51:54try, if you feel like it's not going to,
51:56number one, break the bank, right? If
51:58it's not going to cause harm to you,
52:02um and if you feel like it's reasonable
52:04in the context of your life, right? I
52:06don't want someone to be miserable
52:07because they're cutting out everything
52:09that is enjoyable to them or doing a
52:11diet that like really doesn't fall in
52:13line with their culture or their eating
52:15habits or their their lifestyle.
52:17>> Yeah.
52:17>> Um as long as it doesn't, you know, it
52:19meets that those criteria, I say go for
52:21it, right? Regardless of whether I have
52:23specific evidence for, you know, benefit
52:27or benefit specifically, right?
52:29>> Yeah.
52:29>> Yeah, and also, you know, taking caution
52:31in supplements and advertisements for
52:34that kind of stuff online just because I
52:36think that with a like with a lot of
52:38things, it's
52:41it's targeting
52:42>> Yeah.
52:42>> your need to treat to treat the symptoms
52:46of PCOS and it might not necessarily be
52:49doing any anything other than
52:51um making you spend money.
52:52>> [laughter]
52:53>> This is the thing.
52:53>> So, run those things by your doctor.
52:55>> Totally. Everyone wants to make the
52:57silver bullet, right? For any disease.
52:59Every any any company wants to do it.
53:01>> Yeah.
53:01>> And I think I remind my patients a lot,
53:03I have no problems with, you know, the
53:05natural health industry as like a
53:07general concept.
53:08>> Yeah.
53:08>> But I do remind my patients a lot that,
53:10especially as we, quite rightly, like
53:13scrutinize the pharmaceutical industry
53:15for lots of their practices, the natural
53:18health industry is also a for-profit
53:20industry.
53:21>> Yes.
53:21>> Right? That is actually under
53:22considerable considerably less scrutiny
53:25>> Yeah.
53:25>> than the pharmaceutical industry.
53:27>> Yeah.
53:27>> Right? Just because it's natural doesn't
53:29mean that they're not looking to make
53:30money off of you in the same way or
53:32sometimes more aggressively than the
53:34pharmaceutical industry. So, again,
53:36doesn't mean that those things can't be
53:37helpful, but I think it is a good grain
53:39of salt to take anytime we're
53:40considering things like supplements,
53:42right? Now, there is one supplement that
53:44we're beginning to see some interesting
53:46evidence for. And that one is called
53:47inositol.
53:49So basically it's a naturally occurring
53:50sugar involved in insulin signaling
53:53and in ovarian hormone production.
53:55Um supplements are widely available and
53:57they're generally considered to be safe.
53:59Um research has shown that there is
54:01perhaps a modest improvement with use of
54:04inositol in menstrual regularity and
54:06ovulation insulin sensitivity as well as
54:09some androgen related side uh symptoms.
54:12Um
54:13it can work like metformin but sometimes
54:16people say that that has fewer stomach
54:18side effects than metformin.
54:20So basically the our guidelines in our
54:22societies are saying they inositol can
54:25be considered, right? Since it's safe
54:27and low risk but it doesn't necessarily
54:28perform better in the preliminary
54:30studies that we have.
54:32Um
54:33metformin is certainly still preferred
54:35because it has broader reaching
54:37improvements
54:38um than something like inositol. Um for
54:41overall metabolic management. Um and
54:43again no specific type or dose or ratio
54:46has really been elucidated to be the
54:48best. So I think my overall um note with
54:51that one in particular is that for some
54:54people and I see that actually online.
54:55For whatever reason that's been like
54:56very targeted to me as I've been
54:58scrolling while I was researching this
55:00episode. And inositol it sounds like can
55:03definitely potentially be helpful.
55:05Um it probably isn't the silver bullet.
55:07Yeah. Other medications do to seem to
55:09perform better um in studies but as an
55:12adjunct, right? If it's again not going
55:14to cause harm, not going to break the
55:15bank and you're doing other things to
55:17for instance protect your endometrium,
55:19right? Which may not be addressed by the
55:21inositol, then I see under the guidance
55:24of a physician who's comfortable with
55:26PCOS, it seems like on the outset
55:29there's no, you know, harm to it. I also
55:32got when I was scrolling spearmint tea
55:35specifically was also recommended a lot
55:38which I was like, I drink spearmint tea
55:39every single night before bed.
55:41>> That's [laughter] so interesting.
55:42>> Yeah, there's all kinds of stuff online.
55:44It's like, you don't know what to what's
55:46real and what's not, right? So, I think
55:48our advice too is to always just bring
55:51these things back to your provider who
55:52knows your particular situation, who
55:54can, you know, give you the evidence on
55:56these things because they're experts in
55:58this area. But, one thing I did want to
56:00say was that
56:02um
56:03as you've probably seen online, like you
56:06did not cause your PCOS.
56:08>> No.
56:09>> That is something that I think so many
56:10people probably feel so much guilt about
56:12because it's constantly online it's
56:14saying like, you need to modify your
56:16diet, you need to exercise more. It's
56:18because you you ate so-and-so and you
56:20don't you're not an active person that
56:23you have PCOS and that is not true.
56:25>> Yeah.
56:25>> Okay? So, keep that in mind. Don't blame
56:28yourself. Don't feel guilty
56:30because that's that's not the truth.
56:33There's these things can help to
56:35mitigate symptoms,
56:37but it doesn't necessarily mean that
56:38that's what caused your PCOS in the
56:40first place. That's not the case.
56:42>> Yeah. I think as we talk about like a
56:44multifactorial
56:45like root, right?
56:47>> Yeah.
56:47>> Um sometimes what that makes us think,
56:49particularly if we hear that there are
56:51environmental factors that can impact
56:53things, is that oh well, there's
56:55something I can control and I can walk
56:56it back or I can change that thing. And
56:59while that very well may be true, I also
57:00I totally agree with you said that this
57:02other side to that coin is blame.
57:04>> Yeah.
57:04>> Associated with whatever the thing like
57:06turned on the gene, right?
57:08>> Yeah.
57:09>> And I think when we're really truly
57:10considering multifactorial causes, like
57:12environment absolutely plays a role, but
57:15so it is just the genetic like
57:17conditions. It shows the genetic
57:19component, right? It's far too
57:20complicated a a disease and a syndrome
57:24to simplify it and
57:26>> into like, you ate dairy, so that's why
57:28you have
57:28>> You ate dairy, lay off the gummy bears.
57:31Like I don't know. I use gummy bears cuz
57:32we're like we're big
57:34my husband and I are going to
57:35>> You love gummy bears.
57:36>> We we love Jujubes specifically,
57:38actually. You know what? This is a total
57:40aside, but that was the thing that we
57:42bonded on at the beginning was our very
57:44unpopular favorite candy.
57:46>> Gummy bears, interesting.
57:47>> Oh, Jujubes in general. Like the the
57:49typical Jujube.
57:49>> Yeah, like classic Jujube.
57:50>> My mom loves Jujubes, too.
57:52>> Well, my mom loves Jujubes. That makes
57:54sense.
57:56>> [laughter and gasps]
57:57>> I like black Jujubes. I'm a weirdo in
57:59that way.
58:00>> Weirdo.
58:00>> Yeah, I know. I know.
58:02>> [laughter]
58:02>> So, wrap it up, guys. I am disowning
58:05Sydney as a family member for her
58:07love of black Jujubes.
58:09>> I will eat [laughter] them, okay? So,
58:10it's a good We're a perfect pair that
58:12way. We're a perfect pair that way.
58:15>> Uh anyways, so let's talk about just, I
58:19guess, wrapping things up and um
58:21takeaways from this episode that that
58:23you want people to know.
58:24>> Yeah. You know what? I think again, as
58:26we've discussed, PCOS has a bunch of
58:28different causes. It has a bunch of
58:30different treatments, but I think if we
58:32take really like a a intentional
58:35approach to what is the What are the
58:38symptoms that you're experiencing? What
58:40are the causes or the like upstream
58:43things that are impacting the
58:44development of that symptom? And then
58:46what do we have at our disposal to begin
58:48to target that symptom combined with the
58:51umbrella of lifestyle and um dietary
58:54modifications?
58:55>> Yeah.
58:55>> I think that we can approach PCOS in a
58:57really nuanced way, and the challenge is
58:59that that takes time and it takes
59:00intention from both provider and from
59:02patient.
59:02>> Yeah.
59:03>> And so, I I encourage all of our
59:05providers who may be listening to to
59:07take the time for that in so far as we
59:09can, right? And for patients to continue
59:11doing your homework, become more
59:13informed about PCOS and the things that
59:15might be available to you and what you
59:17would find helpful, right? Like, we may
59:19be the ex- experts in the science and in
59:21the
59:22like the the pathophysiology of it,
59:25but you're the expert in what you're
59:27experiencing in your body. And that is
59:29such an important like this is such a
59:30good example of why
59:32>> Yeah.
59:32>> good communication is essential because
59:35I can't really effectively treat your
59:37PCOS if I don't know what the symptoms
59:40are that you were experiencing and
59:42what's most bothersome to you, right?
59:44That's really going to drive how we
59:45target this and what we do about it.
59:47>> Yeah. And if you're listening to this
59:48episode and you're you know, you're
59:50relating to a lot of the symptoms and
59:52the signs that we talked about and you
59:54suspect that maybe this is something
59:56that you have
59:57>> Yeah.
59:57>> um bring those questions and those
59:59concerns up to your care provider
1:00:01>> Yeah.
1:00:01>> um because they'll they're the ones who
1:00:03ultimately are going to be able to
1:00:05diagnose you with this
1:00:06>> Yeah.
1:00:07>> and then and then help you find um ways
1:00:09to manage the the symptoms that you're
1:00:11experiencing.
1:00:13>> And now we've spoken a lot I mean we've
1:00:15spoken for like an hour about PCOS, but
1:00:18I think it's also important especially
1:00:19in the era of social media where we're
1:00:22all kind of self-diagnosing on the
1:00:23internet and we're as guilty of it as
1:00:25anybody else.
1:00:26>> Absolutely.
1:00:26>> Um that there are lots of PCOS mimickers
1:00:29out there, right? So there are other
1:00:31endocrine disorders other hormonal
1:00:33disorders
1:00:34>> Yeah.
1:00:34>> that can mimic the symptoms of PCOS. And
1:00:37so equally as important as being aware
1:00:39of your symptoms and considering PCOS is
1:00:41also to make sure that other etiologies,
1:00:44other conditions are also considered
1:00:47when we're working with that.
1:00:47>> important. That's why that's why it's
1:00:50important to bring it up to your health
1:00:51care provider who can who can go through
1:00:52that list and knows all the other
1:00:54diagnoses that
1:00:55>> Yeah.
1:00:55>> that are out there um because there
1:00:57there are so many, right?
1:00:59>> sure.
1:01:00>> Um it's important to get checked out
1:01:01though so that ultimately you can live
1:01:03your life
1:01:04live your life to the fullest.
1:01:06>> Yeah.
1:01:06>> [laughter]
1:01:07>> So listen, let us let us know you guys
1:01:08your experiences with PCOS.
1:01:10>> Yes. Yes, especially for September which
1:01:13is PCOS Awareness Month
1:01:14>> Exactly. Exactly. Which is why we we
1:01:15wanted to have this conversation today.
1:01:17So
1:01:18>> What has worked for you? What hasn't
1:01:19worked for you?
1:01:20>> Yeah. We want to know. Um, make sure you
1:01:23comment and follow us on Tik Tok and
1:01:25Instagram at the.push.podcast.
1:01:29Um, that's where, you know, we can have
1:01:31even more of these discussions and we
1:01:33love to hear from you guys. We love it.
1:01:36Um, and just kind of continue to build
1:01:37this community because um, you're not
1:01:40alone in these in these symptoms. A lot
1:01:42of people experience this and we want to
1:01:45be a safe space for you to share your
1:01:47experiences online. So.
1:01:49>> Yeah.
1:01:50>> And your PCOS is not a form of
1:01:51contraception.
1:01:53>> Very [laughter] good points, okay. Very
1:01:54good points. And on that note [gasps]
1:01:56>> On that note, check next Wednesday. We
1:01:59will have a new episode of the Push
1:02:00Podcast. But until then,
1:02:02>> Bye.
1:02:03>> See you next time.
1:02:06>> [music]
1:02:13[music]

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