PCOS finally!


Okay, I wanted to talk about PCOS, polycystic ovary syndrome because a lot of people have been asking me about it over the last several months. Um, and it is not a small topic, so I'm gonna try to keep this brief in the way I keep it brief, which is not a lot. Um, first of all, polycystic ovary syndrome is not a disease. 

It is a syndrome, meaning it's a constellation of symptoms that arise. Some people believe that it should not be called polycystic ovary syndrome, that in fact it should be renamed. what its actual, um, etiology or, or, um, background reasoning is, which is insulin resistance. So there is a correlation between polycystic ovary syndrome and insulin resistance, which means that it can be related to future chance of diabetes and therefore people who have diabetes in their family, meaning type two diabetes, which is the more hereditary type, the type that you guys say to me, oh, I only, my, my dad got it. 

Only when he got older and gained. , that's the more hereditary type and family history of that can increase the [00:01:00] chance of polycystic ovary syndrome. Why is it called polycystic ovary syndrome? It's a terrible name because you guys think that it means you have cysts on your ovaries. Cysts by definition are fluid filled pockets. 

That's Latin for fluid-filled pocket cyst. Right? So you think cyst meaning big things on your ovaries, which I understand cuz we do use that word when you have something growing in your ovary that is typical. Two plus centimeters of fluid, but that's different than the term we're using here. P C O S, polycystic ovary syndrome does not mean cysts in the way you're thinking. 

It means multiple, which is poly fluid-filled pockets, which is cystic. So think about it as an ovary that may be a little bit larger than a typical ovary. Let's say a typical ovary is about this big, this big, like a two centimeters. You may have slightly bigger ovaries, you may have normal size ovaries, but you will. 

Multiple small fluid-filled pockets like a couple of millimeters each. So on an ultrasound, it will look like what we [00:02:00] call a string of pearls or a chocolate chip cookie, meaning an oval with a bunch of little black bubbles. And those are small follicles, which are very small, fluid-filled pockets, which are very small cysts. 

So again, polycystic ovary syndrome has nothing to do with having ovarian cysts. That's first and foremost. Please get that through your mind because those of you who say, oh, I've always had cyst, does that mean I have P C O? No. Okay. What is the background reasoning for P C O S? Nobody really knows, but people who are more at risk are those who have family history of type two diabetes. 

They don't exactly know the cause of even that. We know that excess weight can increase the symptoms of p c. But people can have P C O S even when they are lean. So of all the people who have P C O S, about 20% will have what's called lean P C O S, and the other group will not have what's considered lean P C O S, meaning they may have trouble with their weight. 

So again, what is P C O S? It's a constellation of symptoms that can come together to [00:03:00] form this syndrome. And typical symptoms will be, and you may have any or all of these. Irregular bleeding, and when we say irregular, typically it's missing your period, though occasionally you can have frequent irregular periods, but it's typically missing your period either by just having slightly longer than 35 day cycles or missing it for every two or three months, or not getting it at all, which means that when you do get it, it can be incredibly heavy in irregular because a lot of period blood is coming out. 

So one is irregular periods. The other issues have to do with what we call androgen excess, which means. Essentially in common vernacular, more ver, more testosterone symptoms than you would normally have. So it can be acne, it can be hair, and not just hair. Like I always joke, okay, I'm Iranian, I have hair on my mustache. 

But hair, especially on our chin, if patients say to me, oh yeah, I do get a couple of dark hairs on my chin. Doesn't everybody actually no, everybody doesn't. Second. Um, third thing, so weight issues, um, irregular bleeding, meaning [00:04:00] missing your period, hair on your chin, acne, and the converse, which is losing hair on your head. 

So again, think of typically male type of situations here. There can be a host of other things like actual insulin resistance that can show up on your blood work and cholesterol abnormalities. Um, but outside of those things, the typical patient will present with irregular periods, sometimes acne, sometimes hair, um, and sometimes hair loss Here. 

How do we diagnose it? There are a bunch of criteria that you have to fit, but if you go to your doctor and you say to her, you know what? I've been missing my period. There's a very basic workup she should do, including making sure you don't have a thyroid abnormality. You don't have a prolactin abnormality, which is a hormone that gets released. 

Believe it or not, when you lactate or release milk. During breastfeeding, but it can also happen when you're not breastfeeding and that can suppress your period. So she has to rule out unrelated to P C O S issues, very easy blood work to do. And [00:05:00] then there is a panel of blood work that can be done for polycystic ovary syndrome that includes, but is not limited to, um, insulin. 

Fasting sugar, what's called a1c, which is your last three months of your sugar, just to see if you have any insulin abnormalities. They look at the ratio of your LH and F S H, which are the hormones that can relate in a certain ratio. They may look at something called anti malar hormone. They will make sure that you don't have a reason to have too much hair that is unrelated to P C O S, um, that can be secreted from your adrenal glands. 

They will also look at something called D H E A. And your testosterone levels. So those are all blood tests. They may order an ultrasound to look at your ovaries. So these are all things that your doctor can do to help decide, do we think you have this or not? It is not a cut and dry all the time. Some patients are very obvious, they have all the symptoms. 

Their blood work is very clear. Other patients kind of have a couple of little things like, you know what, occasionally I have a 32 day cycle, and you know what? I get one chin hair and God, you know what? [00:06:00] Sometimes I get some acne and their blood work looks. , you know, certain things are in certain ratios, but unlike other, um, issues like thyroid abnormalities or diabetes where there's kind of a cutoff, there is no cutoff. 

There is no one test. So it's not always so easy. And I've actually had patients where they've been told by other doctors, no, they don't have it, for sure. Whereas I actually think, oh, my suspicion is you do have. , um, what I kind of consider like a predisposition to P C O S. Sometimes patients will have no abnormalities, nothing. 

All of a sudden they say, you know what? I went to college, I gained 20 pounds, and all of a sudden I missed my period. Now those patients probably have P C O S, but it was never unmasked because they were managing their weight. When weight goes up, Your body's ability to kind of manage these hormones for some women will alter and then you'll start missing your period. 

Now, unfortunately, becomes a vicious cycle because your weight goes up just because of circumstances, let's say like college, then your cycle becomes irregular. When your cycle becomes irregular and your hormones shift, it can be harder to actually lose weight. [00:07:00] And the worst thing we can do in general for any of us, but certainly with P C O S, is yo-yo dieting, which of course I am like a veteran. 

Yo-yo dieter. So that's a whole nother topic we could talk about. all the time. Um, so how do, how do you manage P C O S? Well, you can't cure it. And again, it's not a disease or an illness where you have to cure it. It is merely a constellation of symptoms that we can manage either by very western techniques, like you're missing your period and you don't wanna miss your period. 

Therefore, we put you on the pill. But be clear. It doesn't regulate your cycle like people say, meaning it regulates it and gives you a period or purposely skips your period if you want to be on the pill. But it's not gonna reverse the underlying issue, which is your hormone irregularity, your hormone imbalance and, and unfortunately there's nothing that we know of medication-wise, which will absolutely reverse it, but there's a lot of data, anecdotal and scientific that actually just managing your weight. 

And I don. Just managing, cuz it is not easy as I know, but managing your weight can actually really even out your hormones and it seems that the best [00:08:00] way to manage your weight with regard to P C O S, if not with regard to. Everything, if I can make that blanket statement, is by doing a healthy, non-processed food diet, especially that is low in carbohydrates. 

That's a whole nother topic. Again, we're not gonna discuss right now. Now, the biggest thing I want you guys to know about P C O S is that you are not broken. You are not gonna be fat and hair laden and pimply, and completely infertile for the rest of your life. Those things might be happen. But those things can be managed. 

I'm not saying easily, but they can be managed when people read P C O S causes infertility. It's technically correct, but I don't like the way it's, it's phrased because I don't even like the word infertility as much as just fertility issues. Doesn't that sound better? And here's the truth, as I've said to thousands of my patients with P C O S, I can almost guarantee you. 

You will get pregnant. You will, you'll get pregnant. Cannot guarantee you or predict will you get pregnant on your own? [00:09:00] Will you get pregnant with help from a fertility doctor? Will you get pregnant with help? Because you've just managed your weight and your body has started to ovulate because the background issues of what happens. 

And, and I'm gonna try to des like describe this in a very common way for. When you have polycystic ovary syndrome, your estrogen level is still working. Okay? So your estrogen level is working, it's doing what it should be doing to stimulate your cycle. But the progesterone, hormones, imbalance, and this all has to do with a lot of, um, hormone physiology that happens in your ovary and between your body's axes that kind of help with hormones. 

But the irregularities cause the estrogen to still work, but you don't ov. Therefore, the estrogen, which is thickening, the lining of the uterus, does not get the signal from ovulation to shed the lining. So your lining imagine is getting thicker and thicker and thicker. It doesn't shed out, and then all of a sudden, 1, 2, 3 months into it, your lining goes, Jesus, I'm so thick, I need to just randomly shed out. 

But I'm not [00:10:00] shedding myself as a response to the stimulus of ovulation. I'm just shedding myself irregularly, which is why I'll. Very heavy and sometimes very cloy period that lasts more than a week, and it's not even technically a period because a period by definition in our world is response to ovulation. 

It's merely just breakthrough bleeding because your aligning has thickened up too much. Okay? So that's what happens. Why you don't get your period, because you're not ovulating. Why you finally bleed. And it's heavy and irregular because it's not in response to ovulation. Now, that doesn't mean you never ovulate when you have P C O S. 

People are very different. Again, some people ovulate regularly, but have slightly longer cycles. Some people never ovulate, and again, no period. And others will ovulate 1, 2, 3, 4, 5 times a year. And again, this cannot fluctuate with regard to different things that are happening in your. Primarily weight, but also things like stress can can affect it. 

So what can you do about it? Again, like I said, you can go on the pill if you merely want to manage the irregular bleeding, and that [00:11:00] will even out your period or eliminate it altogether, but by giving you a thin lining or you can manage your weight, which indirectly will help you. Potentially ovulate and have more regular cycles and even get rid of some of the acne and hair access. 

Um, or if you're trying to get pregnant, you go see your gynecologist or a specialist, A fertility doctor, I don't like to say infertility, but again, a what's called a reproductive endocrinology and fertility specialist. It's actually reproductive endocrinology. Infertility, R EI is their acronym, and they can do various things to help you get pregnant. 

Sometimes it's something in. Like they give you diabetes medication called metformin, and that can indirectly help your body even out and help you ovulate. Or they can directly give you medications like ch clomophine, um, or another medication that is an off-label use. It's becoming more on-label that we use that is an anti andro, I mean an anti-estrogen. 

It's actually used in breast cancer patients, but it can an antagonize your estrogen and also stimulate, um, ovulation [00:12:00] called, um, Femara. Um, It's Arimidex is the, uh, is the generic name. I think I keep forgetting what the generic name is and I'll think of it by the end of this. Um, and then, sorry, Letrozole is the generic, so not Femara. 

Forget the brand name. I said that. So again, indirect through Metformin, direct through medications like Ch Clomid or Letrozole, ch Clomophine or Letrozole. Um, or some patients actually need to go even further and do in vitro fertilization. But will you get pregnant? Yes. Yes, yes. I can't stress. You will get pregnant. 

If you have P C O S, you just might need help. So eliminate the, oh my God, I'm not gonna have a baby. You're gonna have a baby. You will get pregnant. You might need help. Help is okay. There's nothing wrong with help. If you say to me, I absolutely wanna get pregnant and I don't want any help doing it, well then I can't promise that. 

Cannot promise you the rose garden. I can't. It's just not possible in life, right? But I can promise you that you will get pregnant to the degree that I can promise it. I also say to patient, Do not assume that you won't get [00:13:00] pregnant and forego birth control. I have had young women come to me from other physicians and they've kind of been like, it's been burned into their brain that they're never gonna get pregnant. 

They're gonna have trouble, they don't even use condoms of birth control. And then they surprisingly get pregnant. And I've actually had a couple patients in the 20 years where it's been, um, sadly too bad because they didn't want to be pregnant. They kind of had this underlying fear they wouldn't get pregnant. 

They didn't use birth control, but when it happens, because it happened at an inopportune time, they were unhappy about it. And this, as you can imagine, can really wreak havoc on your psyche. Um, so again, P C O S in a nutshell, not dangerous, not bad, frustrating because the symptoms are not symptoms that many of us want. 

The symptoms can be managed, um, by very medical things like diabetes medication and birth control pills by very, oh, and by the way, something called sperm lactone, which is in. Is actually a blood pressure medicine that is a hormone that can help with hair growth and hair loss and acne. Um, indirectly managed and very importantly indirectly managed through [00:14:00] weight. 

Um, I should even call that direct actually. It's just not as direct as medication, but probably more effective in many ways. Um, certainly again, as always, integrative aspects can help. Like mindset. Meditation is always good for stress. Acupuncture can work. Um, So that is what I have to say about P C O S. I hope it helps. 

Please, don't be worried about it, but go see someone who decreases your anxiety and helps you understand it and helps you manage it. Okay, bye.