Episode #364: Polycystic Ovarian Syndrome (PCOS)

0:00 [SPEAKER_00]: Welcome back to the Barbell Medicine podcast where we bring modern medicine to strength conditioning and strength conditioning to modern medicine. [SPEAKER_00]: I'm your host Dr. Jordan Faganbaum and today we're going to talk about one of the most common endocrine and metabolic disorders of women that's polycystic ovarian syndrome or PCOS.

0:15 [SPEAKER_00]: PCOS is a complex medical condition affecting reproductive, cardiovascular metabolic, and psychological health. [SPEAKER_00]: And while it affects millions of women worldwide, there are many gaps in diagnosis, treatment, and monitoring related to PCOS. [SPEAKER_00]: In this podcast, we'll cover what PCOS is, how is diagnosed and treated, and special considerations for diet, exercise, and sport, with the help of our very special guest, Dr. Lorraine Baraki.

0:38 [SPEAKER_00]: She's the most handsome Dr. North America. [SPEAKER_00]: She's a board-certified obstetrics and gynecology physician. [SPEAKER_00]: Analutana Colonel in the army, she's also competed in powerlifting, making her one of if not the strongest obstetrician in the world. [SPEAKER_00]: What's going on, Marie?

0:52 [SPEAKER_02]: Hey Jordan, happy to be here. [SPEAKER_02]: I will make one correction that I am, but a mere month away from my promotion to Lieutenant Colonel, but thank you for the early shout out. [SPEAKER_02]: It is appreciated. [SPEAKER_00]: Okay, yeah, I mean, there's my knowledge of how the military promotion system works, but you know, captain to Lieutenant Colonel, I, we need to recognize you.

1:10 [SPEAKER_00]: Congratulations. [SPEAKER_00]: Thank you. [SPEAKER_02]: I appreciate it. [SPEAKER_00]: Do you think that you're the strongest obstetrician in the world? [SPEAKER_02]: Jordan, at this time, I have no data that works to just otherwise. [SPEAKER_00]: So that's, that's, that's not a where. [SPEAKER_02]: That's a resounding yes.

1:25 [SPEAKER_00]: That's yeah, I think so. [SPEAKER_00]: Very confident. [SPEAKER_00]: Very cool. [SPEAKER_00]: So this is obviously the Dr. Austin Brocky's better half and she is our resident expert. [SPEAKER_00]: So we're going to talk about PCOS. [SPEAKER_00]: We're going to start off with what is PCOS?

1:39 [SPEAKER_00]: So policy psycho variance syndrome or PCOS does not have a universally accepted definition. [SPEAKER_00]: And the term CIS [SPEAKER_00]: is kind of a misnomer, since we're really talking about dormant ovarian follicles in the ovary, not true cis. [SPEAKER_00]: Still, the syndrome is characterized by three common findings in affected women, such as abnormal ovulation, elevated levels of antigen, like testosterone, and an increase in dormant follicles in the ovaries that look like cis on ultrasound.

2:06 [SPEAKER_00]: Now, Dr. Barackie, when seeing a patient who is concerned about PCOS, how do you describe what PCOS is to them? [SPEAKER_02]: Sure, well, that's a great question and unfortunately not a very straightforward question because PCOS is not one thing and so a lot of how I answer that is going to depend on what brought them to the clinic in the first place.

2:30 [SPEAKER_02]: But to kind of give a better scaffolding for how I would answer, I would just say that the criteria that's used. [SPEAKER_02]: In this case, the Rotterdam criteria that came about in 2003 describes the three elements that you mentioned, ovulatory dysfunction, hybrandrogenism, and then PCO looking [SPEAKER_02]: And that is a criteria that says, yes, this is PCOS, if two of the three are found in an individual, while also ruling out a variety of other conditions that can potentially explain some of the symptoms that brought the person into the office in the first place.

3:19 [SPEAKER_02]: And so I mentioned that because that leads to a little bit [SPEAKER_02]: to how you're going to navigate this conversation with the patient and also how you are going to pursue this diagnostic work up because there's not a one-size-fits-all even in the lab evaluation for coming to the conclusion that this patient may have PCOS.

3:47 [SPEAKER_02]: So that's kind of the quick and dirty rundown of what it can entail but we can get into a little bit more detail of [SPEAKER_00]: That comment, that discussion, and the complications are of, I can appreciate because, yeah, you're right. [SPEAKER_00]: It isn't just like one thing and why the patient came in is, you know, that's the most important thing to them, not like, they're not seeking a diagnosis of PCOS.

4:10 [SPEAKER_00]: For example, they're not like, hey, work me up for exactly this, and the workup as we'll talk about is a little more nuanced, as you mentioned, but I wanted to go through these three, like, principal or common findings and just make sure that everyone understands them a little more thoroughly.

4:24 [SPEAKER_00]: We talk about ovulatory dysfunction, most resources on PCOS, describe abnormal ovulation as like oligoameneria or ameneria, and those are two jargon terms that people may not be familiar with particularly if they're not healthcare professionals. [SPEAKER_00]: So what does, what are those two terms mean exactly in this context?

4:44 [SPEAKER_02]: Sure, so just to break down the Latin of it first, taking the minority portion of it to refer to the men'sies itself or having a period and the oligo suggesting a lower than normal amount. [SPEAKER_02]: or A as an A menorea, suggesting the absence of. [SPEAKER_02]: And so specifically when we use these terms, we are referring to women who have been identified as not ovulating 12 to 13 times in a year.

5:18 [SPEAKER_02]: And that is going to be evidenced by irregularities in their [SPEAKER_02]: a couple of different ways depending on the person, but it can be just the prolonged absence of menstrual flow or it can be marked by periods of weeks to months of bleeding even because there isn't any regulatory reset that the event of ovulation is helping to control and so it can be a little bit chaotic, unpredictable, frequent and prolonged bleeding.

5:55 [SPEAKER_00]: Yeah, that makes sense and there's also some specific concerns around like transit transition periods in a woman's life, whether that's puberty or Perry menopause for example, because there are norms for how often they should be ovulating how regular that should be and so a person who's being evaluated for PCOS, it's not just like, oh, have you had abnormal menstrual periods, it's more like, okay, how old are you, you know, how far you remove from puberty or how close you are Perry menopause.

6:20 [SPEAKER_00]: So yeah, can't be more complicated. [SPEAKER_00]: The second common finding that we discussed and part of the Rotterdam Criteria is this hyper androgenism. [SPEAKER_00]: So, increase levels of testosterone in a woman, which affects a lot of folks with PCOS. [SPEAKER_00]: What sort of signs and symptoms does this actually produce in folks who do have PCOS?

6:42 [SPEAKER_02]: Sure, so the two big ones that really end up causing quite a bit of the distress that's associated with this syndrome tend to be excessive [SPEAKER_02]: thicker hair growth between the thighs, the lower back and so those are some of the the more outward manifestations that can really impact a person's self-esteem, self-image and contribute to some of that psychological distress that I mentioned.

7:30 [SPEAKER_02]: Some other [SPEAKER_02]: Great to be a deepening of one's voice. [SPEAKER_02]: It can be enlargement of the clitoris. [SPEAKER_02]: Those are things that are also going to be queried when a patient comes in and is describing things such as her growth or excessive acne. [SPEAKER_02]: Because I mentioned earlier that when we're making trying to make this diagnosis, we also need to tease out whether there could be other reasons that are causing the patient symptoms.

8:03 [SPEAKER_02]: And so particularly, we're interested to know if it can be explained by something much less common, such as congenital adrenal hyperplasia, an adrenal tumor, things along those lines. [SPEAKER_02]: thinking about when we are looking to satisfy this criteria or to see if the patient rules in this way.

8:30 [SPEAKER_00]: Yeah, so you're describing some like clinical manifestations of a biochemical finding, which is excess testosterone. [SPEAKER_00]: In this case, and so you can get, you can identify that two different ways, a lab test, and then also just by evaluating the patient. [SPEAKER_00]: generally those two things do converge together, but not always.

8:49 [SPEAKER_00]: Humans, as it turns out, are complicated. [SPEAKER_00]: And then the last part of this rhododam criteria is this polycystic ovarian morphology basically saying that the ovaries look a little pickled on on ultrasound, and I don't say that to make a joke about this condition because obviously can affect folks, but [SPEAKER_00]: Yeah, it is interesting that, you know, it's described as being polycystic.

9:10 [SPEAKER_00]: They're not trussists, which would just be like fluid filled or air filled or substance filled sacks. [SPEAKER_00]: What they really are are dormant ovarian follicles that have failed to mature and and other, they're just hanging out. [SPEAKER_00]: And so there's like specific cutoff for how many you see on ultrasound of the entire ovary or per field on an ovary or even ovarian volume.

9:32 [SPEAKER_00]: But really, again, what we're talking about here are like arrested follicles that have not gone through their normal life cycle. [SPEAKER_00]: So what is that? [SPEAKER_00]: What is an arrested follicle and like why does this matter? [SPEAKER_02]: Sure, so if we take it way back to the very beginning when a female embryo is developing in their mother's womb, we actually have the highest number of like precursor eggs that we're ever going to have in our ovarian tissue that's developing.

10:03 [SPEAKER_02]: and there are certain milestones that we reach as after at the time of birth at the time of puberty. [SPEAKER_02]: When you first have your first period and so on and so forth and then ultimately to when you reach menopause and you have [SPEAKER_02]: ovulated your last egg and at each of these different thresholds or milestones, there's a bit of a culling of the initial population or quantity of precursor eggs if you want to think of it that way.

10:35 [SPEAKER_02]: And these precursor eggs essentially all exist in the tissue of the ovary, and when they meet certain triggers, specifically with hormonal stimulation, they are going to be promoted to grow, they're going to be nourished in little groups and cohorts. [SPEAKER_02]: and these groups are intended to go through a trajectory of growth and development and ultimately within each group what you can expect for a reproductive age female is that you're typically going to have one follicle that is selected to be the follicle that's going to go all the way if you will.

11:24 [SPEAKER_02]: And in this case, going all the way means it's going to reach the point of the point where it's going to be stimulated to ultimately release that egg and to ovulate. [SPEAKER_02]: And so all of the other precursor eggs in that cohort will undergo degeneration and and break down and then it's kind of onto the next cohort.

11:47 [SPEAKER_02]: and the next cycle of a pregnancy doesn't happen. [SPEAKER_02]: And so when we're thinking about what we see in PCOS, you think about the cohort that's being stimulated, but they don't get past a certain point. [SPEAKER_02]: So you don't end up having a leader, if you will. [SPEAKER_02]: that goes all the way or that goes on to reach the point of ovulation and you really just have a lot of these follicles that are in between state and they're not waxing or waning, they're not harming you either, they're dormant like you said, and that's something that's characteristic and that can be observed on the ultrasound.

12:29 [SPEAKER_00]: Yeah, no, I like that because effectively you'd want, you know, one, the one that leads them all or the, you know, they're going to leave you one and it's been fully matured and it's ovulated and you know, under the right circumstances can become fertilized and you know, look, that's when the store comes, but [SPEAKER_02]: That's exactly how that works.

12:45 [SPEAKER_00]: I think it's exactly how that works. [SPEAKER_00]: But in PCOS, that's not, it's disrupted due to hormonal things that are going on that are not consistent with the normal physiology. [SPEAKER_00]: We'll cover that. [SPEAKER_00]: We've tried to tease out some of the pathophysiology, but first, [SPEAKER_00]: I wanted to talk about some more of the symptoms of PCOS.

13:03 [SPEAKER_00]: Now, PCOS has a bunch of different subtypes, and it can present in different ways depending on a variety of factors, like the severity of the condition that the person has, the age of onset, much different from somebody who's in adolescence, you know, fresh out of puberty, and somebody who's perimenopausal, for example, and other concomitant health conditions, obesity, for example.

13:23 [SPEAKER_00]: Is there a typical PCOS presentation that you see in clinical practice or a common history among patients that come in to be evaluated by you that kind of triggers your Spidey sense is like, oh, should we might be dealing with the PCOS here? [SPEAKER_02]: Sure. [SPEAKER_02]: I think before describing it, I will caution any listener to recognize that.

13:46 [SPEAKER_02]: This scenario that I will describe can sometimes I think be a little bit harmful in terms of creating a bias for the clinician and potentially be harmful in the way that may exclude other patients that don't necessarily fit this description didn't read this book yet [SPEAKER_02]: exactly.

14:09 [SPEAKER_02]: And so the kind of textbook description or the presenting patient that you think probably has PCOS is going to be someone who is overweight or obese. [SPEAKER_02]: caveat, not at all patients with PCOS or overweight or obese. [SPEAKER_02]: They are going to have a little bit of extra hair growth that you can see usually like on the upper chin or markedly noticeable acne on the face, but not always.

14:39 [SPEAKER_02]: And they're going to be presenting with the chief complaint of either abnormal periods or inability to conceive. [SPEAKER_02]: And so, those are kind of the hallmarks, regardless of what the patient looks like or what they're presenting with, that's kind of our branch point is saying I have super irregular periods, or I've been trying to conceive for six, 12 months or more, and have been unsuccessful with the constellation of other things that I mentioned.

15:11 [SPEAKER_00]: Yeah, you're not looking at a patient and just based on their physical appearance and saying, Hey, you know what? [SPEAKER_00]: I'm kind of concerned that you have PCOS absent of any other concerns, the major concerns that would trigger somebody to get motivated to come see their OBs. [SPEAKER_02]: Right.

15:25 [SPEAKER_00]: Problems conceiving abnormal period, potentially both. [SPEAKER_00]: And you know, and then you can unfold their history and like, oh, well, this all kind of makes sense. [SPEAKER_00]: And now I'm going to work you up a little further. [SPEAKER_00]: But yeah, good. [SPEAKER_00]: Good caveats there because again, there is no like, [SPEAKER_00]: I don't know, model patient for, for this particular condition that's what I call to syndrome and not to syndrome.

15:43 [SPEAKER_02]: Exactly. [SPEAKER_02]: Yeah. [SPEAKER_00]: There you go. [SPEAKER_00]: All right. [SPEAKER_00]: So with respect to epidemiology like who gets this, how many people does this affect, it affects millions of women globally and it appears to be increasing. [SPEAKER_00]: So recent data shows a 54% growth from 1.3 million global cases in 1990 to 2.1 million in 2019 where PCUS affects approximately 10 to 13% of women.

16:10 [SPEAKER_00]: Is this what you're seeing in clinical practice, like an increase in diagnoses, and if so, why do you think it's increasing? [SPEAKER_02]: This is really interesting, especially because you mentioned those dates, particularly as we go back to the original criteria that we used to diagnose.

16:28 [SPEAKER_02]: So in 1990, we were still using the NIH criteria, which was a lot more selective, specifically the NIH criteria in comparison to the Rotterdam criteria was one that said you necessarily had to have [SPEAKER_02]: and hyper-entrogenism. [SPEAKER_02]: And the PCO or the polycystic morphology or look of the ovaries was plus minus in this criteria.

16:58 [SPEAKER_02]: And going off of an NIH, [SPEAKER_02]: description, then that percentage is about five to eight percent. [SPEAKER_02]: And it wasn't until 2003 that the Rotterdam criteria was published. [SPEAKER_02]: And since then has become widely used and has ultimately replaced the criteria for the NIH.

17:21 [SPEAKER_02]: and that's what puts us at about 15%. [SPEAKER_02]: And it's really the inclusion of other factors or capturing women who have different combinations of these symptoms that then end up with this diagnosis of PCOS. [SPEAKER_02]: So I can't say that there's a particular phenomenon or that something is [SPEAKER_02]: even population in the last, you know, 15, 20 years that is leading to more of this syndrome occurring in women.

17:55 [SPEAKER_02]: But rather, I think that we're just capturing more. [SPEAKER_00]: Yeah, yeah, because people are going to see this increase. [SPEAKER_00]: And like, oh, look, it's the GMOs. [SPEAKER_00]: It's something in the water. [SPEAKER_00]: It's, I don't know what I'm trying to tell you. [SPEAKER_00]: But yeah, that was my interpretation as well.

18:08 [SPEAKER_00]: It seemed like that the criteria for diagnoses and inclusion actually brought in to your capturing more people that before would have been plus minus PCOS. [SPEAKER_00]: And now they kind of get that diagnostic label exactly. [SPEAKER_00]: To the extent that's helpful, that's maybe another podcast, but yeah, I just, I want people when they hear that to not think like, oh my gosh, what's happening?

18:27 [SPEAKER_00]: to the female reproductive health is at the SSRIs. [SPEAKER_00]: Is it the water? [SPEAKER_00]: Is it the GMOs? [SPEAKER_00]: It's probably has more to do with the diagnostic criteria in surveillance being a little bit loosened, a little more liberalized than it was. [SPEAKER_00]: But again, exactly.

18:42 [SPEAKER_00]: Yeah, it's nice to hear it from the expert. [SPEAKER_00]: Alright, well, yeah, let's continue on here and we'll talk about this diagnosis and walk and work up. [SPEAKER_00]: We've talked about the Rotterdam criteria a number of times, and as you mentioned, it kind of came out in 2003 and you need to have two, at least two of the three criteria here.

18:57 [SPEAKER_00]: So you have to have some. [SPEAKER_00]: Obelitory dysfunction, so oligolaminorrhea, amenorrhea, something like that. [SPEAKER_00]: You have to have hyper-angernism, so again, increases in testosterone and or these polycystic appearing of ovarian morphology, which you see on ultrasound. [SPEAKER_00]: And so you're using this in clinical practice, and when you're working some body up, is that that's part of your kind of workflow?

19:24 [SPEAKER_02]: Yes, exactly. [SPEAKER_02]: So I mentioned earlier that that diagnostic workup is not going to be the same for every person specifically for those who are presenting with. [SPEAKER_02]: very pronounced symptoms of hyper-anterogenism. [SPEAKER_02]: There are going to be other labs that should be drawn at the same time when we are evaluating for this, that are not necessarily required or part of the usual workup for someone who, maybe doesn't even report any hyper-anterogenism or symptoms of it rather, or who just have kind of mild acne [SPEAKER_02]: quote-unquote hormonal acne, things like that, but really no appreciable.

20:11 [SPEAKER_02]: Pursuitism or hair growth on the face or body. [SPEAKER_02]: And so that's kind of where some of the art comes into play along with the science to say, does this person require, you know, getting a DHEAS, for example? [SPEAKER_02]: from the adrenal potential pathology, not every person that has abnormal periods and PCO appearing over needs a DHEAS or a 17 OHP.

20:44 [SPEAKER_02]: There's another lab that you may get. [SPEAKER_02]: And so you really just need a tailor to work up to the individual, because if you just take it like black and white, there's nothing extra or nothing weird else going on, [SPEAKER_02]: that requires additional investigation when we're looking at the clinical finding of hyperangernism and want to investigate that through a lab, it really should just be through a total testosterone.

21:15 [SPEAKER_02]: There is suggestion of obtaining a DHAS as a surrogate or as another way of determining is this person hyper-endronemic, but there are not very straightforward cutoffs or determining what is normal or abnormal. [SPEAKER_02]: There's a lot better clarity in determining a cutoff on DHAS when it comes to this person could have a tumor.

21:39 [SPEAKER_02]: or below this number could be normal, could suggest that they have hyper-engineism, and it's just not as helpful, but a total testosterone is a bit of a cleaner test in the tighter window, dignosticly, to evaluate that part. [SPEAKER_02]: Getting into the weeds a little bit too, but just total versus free testosterone, just stick to the total because free is going to have more variation as well that that isn't necessarily going to be helpful in making this diagnosis.

22:11 [SPEAKER_00]: Yeah, and you can calculate the free as well with those, the free hydrogen index if you need it. [SPEAKER_02]: Exactly. [SPEAKER_00]: Yeah. [SPEAKER_00]: But it does seem like you're thinking in the back of your head that, okay, look, maybe looks like smells like feels like PCOS, but this particular patient the way they're presenting.

22:27 [SPEAKER_00]: Ah, I don't know. [SPEAKER_00]: they might have this non-classical congenital adrenal hyperplasia or an antigen secreting tumor or, you know, prolapped into something else. [SPEAKER_00]: And so you're like, I want to send these other things but to your point, there's not like this algorithm where you just follow this exactly.

22:45 [SPEAKER_00]: Don't ask any questions. [SPEAKER_00]: Don't think about it. [SPEAKER_00]: There's some art here. [SPEAKER_02]: Yeah, you mentioned you, I just heard you mentioned prolapped and so that also brings us to another branch point too, depending on whether [SPEAKER_02]: one of their concerns is abnormal bleeding.

22:59 [SPEAKER_02]: So if they have abnormal periods and that's a part of the consolation of symptoms going on for them, then it is important to consider checking a complete blood count to quantify, especially if there's someone who's say they have ongoing bleeding that just persists for weeks and weeks without.

23:16 [SPEAKER_02]: And it's important to evaluate their blood count as well as checking a thyroid stimulating hormone [SPEAKER_00]: Yeah. [SPEAKER_00]: Yeah. [SPEAKER_00]: And that's just, you know, again, to try to get at this hormonal sort of basis, like look, like what else could be going on just to make sure.

23:34 [SPEAKER_00]: But even within PCOS, there is additional work up because it is associated with all of these other wide reaching effects on the body and its function, specifically around like PCOS related increases in heart disease, metabolic dysfunction, psychiatric conditions, and so on. [SPEAKER_00]: And so [SPEAKER_00]: There's the work-up is not just like all right, let's get a test toosterone, let's slap an ultrasound on you and let's ask you about your periods.

23:57 [SPEAKER_00]: You also want to make sure that the person's blood pressure has been measured recently. [SPEAKER_00]: You want to check their lipids. [SPEAKER_00]: For example, you want to check their weight, their BMI, wacer conference, an oral glucose tolerance test to see if they, you know, what level of insulin resistance may be going on.

24:13 [SPEAKER_00]: You are testing your test toosterone, certainly, but you may also be looking at some of the other hormones that we had mentioned. [SPEAKER_00]: on the skin exam, you're not just looking for the hair or stuff, but also to have the hair hair loss, some of this androgenic alopecia, do they have evidence of like a canthosis, niger camps, things like that.

24:30 [SPEAKER_00]: And so the list really does go on, I mean even something like obstructive sleep apnea. [SPEAKER_00]: women with PCOS have a much higher prevalence of obstructive sleep apnea compared to women that are age matched but don't have PCOS and so yeah the the work up here again it does highlight the art of medicine because it's not just like okay look we're testing for these handful of things just symptom based management you're really trying to get at [SPEAKER_00]: if I can use a term that's getting a lot of buzz.

24:58 [SPEAKER_00]: The root cause, like, what's going on? [SPEAKER_00]: And also manage any potential sequelaid to the condition. [SPEAKER_00]: Is this done in batches? [SPEAKER_00]: Because I'm just imagining like, the person comes in, and you're kind of getting in their history, you're getting a sense of like, what do you want to do?

25:16 [SPEAKER_00]: Well, you're also trying to, you know, a sergeant, and he's concerns, you don't want to freak the person out. [SPEAKER_00]: Is this just like our shotgun approach? [SPEAKER_00]: We're testing everything, come back, and we're seeing you on a second visit, or is this like, meet it out over a longer period of time?

25:30 [SPEAKER_02]: So I think that different clinical practices, outpatient practices, probably take a variety of approaches, and it's really, [SPEAKER_02]: It's really a shame, I think, some of the pressures that subspecialists like OB-GYN's face and some of the workload that we're needing to achieve on any given clinic day, I think may pressure some clinicians to take a shock on approach.

25:57 [SPEAKER_02]: I think that in ideal world, however, whether I think someone has PCOS or something else entirely, it's really important to establish rapport, set expectations up front and to be very transparent about the fact that [SPEAKER_02]: the evaluation and the time spent reviewing results and in interpreting those results and applying them to the individual as you develop a patient centered plan of care is something that really should take several appointments and [SPEAKER_02]: while an individual's time is valuable, hers and mine.

26:40 [SPEAKER_02]: If we say that upfront, I think that it helps to decrease a lot of the angst and the distrust and the frustration that a lot of patients tend to feel. [SPEAKER_02]: Because I can be upfront and say this matters to your health and you matter to me and I wanna help take care of you. [SPEAKER_02]: It's going to take time if we're going to do a good job of this and also understand that if PCOS is the conclusion that we come to in this case, it is a chronic condition and it is not something that that we're going to establish treatment plan for and that we're going to fix quote unquote not to say that you are broken, but we're going to have to address your goals and priorities.

27:22 [SPEAKER_02]: and also identify risks, and continually think about how we're going to mitigate those risks lifelong. [SPEAKER_00]: It also is nice in that, you know, we don't want people to like have to spend their entire life in the doctor's office and, you know, go to the end of the earth to access health care.

27:37 [SPEAKER_00]: But if there's a silver lining tall of this, you have more opportunities to interface with the patient and when it comes to mitigating long-term risks and improving long-term quality life, having more opportunities to get your foot in the door and, you know, come up with a shared plan. [SPEAKER_00]: I'm going to give you a prescription and then be gone, go on, go forth and prosper.

28:03 [SPEAKER_02]: And unfortunately, I tend to see a lot of that secondarily when a patient then represents later on, or maybe they moved another establishing care again. [SPEAKER_02]: And I just hear tales of patients being told that they had to do this particular treatment plan. [SPEAKER_02]: And that was it.

28:21 [SPEAKER_02]: and they didn't understand why and they're scared of that treatment plan or they don't fully understand it so they don't like it so they don't want to do that and and so it really sets the stage for a little bit of an uphill conversation, but but that person in front of me deserves to understand it's going on with them and and if they will confided me and give a little bit more time, I do appreciate the opportunity to do that over several visits.

28:48 [SPEAKER_00]: Yeah, yeah, it seems like that has the opportunity, at least the potential to work better, although as the amount of appointments increases, there's some level of attrition that happens, and so I could see that being a double-edged sword. [SPEAKER_00]: Yeah. [SPEAKER_00]: When we talk about PCOS, we invariably people are going to ask, well, what causes it?

29:05 [SPEAKER_00]: What's the path of physiology? [SPEAKER_00]: What really is the root cause, again? [SPEAKER_00]: And unfortunately, we don't have a great answer for you. [SPEAKER_00]: And we can write it off as simple as that and say, yeah, sorry, but we don't understand this completely. [SPEAKER_00]: But I think we can get at [SPEAKER_00]: a potential better understanding when we talk about this increased production of Androgens by the ovaries and its subsequent disruption in the normal feedback loop that traditionally goes on between the hypothalamus, the pituitary and the ovarian glands.

29:38 [SPEAKER_00]: And that's happening on some level and as you alluded to earlier, you know, normally females are born with like what? [SPEAKER_00]: Well, one to two million follicles and then by the time they hit [SPEAKER_00]: And then it gets less and less and, you know, what is the difference in normal physiology during a menstrual cycle compared to somebody with PCOS because I think if we can identify like look, traditionally we have these hormone changes, that's what normally happens, and then an individual PCOS, these are the hormone changes that we're seeing and this is kind of why that cycle starts and it's almost like a positive feedback loop that continues to progress unchecked.

30:18 [SPEAKER_02]: Sure, so it's a bit tricky to describe with words alone and is often best supplemented with a diagram or a graph. [SPEAKER_00]: We need that one picture. [SPEAKER_02]: That one, yes, with all the little peaks and troughs and all the roller coasters that tends to show us the relationship between estrogen, progesterone, loot-neasing hormone, and follicle, stimulating hormone.

30:41 [SPEAKER_02]: throughout a normal quote unquote 28 day menstrual cycle that demonstrates essentially a lower estrogen state and the first half of the cycle. [SPEAKER_02]: And as the follicles are being stimulated, you see increases in follicle stimulating hormone, and then about halfway through this cycle, there are triggers that lead to a surge or spike in the lootinizing hormone.

31:13 [SPEAKER_02]: That spike is associated with the ovulation event, and after which time there is an increase in estrogen production, and all of these, all of these, [SPEAKER_02]: interacting with each other and causing a variety of different reactions there in this feedback loops. [SPEAKER_02]: And so if we take it back to kind of one of the one of the fundamental elements of PCOS is this oligo or an ovulation, then what we take from that is that you don't have [SPEAKER_02]: uh, a period where there's lower estrogen than higher estrogen or lower progesterone in the higher progesterone, um, and there's a bit more of a static state, um, where it is more of an estrogen predominant, um, state, uh, more persistently, um, without having that.

32:18 [SPEAKER_02]: interaction to fluctuate into kind of switch places of the progesterone as a progesterone dominant state and that part of the menstrual cycle. [SPEAKER_02]: And so, and that leads to one of the risk factors that we'll talk about here in a moment. [SPEAKER_02]: But [SPEAKER_02]: Additionally, the LH itself is kind of at a steady state too, so it's not, it's not peaking when it should, so it's not triggering that alcohol to ovulate, and that was preceded by a follicle stimulating hormone, not behaving normally to encourage that cohort to progress and so on and so forth.

32:55 [SPEAKER_02]: And so you do find these periods of more static hormonal statuses, which also speaks to the lack of utility of kind of measuring these things in at any point in the work up because none of those levels are going to be diagnostic or really helpful. [SPEAKER_02]: What's helpful is listening to a person's.

33:18 [SPEAKER_02]: story, like what they're actually experiencing. [SPEAKER_02]: If they're telling you they're bleeding, you can tease out more to determine whether it sounds like they are obelating or not. [SPEAKER_02]: And just as a plug to kind of get that out of out of some folks mind that we don't need to be measuring every single hormone at play here.

33:36 [SPEAKER_02]: Just recognize that they are not interacting normally. [SPEAKER_02]: And therefore the downstream effects are something that you experience and that you can [SPEAKER_00]: Yeah. [SPEAKER_00]: I think when people are trying to wrap their head around this, you know, they again, and before we went on air, I was like, man, just trying to figure out this path of physiology.

33:55 [SPEAKER_00]: If I could just understand it better, then I could understand the condition better, and you're like, and not really. [SPEAKER_00]: I'm like, I know, but I just want to, just to summarize for folks, there is this complex interplay between FSH, LH, estrogen, progesterone, and there's a bunch of other players there too, and they cycle.

34:12 [SPEAKER_00]: in this very complex orchestrated month-long journey to ultimately produce a viable follicle. [SPEAKER_00]: And then look, if that doesn't get fertilized, well, you got some changes on the back end of that, too. [SPEAKER_00]: That's the, quote, normal physiology, but instead of having these cyclical cascade of multiple things happening, it's pretty much static.

34:33 [SPEAKER_00]: the whole way through. [SPEAKER_00]: And you know, if you had to take home one thing, it's like, well, LH is way too high. [SPEAKER_00]: And FSH is well too is way too low. [SPEAKER_00]: And because LH is high, you get a bunch of weird things that happen. [SPEAKER_00]: Testosterone levels are higher.

34:47 [SPEAKER_00]: Anderson dial and these are pre precursor [SPEAKER_00]: that those end up being higher and so the outcomes from a hyper-antigenism standpoint that almost predictably like, we'll shoot if my testosterone, my Android, you know, staying dion is higher and all these things are higher and FSH never gets as high as it should be.

35:09 [SPEAKER_00]: I don't get this isolation event. [SPEAKER_00]: We'll shoot on my have all these dormant follicles. [SPEAKER_00]: I'm gonna have all this excess testosterone and oh shoot dang, that's kind of. [SPEAKER_00]: That's PCOS. [SPEAKER_00]: Now, I don't want to reduce PCOS to just that because it's much more complex, but I think if you wanted to wrap your head around it, like maybe you could do worse.

35:24 [SPEAKER_00]: You could do worse than that. [SPEAKER_00]: Do you agree with that? [SPEAKER_02]: I think you did pretty well. [SPEAKER_02]: Yeah. [SPEAKER_02]: I know that's the great summary. [SPEAKER_00]: It's been a spend a lot of time on the B. [SPEAKER_00]: With respect to risk factors, here's where it starts to get a little weird in my mind, because there are significant risk factors that are like independent of PCOS, the condition itself.

35:46 [SPEAKER_00]: And then there are ones that not only contribute to PCOS, like having it. [SPEAKER_00]: but also contribute to the severity of the condition. [SPEAKER_00]: And so just to give an example, like genetics, certainly genetic targets, mostly having to do with like sex, steroid, hormone signaling, a variant, follicle, maturation, insulin, production, and activity.

36:05 [SPEAKER_00]: Those sort of things, there's a lot of genetic targets here at that. [SPEAKER_00]: When combined, it's not a single gene, one weird, you know, gene is contributed, but it's polygenic. [SPEAKER_00]: That doesn't, you know, it influences the likelihood of somebody developing PCOS and their course, but that static.

36:20 [SPEAKER_00]: It doesn't really change over time. [SPEAKER_00]: Whereas something like obesity, you have a higher risk of not only experiencing PCOS, but the worst the obesity is also tends to make it more severe too. [SPEAKER_00]: So it's kind of like works in both ways. [SPEAKER_00]: When you think about risk factors and you're in a patient's, you know, an environment where you're [SPEAKER_00]: Do you bring up risk factors at all or is it more like it's in the back of your head trying to stay like, oh, this makes more sense why this person's experiencing this.

36:51 [SPEAKER_02]: Sure. [SPEAKER_02]: So the main risk categories that that my counseling will cover includes endometrial risks. [SPEAKER_02]: We talk about metabolic health. [SPEAKER_02]: We talk about psychological propensity towards stress depression anxiety. [SPEAKER_02]: Essentially tie those into, like you said, it can be linked to or tied into the diagnosis of PCOS.

37:16 [SPEAKER_02]: In other words, we're going to talk about mitigating risk and also addressing some of their symptoms that are part of their diagnosis or independent of their symptoms, say you have PCOS and therefore going forward, you do have an increased risk with regard to [SPEAKER_02]: health outcomes.

37:40 [SPEAKER_02]: And so we talk about healthy, you know, establishing what their baseline for physical activities and healthy weight and some strategies to achieve that as well as in terms of the anometrial health, we talk about how we can try to prevent [SPEAKER_02]: basically an excess of endometriol stimulation.

38:07 [SPEAKER_02]: So what do I mean by that? [SPEAKER_02]: I mentioned that in PCOS it tends to be a higher estrogen state. [SPEAKER_02]: And especially if you are not having a period on a regular basis, that means that the uterine lining or the endometrium is not shedding. [SPEAKER_02]: regularly, and therefore has the opportunity to overgrow, essentially, and what we would call hyperplasia.

38:34 [SPEAKER_02]: And hyperplasia exists on a continuum, which can lead to basically like a pre-cancerist condition, and ultimately endometrial cancer. [SPEAKER_02]: And so this is not to say that anyone with a PCUS diagnosis [SPEAKER_02]: will have or might have anometrial cancer, it totally depends on what their menstrual patterns are, how often they are having withdrawal blades and whatnot.

39:00 [SPEAKER_02]: But we talk about strategies for either regulating or just suppressing anometrial growth. [SPEAKER_02]: And then to address the psychological [SPEAKER_02]: Identify the individual is just a whole person that is there to see me for this one thing, but it's really not just one thing and Depending on what their goals are or what their concerns are, what their insecurities are.

39:32 [SPEAKER_02]: What their hopes and prospects for whatever the future may hold, whether it includes fertility goals or not, whatever the case may be, it's important to just recognize that they are a whole person and to encourage just behavioral health resources to just have the opportunity to talk through these things because I just mentioned that it's a chronic disease as well or a chronic syndrome I should say.

39:55 [SPEAKER_02]: And so those are kind of the big categories for risk identification and mitigation circling back to the healthy weight part. [SPEAKER_02]: I did want to mention that in patients who are overweight and obese, who [SPEAKER_02]: do have some weight loss that it is quite common to see improvement in symptoms specifically, symptoms of abnormal bleeding.

40:23 [SPEAKER_02]: So it's it is quite common to experience normalization of [SPEAKER_02]: If I regulate your mentees, we'll not meet directly, but if your mentees regulate because you had some weight loss, then that is telling me that you are probably ovulating on a more regular basis. [SPEAKER_02]: And the more often you are ovulating, and if you are engaging in a protected intercourse, then the more likely that pregnancy can happen, if that's what you desire.

41:07 [SPEAKER_00]: The store comes, that's what you're saying. [SPEAKER_02]: That's that's exactly what I'm saying. [SPEAKER_00]: Yeah, I actually this is a good segue because I I didn't want to belabor the point too much on on weight management body fat management body composition or even obesity generally speaking mainly because in my, you know, coming up with this outline and working on this and and relearning a lot of stuff that I had selectively blocked from my medical training.

41:33 [SPEAKER_00]: I became a cutely aware that as far as obesity stigma goes or which weight stigma in general goes, PCOS may be like one of the most affected medical conditions by that and I don't mean that just from like a general populist standpoint, but even amongst medical professionals, they see an individual with PCOS and the person may be overweight or have obesity for example and they're like, oh, I'll just lose weight.

42:00 [SPEAKER_00]: just lose weight, you know, and it's like, well, that may, in some cases, yeah, lead to a big improvement in their the symptoms and help them reach their goals, whether it's fertility or otherwise, but the actual effect of obesity on this condition is far more complicated than that. [SPEAKER_00]: And, you know, there's been a lot of research into this.

42:20 [SPEAKER_00]: do are the appetite promoting hormones significantly higher in individuals with PCOS, are the satiety or fullness hormones that people experience during, you know, as they eat and when they finish eating a meal, are those lower right as that would's tripping off this propensity to gain weight at a faster rate than individual without PCOS or have more difficulties with weight management.

42:40 [SPEAKER_00]: Yeah, not really has been a lot of investigation here, but my point on saying all this is that we haven't had great treatments for obesity, you know, previously it's mostly about, hey, have you considered exercise or eating differently and it's like, yeah, my whole life, I've been trying this and we've been limited with with opportunities to to intervene otherwise.

43:01 [SPEAKER_02]: And so and having having gone to medical school together, Dr. Fang. [SPEAKER_02]: and I, we're speaking from the same era and literally from the same learning environment. [SPEAKER_02]: But we, we, we now me as a, as a board-certified OB-DYN. [SPEAKER_02]: We don't come into this specialty and have an hour armed with extra knowledge or information on how to effectively handle this particular topic.

43:27 [SPEAKER_02]: And it is something that I think that each of us need to take upon ourselves to stay in the know and to stay up to date with any other ways that we can approach this topic without coming off [SPEAKER_02]: tone to the patient too because it's not her fault that she has PCOS and while some weight loss can help with the symptoms.

43:58 [SPEAKER_02]: any weight gain that she's experienced is not the result of her in, you know, in activity or sloth or or decision to gain weight, whatever the case may be. [SPEAKER_02]: And honestly, we just need to get smarter on how to address this in a multidisciplinary way and a multifactorial and really like in a biosyco-social way.

44:19 [SPEAKER_02]: I mean, obviously, I know that [SPEAKER_02]: It's been discussed on this podcast and a lot just on the interwebs in general, but obviously with various weight loss medications that are becoming more and more popular. [SPEAKER_02]: like with a lot of things in reproductive health or pregnancy in general, it's important to recognize that the side effect of some weight loss in a person who has had fertility issues can be increased fertility because of like a downstream effect.

44:58 [SPEAKER_02]: ultimately, um, leading to ovulation, leading to that opportunity for the stroke to come. [SPEAKER_02]: And, uh, and so, and at this point in time, we don't have, um, any safety data really, um, we're in the information gathering phase for that. [SPEAKER_02]: You may have heard of some o's and pick babies in the like, um, there are registries for these things.

45:20 [SPEAKER_02]: Um, so, uh, [SPEAKER_02]: It's one of those things that I think that as time goes on, there will be more and more and will be in a position to try to speak on the safety and efficacy of that. [SPEAKER_02]: In the pre-conception timeframe, but for now, if someone's trying to conceive and you're on a GLP one, it's advised to come off of it for a couple of months.

45:37 [SPEAKER_02]: And then the other other thing I wanted to mention is just when it comes to weight loss surgery. [SPEAKER_02]: That's another thing that is not really [SPEAKER_02]: heavily anchored in our curriculum, just in medical school in general, and certainly not like an OB-GYN training, but I am a surgeon, and I have patients that can absolutely benefit from, at least having a discussion with a bariatric surgeon to talk about some of the benefits of potential weight loss surgery, and just the myriad of health considerations that we can positively impact through that.

46:16 [SPEAKER_00]: Yeah, yeah, and it's a great segue into our break when we come back after this. [SPEAKER_00]: We'll talk about more about PCOS and how to treat it. [SPEAKER_00]: All right, we're back here on the barbell medicine podcast with Dr. Lorraine Baroque, the most handsome doctor in North America.

46:29 [SPEAKER_00]: She's a board certified upset tricks in gynecology physician. [SPEAKER_00]: Again, we're talking about PCOS and now how to treat it. [SPEAKER_00]: So we're going to start with lifestyle stuff here, and when it comes to lifestyle-based treatments for PCOS, weight management is a big component for nearly all published guidelines.

46:45 [SPEAKER_00]: Now, most of these guidelines acknowledge that the rate of weight gain and the prevalence of obesity are higher in those with PCOS compared to those without. [SPEAKER_00]: And in addition, excess body weight and body fat appear to increase the risk of not only developing PCOS and PCOS related symptoms, but also increasing the severity of those symptoms.

47:04 [SPEAKER_00]: So the question to you, Dr. Baraki, is when it comes to lifestyle based treatments for both PCOS and weight management in general, exercise is at the top of the list. [SPEAKER_00]: Now recent studies show that individuals with PCOS tend to engage in similar levels of physical activity and exercise as those who don't have it.

47:22 [SPEAKER_00]: the problem with that is most people are not meeting the current physical activity guidelines, most people are not exercising. [SPEAKER_00]: So when it comes to counseling individuals with PCOS on exercise, how do you start this conversation? [SPEAKER_02]: I would argue that it doesn't differ too much from anyone that's a perfect response.

47:43 [SPEAKER_02]: Yeah, that is my answer is that there's not a special [SPEAKER_02]: applies to patients who have been diagnosed PCOS and that general health guidelines and general physical activity guidelines apply to this population as it does to anyone else. [SPEAKER_02]: With the understanding that the prevalence of insulin resistance [SPEAKER_02]: is quite a bit higher in this population and goes back to the conversation of expectation management and just acknowledging some things of front, including the fact that achieving your weight loss goals can and usually are a bit more difficult.

48:29 [SPEAKER_02]: And our timelines probably need to stretch out a bit more, [SPEAKER_02]: But it's, it's important to be encouraging and to not take those factoids as deterrence to getting started or to even moving in that direction. [SPEAKER_00]: Yeah, yeah, this is, it, this actually brings up a better, a bigger, maybe we'll call it a barbell medicine point if I can be so bold.

48:50 [SPEAKER_00]: Well, because, you know, people invariably will say, look, I have this medical condition, what specific exercise prescription, you know, do I need to undertake? [SPEAKER_00]: And in the majority, but not all, certainly not all. [SPEAKER_00]: of cases, medical conditions, there's not really a unique secret sauce here when it comes to exercise prescription.

49:08 [SPEAKER_00]: Generally the same as somebody who did not have that particular condition and PCOS is exactly like that. [SPEAKER_00]: There's not a particular look. [SPEAKER_00]: They need a particular split, particular amount of exercise, or anything like that. [SPEAKER_00]: We want people to first achieve this sort of minimum amount of exercise.

49:22 [SPEAKER_00]: That's consistent with the current physical activity guidelines. [SPEAKER_00]: and generally speaking, more would be better. [SPEAKER_00]: We effectively want people to be as active as humanly possible where the limitations are really logistics and then they're physiological tolerance to exercise.

49:37 [SPEAKER_02]: The limit does not exist. [SPEAKER_00]: The upper limit does not exist, but if there's anything that's unique about this particular situation with PCOS to my mind, it's mostly that we can use some of these long-term risks that are associated with PCOS as leverage [SPEAKER_00]: And that also tends to bolster people's understanding of the condition.

49:58 [SPEAKER_00]: So for example, you mentioned insulin resistance and you're like, look, insulin resistance is associated with the condition that you have. [SPEAKER_00]: It can lead to type 2 diabetes, it can lead to increased rates of heart disease, it can lead all these other things. [SPEAKER_00]: Exercise is a very potent tool that we can use to limit that, attenuate that or even, in some cases, reduce it back to what would be considered like baseline.

50:20 [SPEAKER_02]: baseline. [SPEAKER_00]: Same thing, body image improvement if that's a big issue. [SPEAKER_00]: with a particular patient, their mental health. [SPEAKER_00]: There's just so many levers that you can pull. [SPEAKER_00]: And again, these aren't really unique to PCOS because this would otherwise be true of anybody.

50:33 [SPEAKER_00]: But because it is pertinent to this condition, you could use that theoretically in this motivational interviewing process. [SPEAKER_00]: But there's not a specific, I'm not going to release a PCOS template. [SPEAKER_00]: Like, look, here's the training that you need to do. [SPEAKER_00]: It would more, if I did do something like that, if we collaborated and did something like that, it would look a lot like the rest of our exercise programs.

50:55 [SPEAKER_00]: It would just have more information about PCOS and how like, you know, this would benefit you. [SPEAKER_00]: And so that would be the template, but the template would it look really any different than a general template for strength conditioning that we'd release to the public. [SPEAKER_02]: Absolutely.

51:10 [SPEAKER_02]: So why are beware for that? [SPEAKER_02]: Yeah, what that's going to trick. [SPEAKER_02]: Yeah, the just for you. [SPEAKER_00]: Yeah, if somebody's put it out stuff that's like, look, this is, you got to do this exercise, the PCOS patient. [SPEAKER_00]: Like, that's, yeah, that's the red flag.

51:23 [SPEAKER_00]: If it's to lure people into this, like, get more physically active thing, then maybe, I don't know. [SPEAKER_00]: I don't know that you need to use misinformation to get there. [SPEAKER_00]: It seems a little sketch. [SPEAKER_02]: Right. [SPEAKER_00]: A little sketch. [SPEAKER_00]: It doesn't make a feel good, no woman fuzzies from that, but maybe more important to this population with respect to exercise.

51:40 [SPEAKER_00]: Now, there's little data available on exercise counseling and prescription practices delivered to individual PCOS, but if you go to other medical conditions, whether it's heart disease, whether it's individuals with obesity, whether it's diabetes. [SPEAKER_00]: Unfortunately, you see the exact opposite of what you would want to see from like a public health perspective.

51:58 [SPEAKER_00]: If anything, you'd want folks with these chronic medical conditions and risks to be counseled more frequently on exercise, then folks who are otherwise healthy. [SPEAKER_00]: Of course, you'd want everybody to be counseled. [SPEAKER_00]: If you had to choose, you would want folks who stand to benefit the most, the most vulnerable populations.

52:15 [SPEAKER_00]: So the question to you, Dr. Barackie, is do you think that exercise is being discussed with the majority of patients with PCOS? [SPEAKER_02]: I do not. [SPEAKER_02]: I absolutely do not. [SPEAKER_00]: Why do you think that is, do you think it's because this syndrome is so complex and to your point earlier, multiple sort of appointments and multiple, like a pretty extensive work up and there's a lot of co morbidities going on, is it because the complexity or is it because doctors look, we just don't know anything about exercise and so we don't know what to do.

52:43 [SPEAKER_02]: I think it is twofold. [SPEAKER_02]: I think that the thing one. [SPEAKER_02]: would be that there is so much to cover and there is so much on the interviewing and the exam side of the house that is going to take up time so that you can find yourself in a diagnosticly appropriate place to then recommend a way forward for working this patient up and then there is all the all the different interpretations and how do we apply meaning to these things?

53:11 [SPEAKER_02]: What does this mean to you? [SPEAKER_02]: That by the time we get to treatments or interventions [SPEAKER_02]: we can be very well passed in a normal appointment time at that point and the plate is very clinically full. [SPEAKER_02]: It's not a great excuse, but I suspect that it is a very common cause for that to be next.

53:35 [SPEAKER_02]: And the other thing is that we tend to avoid the things that we don't feel super confident in, just as humans and that applies to physicians and health care providers as well. [SPEAKER_02]: So that's thing too, [SPEAKER_02]: If we are not trained or don't feel super savvy in what to tell a patient that is meaningful or actionable, don't feel super confident in that, then we're typically going to skip over those things or leave them out or at the very most may be provide a handout or a resource or something like that that's not individualized or tailored to the patient, so I think it is [SPEAKER_00]: So if you're a fitness professional, listen to this and you have a client with PCOS, standard exercise prescription techniques apply.

54:23 [SPEAKER_00]: what amount of exercise are they willing to do or can they do based on their previous recurrent fitness level and resources what types of exercise do they want to do and you come up with a shared sort of plan for for that all shakes out and ideally that at least meets the current physical activity guidelines of twice weekly resistance training for all major muscle groups and you're doing at least 150 minutes of moderate to vigorous physical activity [SPEAKER_00]: And ideally, you'd get them to do more, and you'd monitor the results.

54:55 [SPEAKER_00]: Ideally, you'd like a program that makes them stronger. [SPEAKER_00]: Ideally, you'd like them to be doing a program that makes them more fit from a cardiovascular standpoint. [SPEAKER_00]: And you go from there. [SPEAKER_00]: But there's no specific PCOS related concerns to who don't have them do back squats because...

55:11 [SPEAKER_00]: or don't have them do supersets because or something like that. [SPEAKER_00]: That's there's nothing really really there. [SPEAKER_00]: So you can feel confident in your exercise prescription techniques, provided that you're actually doing it. [SPEAKER_00]: And that message is to our healthcare professionals.

55:23 [SPEAKER_00]: Make sure that if you don't feel comfortable doing it, no hate coms, peace and love, but a referral would be appropriate in that case. [SPEAKER_00]: I did want to bring up something interesting. [SPEAKER_00]: And I don't, I don't, this is, I don't know that you're going to have expertise here, but I don't, I don't want to like, you know, [SPEAKER_00]: box you in, but this I thought it was interesting.

55:43 [SPEAKER_00]: It's about PCOS in sport. [SPEAKER_00]: All right. [SPEAKER_00]: So the proportion of women who engage in sports at all levels is at an all-time high. [SPEAKER_00]: It's increased dramatically over the past 50 years and this is reflected in the proportion of female Olympic athletes. [SPEAKER_00]: This is probably when the cohorts we have the most data in.

56:00 [SPEAKER_00]: So for example, in the summer Olympics in Munich in 1972, only 15% of all participants were women. [SPEAKER_00]: And [SPEAKER_00]: in 2012, the London Summer Games, that increased to 44%, but it wasn't until this past Olympics 2024 Paris Games that we finally reached the 50-50 thing we're half of all together.

56:19 [SPEAKER_00]: Apparently. [SPEAKER_00]: Hey, finally. [SPEAKER_01]: Things good. [SPEAKER_00]: Yeah. [SPEAKER_00]: Took us also, by the way, if you're keeping score at home, London 2012 was the first Olympic Games where women competed in all disciplines that men competed in. [SPEAKER_00]: So just if you're keeping score at home about, you know, opportunity to participate in sport and how that made affect participation rates.

56:40 [SPEAKER_00]: Well, there you go. [SPEAKER_00]: Here's where it gets interesting. [SPEAKER_00]: Amen, Maria and Hyper androgenism are far more common in female athletes than in non athletic female populations. [SPEAKER_00]: And in addition to that ultrasound evidence of polycystic ovaries are get far more prevalent about 37% of female athletes compared to the prevalence [SPEAKER_00]: And so, at the time of this recording, there's limited evidence comparing the true rate of PCOS in female athletes, but it does seem a bit higher.

57:14 [SPEAKER_00]: So in your opinion, Dr. Baraki, is it possible that there's an athletic advantage to having PCOS? [SPEAKER_00]: Is it the hyper-antrogenism, for example, that maybe advantageous or something else? [SPEAKER_00]: Any insight there? [SPEAKER_02]: I will acknowledge to your point that you're right.

57:30 [SPEAKER_02]: I am not an expert in this very specific question. [SPEAKER_02]: Not being boxed in, but I think that it's a very interesting finding. [SPEAKER_02]: It is certainly hypothesis generating. [SPEAKER_02]: And it takes us back to questioning or just looking at the diagnostic criteria, [SPEAKER_02]: evaluate whether any of these individual components can be clinically reasonably explained by some other physiology or pathophysiology and also kind of highlights the place that we find ourselves in that we have found ourselves in for decades now is basically like a chicken or the egg situation where [SPEAKER_02]: is the insulin resistance leading to increased levels of LH, which is leading to ovulatory dysfunction, and also just circling back to more insulin resistance and increase adipose and higher weight and obesity and cardiovascular metabolic outcomes.

58:39 [SPEAKER_02]: Is that the cycle that we're in or are there offshoots of this equation? [SPEAKER_02]: that are operating with a completely different rulebook, which I have to believe that it may be more the latter, but it's certainly interesting query and worth further investigation to know, are we on the same continuum?

59:01 [SPEAKER_02]: Or are we so far down in a different branch entirely that we're just seeing similar findings? [SPEAKER_02]: But how we got there? [SPEAKER_00]: This is just right. [SPEAKER_00]: Right, different. [SPEAKER_00]: Yeah. [SPEAKER_00]: So I'm going to present two hypotheses. [SPEAKER_00]: Oh, right.

59:15 [SPEAKER_00]: And you get to pick one. [SPEAKER_00]: Okay. [SPEAKER_02]: Sounds great. [SPEAKER_00]: With the full understanding that both could be wrong. [SPEAKER_00]: To your point, I agree. [SPEAKER_00]: More research needs to be done. [SPEAKER_00]: And ultimately, this is a twad. [SPEAKER_00]: It's a time wasted on useless detail.

59:26 [SPEAKER_00]: But like, you know, could be used. [SPEAKER_02]: Maybe you can. [SPEAKER_01]: Maybe not. [SPEAKER_00]: Look, could be used as leverage during the motivational interviewing process for active. [SPEAKER_00]: You like, look, you got PCOS. [SPEAKER_00]: You could be a world beater. [SPEAKER_00]: If only.

59:38 [SPEAKER_00]: So here are the two hypotheses right hypothesis number one is a teleological or evolutionary based argument for PCOS like hey why does this thing persist in populations why what the hex going on so is it [SPEAKER_00]: the relatively high testosterone had conferred some sort of survival advantage to women in ancestral environments because they had increased strength, reduced fracture risk, and maybe the insulin resistance was actually adaptive to ameliorate some of the signs of low energy availability for example, and because that that can happen.

1:00:15 [SPEAKER_00]: And so maybe this is like, look, it just persists and now our ancestral environment, the close thing we can get to is sport, and so women who are [SPEAKER_00]: You know, they just they thrive. [SPEAKER_00]: So that's hypothesis one. [SPEAKER_02]: Sure, just to like add a little bit more type of hypothesis one, I have heard a semblance of that and there's also like a layer of like war and famine and, you know, this mortal threat and and also tying that into fertility or relative infertility and basically being a manifestation of [SPEAKER_02]: Basically genetics getting it right and saying this is not a great time to produce.

1:00:52 [SPEAKER_00]: Yeah, yeah. [SPEAKER_02]: To reproduce exactly. [SPEAKER_00]: All right, so that's hypothesis one. [SPEAKER_00]: We'll call it the evolutionary hypothesis. [SPEAKER_00]: And then the second hypothesis is the artifact hypothesis. [SPEAKER_00]: So for example, a manoria being common is not surprising in sport due to the high volumes of intense training, perhaps with insufficient fueling, right, and the types of people that end up selecting themselves in the sport.

1:01:16 [SPEAKER_00]: And same thing for hyper-androgenism, people with, truly women with high volumes of exercise and sport tend to have higher testosterone levels, mainly in comparison to their levels of estrogen, which tend to be lower, right? [SPEAKER_00]: And so proportionally, there's this hyper-androgenic.

1:01:31 [SPEAKER_00]: type state. [SPEAKER_00]: And so maybe these are just artifacts of participating in sport for a long period of time at a high level with high levels of training and not sufficiently fueling because various body types, body compositions are selected for it's sport and so you have to maintain that.

1:01:50 [SPEAKER_00]: So that's hypothesis to this artifact thing. [SPEAKER_00]: It's like we're seeing similar signs. [SPEAKER_00]: And maybe by a chemical findings to PCOS, but they're more reflective of the person's general practices in this case in sport, but it's not PCOS. [SPEAKER_02]: Sure, I of the two, I certainly do find hypothesis number two to be more likely just based off of that energy equation imbalance if you want to call it that and how that affects the hypotheralamus and how that's affecting downstream [SPEAKER_02]: signaling to your overseas and so on and so forth and how that manifests in not having a period, for example, as well as looking at individuals who for one reason or other typically a genetic predisposition to adapt very well to high levels of

1:02:43 [SPEAKER_02]: intense physical activity in this sport or that sport, also tend to express more in the realm of a higher circulating energy. [SPEAKER_02]: And so it's just kind of happened stance exactly. [SPEAKER_02]: And then we see it or catch it, so to speak, because they're highly visible, because they are performing at such a high level, such an elite level.

1:03:06 [SPEAKER_02]: And so therefore presenting these artifacts that you mentioned. [SPEAKER_00]: Yeah, well, look, if you're listening to this, you made it this far in the podcast and you got a hot take. [SPEAKER_00]: Remember if it's a tepid take, let us know, weigh in comment, you know, helps the algorithm anyway, but we want to know.

1:03:19 [SPEAKER_00]: Is it takes only is it evolution or is it artifact maybe or or option C neither and you're bunch of idiots and move on Fair fair All right, so I'm kind, but okay, so that's the exercise that's a story on exercise We want everybody who is able to exercise to exercise and that certainly includes antivisol individuals with PCOS I'm trying to get them to not only meet the physical activity guidelines, but to more than that if possible [SPEAKER_00]: and no specific exercise considerations other than starting and maintaining that.

1:03:50 [SPEAKER_00]: Those are the real considerations here. [SPEAKER_00]: Now moving on to dietary interventions, similar to exercise and its effects on PCOS related health risks. [SPEAKER_00]: Dietary interventions are also heavily promoted in nearly all PCOS guidelines. [SPEAKER_00]: Now despite individuals with PCOS having a higher prevalence of obesity, [SPEAKER_00]: Most evidence shows that women with PCOS have comparable total energy and macro nutrient intakes as individuals without PCOS.

1:04:18 [SPEAKER_00]: Now, despite that, it is unfortunate that there's a widespread misinformation campaign and promotion of specific dietary compositions that are designed to treat PCOS, particularly on social media, most of these lacking evidence. [SPEAKER_00]: In fact, if you go to the evidence, you'll see that there's a wide range of macronutrient compositions and dietary patterns that can be used to improve health and quality of life in individuals with PCOS.

1:04:43 [SPEAKER_00]: So the question to you, Dr. Barack, is how do you discuss changing nutrition with your PCOS patients? [SPEAKER_00]: And is there any difference in how you would approach that conversation with any other type of patient? [SPEAKER_02]: Yeah, this answer does mirror the exercise answer a lot, but just like with exercise, if we're starting out with nothing, then we want to trend towards something and ultimately get to a place where we are meeting and ultimately exceeding the movement guidelines and recommendations.

1:05:18 [SPEAKER_02]: So when it comes to diet. [SPEAKER_02]: Like you said, there isn't a single PCOS diet. [SPEAKER_02]: It has been query time and time again. [SPEAKER_02]: It's been looked at and folks certainly want to promote and usually sell some kind of diet that they've slept PCOS onto. [SPEAKER_02]: But the reality is that at this time, we don't have compelling evidence that tells me that there is a unique composition, like macronutrient composition or micronutrient composition, [SPEAKER_02]: in the diet of someone who has PCOS that will be more effective at healthy weight loss or optimizing anything else under the hood so speak that's going to impact their symptoms.

1:06:05 [SPEAKER_02]: There are some investigations and some recommendations based off of not great data of some supplements talking about things like Chromium and Ossetol, things like that, which in particular in Ossetol, the thought being that it can help to improve sensitivity and sensitivity specifically.

1:06:35 [SPEAKER_02]: pose a very low potential for harm and might demonstrate a marginal response. [SPEAKER_02]: So far, there's not an overwhelmingly compelling response that tells me that anyone that has PCOS needs to be supplementing with its YRZ at this time. [SPEAKER_02]: And so essentially my discussion with someone with PCOS is the same discussion as someone without PCOS that's in my office for something else, but also has a be city and we're talking about some strategies too.

1:07:09 [SPEAKER_02]: to increase fiber intake, to identify and ultimately decrease saturated fats in their diets and increase monounsaturated fats and just look at the overall balance between their macronutrients but not to say that there is like a perfect recipe for PCUS specifically. [SPEAKER_00]: Yeah, large variety of dietary interventions are going to work here and they've been studied almost to the end degree, you know, whether it's very low calorie diet, low calorie diet, very low carb ketogen and high carb wouldn't it's all there it's all been studied and yeah, there's no one diet to rule them all.

1:07:42 [SPEAKER_00]: Mainly, you would want to involve the patient, whatever their preferences are for dietary pattern, what they have access to, and it focus on minimally processed foods, lean proteins, fruits, vegetables, whole grains, high fiber, limiting foods with added sugar, especially sugar-sween beverages, the standard dietary pattern, recommendations to the extent somebody can do that, modifying the food environment, eating environments, and we've discussed at length on this podcast, however.

1:08:05 [SPEAKER_00]: I'm going to push back just a little bit on what both of us have said. [SPEAKER_00]: So talking at both sides of my mouth, there are, in my mind, to my mind, three, maybe unique concerns, respect with respect to the diet for a person with PCOS, the first one being that there are generally speaking higher rates of disordered eating amongst individuals with PCOS.

1:08:26 [SPEAKER_00]: And so that may deserve its own particular not only work up, but subsequent [SPEAKER_00]: And you may not pick that up, initially, especially if you're not listening to the patient, so ideally you're listening to women. [SPEAKER_00]: Yes, again, the second thing I would bring up is that there does tend to be a lower baseline dietary quality in those with PCOS.

1:08:51 [SPEAKER_00]: Now, this doesn't really affect management because when we talk about dietary quality and how it's measured, these are just standard indices, healthy eating index, for example, is one of them. [SPEAKER_00]: And so your recommendations don't really change. [SPEAKER_00]: It's just a maybe a bigger gap to go from your average PCUS patient compared to somebody without.

1:09:08 [SPEAKER_00]: But again, it doesn't really change what you prescribe or what you recommend, but more so like how much effort it may take to get there. [SPEAKER_00]: And there are multiple contributors to that re, you know, why that is in the first place. [SPEAKER_00]: And the third thing, perhaps the most actionable thing here, with respect to dietary interventions for PCOS to my mind, is this idea around chrono nutrition, but this isn't PCOS specific.

1:09:31 [SPEAKER_00]: It's more like insulin resistance, specific, and so individuals with insulin resistance, whether it's the run of the, I hate to call it run in the middle, but it kind of is like type 2 diabetes, something like that, metabolic syndrome, or in this case PCOS. [SPEAKER_00]: There does seem to be a benefit to time-restricted feeding, but not what most people think about when I say those words.

1:09:54 [SPEAKER_00]: When I say time-restricted feeding, people jump to intermittent fasting, and then the way most people think about intermittent fasting is that, oh, you skip breakfast, and then you have a big lunch, you're eating windows like 1pm to 9pm. [SPEAKER_00]: Right? [SPEAKER_00]: You just eat throughout the rest of the day, [SPEAKER_00]: That's how you do it and there's been a bunch of weird mechanisms that people propose look, you're fasting, autofagey in the beginning of the day, and ultimately the way that works as far to the extent that it does is that it gives people less opportunity to eat if they follow it and so calorie restriction.

1:10:23 [SPEAKER_00]: But in this particular case, time restricted feeding is flipped the complete other way, where most of the calories are consumed earlier in the day, less later in the day, and it seems like there's some circadian rhythm, some bio-rhythm related [SPEAKER_00]: helps regulate a little bit better in individuals with metabolic syndrome or insulin resistance.

1:10:43 [SPEAKER_00]: And so if you were trying to like ratchet things up to the end degree, persons already eating a health promoting dietary pattern, they're exercise and like crazy and they're like, what else can I do? [SPEAKER_00]: Lifestyle wise. [SPEAKER_00]: You could suggest, hey, look, if dinner is your biggest meal of the day, right?

1:11:00 [SPEAKER_00]: Perhaps if you flip that on its head where breakfast is a bigger meal, lunch is a bigger meal and dinner is a little bit less, that may work a little bit better in this particular setting. [SPEAKER_00]: Cavioce to that include, if somebody's working out at night, that's all off the table.

1:11:15 [SPEAKER_00]: like just doesn't it doesn't seem to matter and the effect of doing this is not like crazy big where it's going to completely change somebody's life. [SPEAKER_00]: But if somebody was looking to pull every possible lever, that is maybe a unique consideration for an individual with PCOS.

1:11:29 [SPEAKER_02]: Sure. [SPEAKER_00]: Cool. [SPEAKER_00]: All right. [SPEAKER_00]: No disagreement. [SPEAKER_00]: I love that. [SPEAKER_02]: Let's do it. [SPEAKER_00]: Yeah. [SPEAKER_00]: Well, the final. [SPEAKER_02]: Anything we can add to the old toolbox. [SPEAKER_00]: Yeah. [SPEAKER_00]: There you go.

1:11:37 [SPEAKER_00]: Yeah. [SPEAKER_00]: You have more arrows in your quiver. [SPEAKER_00]: Yeah. [SPEAKER_00]: We went Renaissance fair on that. [SPEAKER_00]: The last thing I wanted to talk about here were actual treatments for PCS, with respect to medical management and perhaps even surgical interventions.

1:11:52 [SPEAKER_00]: And so, you know, if you go look online and you have access to [SPEAKER_00]: to some of the professional materials, you'll see different groups or categories of medication. [SPEAKER_00]: So everything from contraception, hydrogen blockers, certain metabolic care, type medications like metformin, for example, things related to pregnancy infertility.

1:12:13 [SPEAKER_00]: And so just briefly, can you give us a general lay of the land when you have a patient that you have diagnosed with PCOS? [SPEAKER_00]: You've gone through the whole work up. [SPEAKER_00]: Um, when you start thinking about our medical management, where do you start and what are some common things that you end up using in these patients?

1:12:31 [SPEAKER_02]: Yeah, so before I invariably end up with my foot in my mouth and start talking about a particular treatment strategy or path if you will. [SPEAKER_02]: I always always always try to remember to get their goals written down upfront. [SPEAKER_02]: Because I can counsel and counsel and counsel until I'm blue in the face and whatever I've counseled them on is just not consistent or not compatible with what their goal is and we just wasted a lot of time.

1:13:00 [SPEAKER_02]: And so super important to not only ask the individual what are the things that concern you the most and what are your goals. [SPEAKER_02]: And so particularly, if they're not sure what kind of goals I'm referring to, I will then specify, do you want to become pregnant in the near term? [SPEAKER_02]: Or would you say that your primary goal is to regulate your menstrual bleeding if that is one of their presenting [SPEAKER_02]: Because that's going to take us down to very different pathways because if I'm talking about regulating menstrual cycles, it will involve some form of a recommendation for a hormonal contraceptive.

1:13:53 [SPEAKER_02]: It's going to be mainstabbing oral birth control pills. [SPEAKER_02]: It doesn't have to be that and I can explain some of the differences there. [SPEAKER_02]: It's going to be something that prevents pregnancy usually and if your goal is to become pregnant then we need to go in a different direction entirely.

1:14:16 [SPEAKER_02]: With regard to hormonal birth control, I mentioned the oral form specifically and that's going to be the mainstay for that individual that has clinical signs and features of hyper-anterogenism. [SPEAKER_02]: that have the acne or oily skin, perhaps hersthism, as well as irregular bleeding patterns, from that obligatory dysfunction.

1:14:41 [SPEAKER_02]: The thought being that if you take the pill that has a synthetic estrogen, in this case, ethanol, estradiol combined with a progestin. [SPEAKER_02]: Then we are seeking to have that pill be processed like at the level of your liver and once it is absorbed in process there, then you are ultimately going to produce more sex binding sex hormone binding globulin.

1:15:11 [SPEAKER_02]: You can think of that as something that is produced by the liver that circulates in your blood and that will grab up any free testosterone. [SPEAKER_02]: circulating endrogens, and it will bind to them. [SPEAKER_02]: And when those things are bound, then they don't have the opportunity to bounce around the rest of your body and to have some of those outward effects that you see, such as the acne, the oily skin, the herbstism, and whatnot.

1:15:38 [SPEAKER_02]: And so if you go with a birth control option that is not ingested, [SPEAKER_02]: then you are not necessarily going to get that benefit, but you do have other approaches to trying to control the disordered bleeding patterns. [SPEAKER_02]: And so that could be with a vaginal ring that can be with a patch.

1:16:00 [SPEAKER_02]: If there is a reason that an individual can't or shouldn't have estrogen, there are progesterone only options as well that would include [SPEAKER_02]: pill could include an intrauterine system, such as the Marina iUD, as well as an implant in your arm, and then finally the option for an injection, which is the depot proverb.

1:16:24 [SPEAKER_00]: Yeah. [SPEAKER_00]: So you move to like, Androgen blockers, afterwards, most common Androgen-related features PCUS being like here, Cytism, acne, female pattern, uh, uh, Androgen-related pattern hair loss. [SPEAKER_00]: Um, and so like, Spur on a lactone or out lactone is like, one of the mainstays here.

1:16:42 [SPEAKER_00]: It inhibits ovarian and adrenal steroid genesis, it's just making the, the sex aerodes and, and other various pathways are like a ton of different mechanisms of action. [SPEAKER_00]: Yeah. [SPEAKER_00]: Uh, and that's a standby. [SPEAKER_00]: There's also a flutomide, I think, but I don't know how widely [SPEAKER_00]: The only thing to add about Sprone Electone, I'll let you talk about it some more if there's other concerns, but this is a band substance in tested sports and so you need a therapeutic use exemption and so each organization that follows water or you saw the United States has a TUE therapeutic use exemption form.

1:17:15 [SPEAKER_00]: that you would need your physician to help you fill out and submit. [SPEAKER_00]: So that way, you know, you wouldn't want somebody who was diagnosed with something started on a treatment to go to a competition, right, recreational powerlifting meat. [SPEAKER_00]: They get drug tests in them all your band, because you're taking sperm and lactone.

1:17:31 [SPEAKER_00]: It can be a, it's a diuretic, uh, not great one, but what a bummer. [SPEAKER_00]: Yeah. [SPEAKER_00]: And a, and a masking agent. [SPEAKER_00]: So they're like, look, it's banned. [SPEAKER_00]: Uh, so you need this to you, but yeah, that's what I think about energy and blockers in PCOS.

1:17:42 [SPEAKER_00]: I think about sperm and lactone. [SPEAKER_00]: And then I start thinking about other medications from maybe a hair loss, like a finasteride, for example, how often are those being prescribed in practice? [SPEAKER_02]: The finasteride, not very much. [SPEAKER_02]: This is for an electron.

1:17:56 [SPEAKER_02]: I would say that gynecologists are much more comfortable and more commonly prescribing that. [SPEAKER_02]: And that would be usually in series. [SPEAKER_02]: So first step would be to try the oral birth control pill [SPEAKER_02]: and typically after about three to six months wanting to reassess symptoms.

1:18:16 [SPEAKER_02]: And if there hasn't been really any movement or improvement in the symptoms, specifically hersuitism, then you can consider adding on sperm lactone at that time to use both of those agents to address those symptoms. [SPEAKER_02]: And then further down this pathway is the option to consult with dermatology as well.

1:18:36 [SPEAKER_02]: to talk about other management options for excess hair growth for those patients that do suffer with him, for such as him. [SPEAKER_00]: Yeah. [SPEAKER_00]: And then you move along. [SPEAKER_00]: There's like some metabolic concern, so metformance, commonly prescribed in PCUS. [SPEAKER_00]: Is that something you guys are still doing?

1:18:52 [SPEAKER_00]: Or is that you're getting a little a little standoff when it comes to metformance? [SPEAKER_02]: Oh, well, it's not, it's not stand-offish due to any specific harm I would say other than pretty common GI side effects, but the fact is that we've had some pretty reasonable theories in hypothesis over time.

1:19:12 [SPEAKER_02]: They've been studied. [SPEAKER_02]: They're, at this time, there is not compelling evidence that [SPEAKER_02]: that would indicate that the addition of foremen to your treatment strategy or met foreman alone is a particularly effective for regulating opulatory dysfunction for improving fertility outcomes or for reducing some of these hyper-engineering symptoms.

1:19:42 [SPEAKER_02]: And so, [SPEAKER_02]: it has mostly fallen out of favor, you'll see that folks of our generation and then slightly older will just need your reflexively still be tacking this on to the treatment plan for anyone with PCOS. [SPEAKER_00]: Met format, contraception, let's go. [SPEAKER_02]: Yeah, exactly as the combo.

1:20:05 [SPEAKER_02]: but individuals who are staying a little bit closer to the evidence and really scrutinizing and over time seeing is this actually doing anything for us. [SPEAKER_02]: At most for all of those different dimensions that I mentioned, they have a very, very, very modest impact, but should not be considered [SPEAKER_00]: Yeah, that's the same thing like when I was doing my reading on an ocetal, an ocetal being.

1:20:34 [SPEAKER_00]: It's a sugar alcohol, plays a role in insulin signaling. [SPEAKER_00]: You do make it and you obviously can ingest it and can supplement it. [SPEAKER_00]: There's some thought that it improves insulin sensitivity and some other glucose uptake by the cells and a bunch of other stuff. [SPEAKER_00]: And there is some, I don't want to call it defectiveness, but there's a change in the enosetal pathway [SPEAKER_00]: Problem is it's expensive, uh, thing one, thing two supplements generally speaking are poorly regulated and then three, the effects are relatively modest and so like my interpretation of this as a non, uh, OB, GYN is that it's like, look, if this was a slam dunk, this thing works and does a great job at it, you guys would be like, take an acetalino by the way, like maybe there's some pharmaceutical grade.

1:21:23 [SPEAKER_00]: one. [SPEAKER_00]: Similar to like like fish oil. [SPEAKER_00]: Well, there's, uh, Levaz, there are other options that her prescription grade. [SPEAKER_00]: Um, but that's not really the case. [SPEAKER_00]: And so my interpretation tell me if you agree is that look if somebody wants to take and ask to call that PCOS, um, they want to take it.

1:21:37 [SPEAKER_00]: They had discussion with their physician that they're all behind it. [SPEAKER_00]: find a brand that is third party tested. [SPEAKER_00]: It's going to be on the label is GMP accredited. [SPEAKER_00]: You can either search it, or it should be on the label. [SPEAKER_00]: And, you know, again, setting the expectation that it's not going to set the world on fire, but maybe a potential benefit, is that how you kind of see this?

1:21:56 [SPEAKER_02]: On this start frying bomb, I agree. [SPEAKER_00]: Lee, you concur. [SPEAKER_00]: Fair enough. [SPEAKER_02]: Yes, Doctor. [SPEAKER_00]: Fair enough. [SPEAKER_02]: We concur. [SPEAKER_00]: The other two components I was thinking about with Metabolic Care had to do with Anto, BCD medications.

1:22:07 [SPEAKER_00]: And, and unfortunately, you alluded to this earlier, there's not really great data on, you know, the newer agents, some aglytide, for example, Tersepotide, and they're going to be other ones coming down the pike. [SPEAKER_00]: Most of the data is on Exanotide, with a very old drug, the raglytide, a very old drug.

1:22:23 [SPEAKER_00]: And, you know, a phantramine top here may, though that data does exist, and it's mostly for treating obesity that can be associated with PCOS and individuals with PCOS who also have obesity, so it's more like a weight management thing versus like, let's look at the PCOS specific outcomes fertility and ovulation, whatever.

1:22:41 [SPEAKER_00]: Now, can weight loss 5-10%, 5-10%, which is very consistent with these drugs and sometimes they do, they do much more than that. [SPEAKER_00]: that that would be helpful. [SPEAKER_00]: But unfortunately, we don't really have good evidence on that, and in particular around like conception and fertility, like that's even more.

1:23:01 [SPEAKER_02]: Yeah, I think the matter of time, though, with how the tides are have turned recently and just the direction that we're going, I think it's a matter of time. [SPEAKER_02]: If, and it's a big if, if research dollars are allocated to find it an important enough query to fund into ultimately study.

1:23:18 [SPEAKER_02]: Yeah. [SPEAKER_02]: But I think that it's a matter of time. [SPEAKER_00]: Okay, that's the same thing. [SPEAKER_00]: I mean, metabolic bariatric surgery is also like, it's not that it's new, right? [SPEAKER_00]: But in this field, it's relatively under research. [SPEAKER_00]: There are some studies on individuals with PCOS undergoing metabolic bariatric surgery.

1:23:33 [SPEAKER_00]: And effectively, all of the will call it excess atoposity related concerns of the condition 10 to get better. [SPEAKER_00]: So cardiovascular risk, because blood pressure tends to normalize insulin resistance tends to get much, much better here, [SPEAKER_00]: Sure, but this doesn't appear to be like a mainstay in treatment.

1:23:53 [SPEAKER_00]: And I don't know if there's just like a disconnect between like obesity management and PCOS management or if there's more of this concern related to women or it's like, well, I don't know. [SPEAKER_00]: These are reproductive age females. [SPEAKER_00]: Mostly we don't want to surgirize them prior to conceiving.

1:24:06 [SPEAKER_00]: I don't know. [SPEAKER_00]: What's your take on that? [SPEAKER_02]: I don't know that, well, there's lots of hot takes and opinions as to why there is not better integrated considerations for conditions that only affect women in greater health questions and concerns. [SPEAKER_02]: But I will say, like, on the ground, I don't feel that necessarily, like, within myself and my colleagues and the spaces that I practice, I don't think that there is a concern for [SPEAKER_02]: Procluding these treatment strategies for women because of their reproductive potential, I don't see that at all.

1:24:48 [SPEAKER_02]: I'm certainly not the way that I practice. [SPEAKER_02]: And so it comes back to what their goals are and whether or not that includes fertility and what that timeline looks like and how we optimize things from here to there. [SPEAKER_00]: Yeah, I was unable to find any evidence on this.

1:25:04 [SPEAKER_00]: For example, how many individuals with PCOS are being, there will be cities being managed using current evidence, which would include either pharmaceutical interventions and or metabolic bariatric surgery early sort of referral for a surgeon's opinion on the, here you could candidate for this or not.

1:25:24 [SPEAKER_00]: I couldn't find any evidence on that, but my suspicion [SPEAKER_00]: is that it's really low. [SPEAKER_00]: I mean, it's low in general, like it's just underutilized. [SPEAKER_00]: You know, people talk about metabolic bariatric surgery, like, oh, too many people are getting surgerized.

1:25:37 [SPEAKER_00]: They're getting the, you know, the lap and the, just to make your stomach smaller, make your gut smaller. [SPEAKER_00]: Like, well, that's not really why we're, how it works. [SPEAKER_00]: We talked about that in our podcast on metabolic and bariatric surgery. [SPEAKER_00]: But overall, it's underutilized right now.

1:25:48 [SPEAKER_00]: I assume it's even more underutilized in patients with PCOS. [SPEAKER_02]: Yes, I would agree, and just to kind of add that on to that clinical plate we were referring to earlier. [SPEAKER_02]: And, and then thinking about the clinician's prowess and they're like they're bandwidth essentially to navigate all these different topics is exactly the reason why this particular problem set or these particular symptoms in this particular syndrome is something that I capture in a very comprehensive template that I use in the clinic.

1:26:24 [SPEAKER_02]: my documentation. [SPEAKER_02]: It serves as a great reminder to help QMe to cover all this variety of risk identification and counseling topics and as reminders as they say, hey, don't leave this out. [SPEAKER_02]: Don't leave out that physical activity, motivational discussion with the patient and don't forget to [SPEAKER_02]: weight loss medications or metabolic bariatric surgery.

1:26:56 [SPEAKER_02]: So you protocolize it for yourself, you put it in a checklist and it can cue you to to make it a part of the regular conversation that you're having. [SPEAKER_02]: And the more and more we have these conversations too, hopefully that leads to continuing to reduce stigma around this topic as well.

1:27:15 [SPEAKER_02]: And ultimately, just in the name of trying to do what's right for the patient, and really set them up for success. [SPEAKER_00]: You'll check this manifesto. [SPEAKER_00]: Love, love, love, love. [SPEAKER_00]: Yeah, shout out loud. [SPEAKER_00]: Don't get it, yeah. [SPEAKER_00]: Last thing I wanted to get you to talk about where we wrap this up is about fertility-related treatments.

1:27:32 [SPEAKER_00]: So you have a person who, you know, you've diagnosed with PCOS, you're managing all of these other constellation of potential risk factors in long-term health-sequally. [SPEAKER_00]: And they desire pregnancy and there are the laundry list of different agents and interventions that can be used with its clomophane letters all going to add a trope and et cetera.

1:27:51 [SPEAKER_00]: Can you just give us like a two or three minute summary of like how your brain is operating in that space and like how you communicate that to the patient. [SPEAKER_02]: Sure. [SPEAKER_02]: So before getting even to the treatment part, I always want to remember remind myself that someone who's been identified as having PCOS is not someone who needs to reach a 12 month of actively trying to conceive without a pregnancy criteria for that infertility criteria.

1:28:21 [SPEAKER_02]: before you're moving forward with a general fertility evaluation and starting to counsel them on some treatment strategies. [SPEAKER_02]: So this is going to be someone that we are moving forward with those things probably more like at the six month mark because they [SPEAKER_02]: You can have someone to PCOS wait 12 months, but the reality is the rate of pregnancy is going to be lower, especially if they have that oligo or an ovulation, if there's not an opportunity for that egg to have that handshake with the stork, then we're going to find ourselves in the same place, but just like kicking the can down the road essentially.

1:29:00 [SPEAKER_02]: So just keeping that in mind. [SPEAKER_02]: to go down this path a little bit sooner. [SPEAKER_02]: And after completing a workup for female and male infertility, then we are, at this point, looking at offering lectures all in a room of taste inhibitor, you mentioned clomphine and that is an old and very widely used medication.

1:29:28 [SPEAKER_02]: It's been looked at head to head in a variety of studies [SPEAKER_02]: Where we are now with the body of research is just that patients with PCOS, the preferred agent as lectures all. [SPEAKER_02]: They can receive this from a general gynecologist, not necessarily from an infertility specialist, and they can take this medication during specific days in their menstrual cycle, that would typically be within the first half.

1:30:02 [SPEAKER_02]: It's going to be for five days that they take it, usually like starting on day two or day three. [SPEAKER_02]: And if they are someone who does not have regular cycles, say they are an ambulatory, they can do something that's called like a quick start. [SPEAKER_02]: So they just take it any time.

1:30:17 [SPEAKER_02]: Regardless of where they may be, because the truth is, we're not sure where they are, because they haven't had a period, which means has ovulation happened most last time. [SPEAKER_02]: It happened not sure, but this romanticine inhibitor is intended to, [SPEAKER_02]: induce ovulation. [SPEAKER_02]: So the strategy is called ovulation induction.

1:30:37 [SPEAKER_02]: And there's a variety of ways to also test if they take that medication at the first part of that cycle or a quick start approximately. [SPEAKER_02]: 10 to 14 days later, depending on whether or not they are cycling normally when an LH surge would potentially lead to an ovulation event and the opportunity to become pregnant.

1:31:03 [SPEAKER_02]: You can do ultrasounds that can verify whether someone has ovulated, you can you can test a progesterone and what should be like the midlutual phase of the cycle. [SPEAKER_02]: Or you can just wait and see. [SPEAKER_02]: because if they go on to have a period, if pregnancy does not occur, then at least we know, okay, that did induce ovulation.

1:31:27 [SPEAKER_02]: Because the period is something that we also call like a withdrawal bleed because ovulation happened, a pregnancy did not occur, and then we're kind of wiping slate starting over. [SPEAKER_02]: And so, that is just like a very rough summary of what this medication is, how it works when you take it and what should happen afterwards.

1:31:48 [SPEAKER_02]: This is something that can be prescribed for three to six cycles consecutively. [SPEAKER_02]: And if pregnancy does not occur, then referral to a fertility specialist is absolutely an option at that point. [SPEAKER_00]: Yeah. [SPEAKER_00]: No good summary. [SPEAKER_00]: Well, I appreciate your time on this.

1:32:10 [SPEAKER_00]: We've we've talked. [SPEAKER_00]: I would argue not long enough about PCOS, but I also understand the attention span in the podcast universe, you know, if perhaps if we normally had four-hour podcasts, we could keep it going. [SPEAKER_00]: But I think just to summarize briefly, you know, PCOS is a complex medical syndrome, the diagnostic work up is complex, the patient care, it's all complex, and you would really be best served by having an individual [SPEAKER_00]: who is a coordinating all of these moving parts here.

1:32:42 [SPEAKER_00]: It's not just one thing and there's no weird trick that I can I can sell you or she can sell you or anyone can sell you. [SPEAKER_00]: And so I've listed a ton of resources in the show notes for you. [SPEAKER_00]: And also Dr. Barack is going to be [SPEAKER_00]: doing some work here with barbell medicine with respect to women's specific consultations and such.

1:33:02 [SPEAKER_00]: So if you're an individual with PCOS and you want some more hands-on care, you can contact us support at barbellmedicine.com. [SPEAKER_00]: Dr. Baroque is there anything you want to leave the audience with? [SPEAKER_00]: I know I've taken up too much of your time, but if it was a parting shot here.

1:33:15 [SPEAKER_02]: No, for Naleko, what you said, yes, complex is complex. [SPEAKER_02]: Yes, it's complex, but it's not insurmountable. [SPEAKER_02]: And it's not impossible to overcome and to optimize and to reach a healthful place in your life if this is something that affects you. [SPEAKER_00]: I like that.

1:33:32 [SPEAKER_00]: Well, that is a wrap here on the Barbell Medicine PCOS podcast. [SPEAKER_00]: Now, before you guys go anywhere, please leave us a five-star rating and a review. [SPEAKER_00]: It really helps drive traffic to our podcast so we can keep bringing you all the latest new ones and health. [SPEAKER_00]: In fitness, a special shout out to Dr. Lorraine Baraki, the most handsome doctor in North America for joining us here, and we'll catch you next week and every week right here on the Barbell Medicine podcast.