Female Hormone Health, PCOS, Endometriosis, Fertility & Breast Cancer | Dr. Thaïs Aliabadi

Every single opthalmologist knows about cataract. >> Yes. Most common form of of blindness. >> So it would be rare for you to go to an opthalmologist with cataract and not get diagnosed. Correct. >> Correct. >> So why is it that the leading cause of infertility on this planet? 90% of women are not diagnosed. Women's health is very different than other fields of medicine. It's very it's a different monster. It's that cataract patient that goes to 20 opthalmologist and she keeps saying, "I can't see." And the opthalmologist says, "You're crazy. There's nothing wrong with you." Welcome to the Hubberman Lab podcast, where we discuss science and science-based tools for everyday life. I'm Andrew Huberman and I'm a professor of neurobiology and opthalmology at Stanford School of Medicine. My guest today is Dr. Tais Aliyabati, an obstitrician, gynecologist, and surgeon and one of the most sought-after experts and trusted voices in women's health. Today we discuss crucial topics in women's reproductive and general health, including PCOS, endometriosis, breast cancer, pmenopause, and menopause. Dr. Dr. Aliabati explains why so many cases of PCOS and endometriosis go undiagnosed and how many physicians unfortunately write off things like pain, hair thinning, mood changes, and other symptoms as normal when in fact they reflect larger underlying issues that can impair fertility and lead to bodywide health complications. And she explains the key things to do to diagnose and treat PCOS and endometriosis. Everything from how to adjust insulin sensitivity to hormone replacement, over-the-counter, and prescription-based protocols. As you'll soon hear, Dr. Aliabati is incredibly passionate about women's health and has developed various zerocost online tools that women of any age can use to assess their risk for things like breast cancer, PCOS, and endometriosis. I should also emphasize that today's discussion is relevant to women of all ages. Many of the conditions we discuss are starting to show up in women even in their mid- teens and 20s and can carry serious health risks. Dr. Aliabati makes very clear that often these issues can be resolved, but that it requires knowing the telltale signs and taking the appropriate steps. She explains that alas, many doctors and even OBGYNS are unaware of those telltale markers. So, what you're about to hear is an extremely eye-opening conversation that thanks to Dr. Dr. Aliabati's passion for and expertise in women's health could very well save someone's mental and physical health, their fertility, and in the case of breast cancer screening, even their life. Before we begin, I'd like to emphasize that this podcast is separate from my teaching and research roles at Stanford. It is however part of my desire and effort to bring zerocost to consumer information about science and science related tools to the general public. In keeping with that theme, today's episode does include sponsors. And now for my discussion with Dr. Tais Aliabati. Dr. Tais Aliabati. Welcome. >> Thank you for having me. >> Super excited to talk about today's topics and there are a lot of them because I think these days we hear a tremendous amount about how fertility rates are dropping. We hear that sperm counts are dropping. We hear that things like PCOS, which he'll explain to us, are on the rise. I'm curious if they're on the rise or they're just being detected or not detected as much. Let's start off quite simply and just bracket for people what the sort of standard trajectory of fertility looks like for the quote unquote average woman. I realize there's no such thing as an average woman, but I think we hear so much these days about people are waiting to have kids, some people are freezing eggs early, all this. If we were to just march through and say, you know, um what fraction of healthy women are fertile in their say 20 to 25, 25 to 30 and march that forward just to give people a sense of what the data and your experience really tell us. >> First of all, before I go there, I want to tell you something. I want to tell you how excited I am to be here today. And I'll tell you why. Because I've been in women's health for 30 years. And one thing I learned is that women's symptoms get dismissed, minimized, or completely ignored, right? It's normalized. These women, every time they complain, they say, "It's in your head. You're anxious. You're stressed. Um, you know, it's it's normal. It's part of being a woman." And behind these dismissals are millions and millions of women suffering undiagnosed PCOS, endometriosis, chronic pelvic pain, infertility, which we're going to cover right now, and so many other issues because no one takes the time to listen to them. And um the reason I'm so excited to be on this podcast is I want to shed light on these topics, especially endometriosis and PCOS, because they're the top leading causes of infertility on this planet. Majority of these patients are never diagnosed. Majority. And that's why I'm so excited to be here and I love talking about fertility because the reason these women end up in a fertility clinic in the first place Majority of them have undiagnosed PCOS and endometriosis. So we are born with certain number of eggs, millions of them. And we don't make more eggs after we're born. And as we go through life, we start losing these eggs until at about menopause, we have about a thousand of them left. So as we get older, the number goes down, but the quality also declines. The issue is PCOS and endometriosis affect your egg count and your egg quality. So because 90% of these patients are never diagnosed. What happens is they start losing their eggs. Let's say take an endometriosis patients which we're going to get into it. But they start losing these eggs. The quality starts shooting down. Some of them by age 30 they have zero eggs left. And these are patients who bounce from doctor to doctor and their symptoms are dismissed. They're being told that their painful period is normal, that their painful sex is in their head, that they're exaggerating their pain, and meanwhile their ovarian reserve is completely depleting, and no one is addressing that. Andrew, I've always said this, and I really mean it. If every 20-year-old in this country would go through my office once at age 20, I would shut down these fertility clinics. Because where do these patients end up? In fertility clinics. That's why these doctors are so busy. And that's why these patients go bankrupt, selling their homes, selling everything they have to pay for an IVF cycle that could have been completely blocked had they been diagnosed correctly and treated at a very young age. And I'm talking sometimes I treat 13y olds with endometriosis. I have right now in my practice a girl at 14 with endometriosis whose egg count is the egg count of a 40year-old. That's why you can't I can't sit here and generalize that if you're in your 20s you're going to be fine. It's not true. You need to know at a very young age, every girl on this planet needs to be screened for endometriosis, for PCOS, and they need to know their egg count. Egg count, AMH, antimmalarian hormone, is a simple blood test. It's covered by most insuranceances. It needs to be offered if you don't want to offer it to your young patients because, you know, teenagers are tricky because they have so many eggs. But if they're complaining of severe pain, if they're missing school, if you're have if you as a parent, you have to go pick them up from school, the nurse is calling you, they don't want to take their test because they're rolled up in bed from pain. That patient, even at 14, deserves an egg count check because for these patients, sometimes by age 16, I freeze their eggs. >> Incredible. So I'm going to reframe my question on the basis of what you just said um and ask is the typical plot that we see of you know this x number of uh or x percentage of of women of a given age bracket are of this fertile or not fertile meaning how many trials or times it would take in order to successfully um get pregnant carry a baby to turn. Should we either discard or think differently about the data that we see plotted out? Like if I were to go into one of the AI platforms and ask, I'm sure it would generate a plot for me. What I'm hearing from you is that because PCOS and endometriosis are not taken into account. The textbook picture is a false picture of fertility as a function of age. >> Correct. And that's why I have a patient who came to me, she was 24, severe pain. She said, I listened to your podcast. I went to my doctor and I asked her, my gynecologist, and I said, "I have really bad painful periods and I think I have endometriosis. Can you check my egg count?" You know what the doctor told her? Her gynecologist, "You're too young. It would be malpractice for me to check your egg count because at 24, you should not have any issues and you have no problems getting pregnant." I operate on stage 4 endometriosis patients at age 18. That's why I'm here. That's why I want to grab this mic. And that's why I want to just focus first on PCOS and then focus on endometriosis. Cuz these two conditions, you don't need a doctor to diagnose you. If you listen to this podcast, by the time you and I are done, whoever is listening, if it's a parent, if it's your sister, if it's yourself, if it's your daughter, you're going to be able to diagnose these conditions, the leading causes of infertility on this planet. It can be diagnosed by the time we're done. You're going to walk on the street and you're going to say, "I think that woman has PCOS." I'm serious. That my patients are so smart. They literally send their friends. They're like, "I'm sending you my cousin because she has endometriosis." Patients are diagnosing when doctors are not. >> Incredible. >> That's why I'm looking forward to these robotic doctors. I read that China has this robotic hospital. I'm like, "Praise the Lord. These robots are not going to dismiss women. If you tell a robot, sex hurts, I stay in bed, I end up in the emergency room every time I have my period," the robot will not call you crazy. The robot will say, "You probably have endometriosis." But let's work it up. >> Glucose is a key player in how our body functions, not just in the long term, but in every moment of our lives. That's because it is the major fuel for our cells, especially our brain cells. Glucose directly impacts our brain function, mood, and energy levels, and it may even affect our levels of tenacity and willpower. This is why I use the continuous glucose monitor from Lingo. I absolutely love it and I'm thrilled to have them as a sponsor of the podcast. Lingo helps me track my glucose in real time to see how the foods I eat and the actions I take impact my glucose. When glucose in your body spikes or crashes, your cognitive and physical performance do too. In fact, large glucose peaks and valleys lead to brain fog, fatigue, irritability, and hunger. What you eat, of course, plays a major role in your glucose. Some foods cause sharp spikes and big crashes, and others do not. But not everyone is the same in terms of how they respond to particular foods. 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But again, nothing sticks to it, so it's really easy to clean, and it's even dishwasher safe. I love it, and I use it constantly. Our Place now has a full line of titanium Pro cookwware that uses the firstofits-kind titanium non-stick technology. So, if you're looking for non-toxic, long-lasting pots and pans, go to fromourplace.com/huberman and use the code hubman. Right now, HourPlace is having their biggest sale of the year. You can get up to 35% off all products now through January 12th, 2026. With a 100-day risk-free trial, free shipping, and free returns, you can try HourPlace with zero risk, and you can see why more than 1 million people have made the switch to ourplace kitchen wear. Again, that's from hourplace.com/huberman to get up to 35% off. >> Well, clearly you're on an important mission and clearly it's good that we reframe the question that I initially asked and start with PCOS and then endometriosis. But before I do that, I just want to um just give a reflection which is u one of the takeaways from what you just said and just one there are many but one of them is that >> most young women learn about the menstrual cycle. I think they also make an attempt to teach boys about the menstrual cycle when we were in high school. They they try to teach everybody. Whether or not it sinks in to to the males brains is is a question of debate, but most every woman learns at some point about the menstrual cycle. It sounds to me like female health education should also include education about PCOS and endometriosis at a very young age. >> Mandatory. It should be mandatory. >> And currently I it's not. In fact, many um female listeners of this podcast, I believe, um either suffer from or know somebody who suffers from PCOS or endometriosis. I know this cuz I get asked a lot uh to cover these topics, which is one of the reasons you're here. And the other thing is that I'm I'm certain that many do not that many do not because they came up through an education system where that just didn't happen. So, we can start this important initiative now. Um what is PCOS? Very good question. So PCOS is the most common hormone disorder in women in the reproductive age. The most common. So we're not talking about some rare diagnosis. Number one, it affects 15% of women in this country. If you go to Middle Eastern countries, that number can go north of 20%. Studies show that 70% of these patients are never diagnosed. I tell you today that that number is over 90%. Majority of these patients are never diagnosed or even when they're diagnosed, they're not being treated correctly. I listen to podcasts on PCOS where doctors come and uh you know, whoever's interviewing them ask them, "So, what do we do for PCOS?" And the answer is we give birth control. That's not true. Birth control is just one tiny little aspect of the entire treatment plan and that's why patients get frustrated. So when it comes to diagnosing PCOS, right, you need to meet two out of three criteria. The first one being symptoms of high testosterone or high androgens. What are those? Facial hair, body hair, the most common acne, oily skin or male pattern hair thinning which a lot of women complain of. Number two is basically uh ovulation dysfunction. These are women with irregular periods. They get their periods um over like you know 35 days. It's not regular 28 days or they get about eight periods per year. These are patients who usually come to the doctor and when you ask them how your periods are, they can't really tell. They tell you it's irregular. I can't quite pinpoint when I'm going to get my period. And number three is PCOS looking ovaries on ultrasound. Polycystic ovary syndrome does not mean cyst. That's a bad name. >> It's a very specific finding on ultrasound. When you see almost like 20 plus follicles in the ovary and these are follicles. They look like string of pearl. It's very specific to PCOS. The issue is doctors don't recognize it. they dismiss it and they look at the ovary and they like they say, "Oh, you have so many eggs you have no issues with fertility." So PCOS looking ovaries on ultrasound does not mean cyst. To this day, doctors tell patients, "I don't see a cyst on your ovary, so you don't have PCOS." So PCOS is an ultrasound finding. However, in 2023, they added another criteria to this third um criteria, which is elevated egg count or elevated AMH. So, women who have very high AMH, that is a telltale sign for PCOS. And that's what we were talking about before this podcast. >> Yeah. Because so many women who are interested in and concerned about their fertility will go in and get their AMH measured. And so many just have in mind to that you just want the higher numbers. Higher is better, right? >> The higher is better. But in case of PCOS, higher does not mean good quality eggs. >> I see. >> We're going to talk about that. So you need to meet two of these three criteria. >> Only two of the three. You don't need all three. >> No. So if you have irregular periods, right, and you have uh PCOS looking ovaries on ultrasound, you meet the criteria. If you have uh irregular periods and you have symptoms of high testosterone, you qualify. Now, let me tell you, you do not need to have a high testosterone in the blood to get the diagnosis of PCOS. If you do, great. Then you qualify for that high testosterone symptom or in blood. But you do not need to have a high testosterone in your blood. And that's why a lot of doctors tell their patients, well, I checked your hormones and your testosterone is normal. That's not one of the diagnostic criteria. So if you're sitting at home, if you have irregular period, if you have a daughter who gets laser of, you know, constantly is lasering her face, she has acne, she's on spirolactone, she takes Accutane, these are criteria. She meets the criteria of PCOS. PCOS patients have mood disorder. If you listen to them, they struggle from with anxiety, depression. They're moody people. Uh 75% of them gain weight. 25% of them are very lean. I see a lot of eating disorder or disordered eating in my PCOS patients. I would literally tell you that 60 70% of my PCOS patients have disordered eating. You want to find PCOS patients, go knock on the doors of these eating disorder centers. They're sitting behind those doors, undiagnosed, and it's the leading cause of infertility. So this is the big picture of PCOS. So imagine these women who are walking around, they're gaining weight, they can't lose it, they're anxious, they can't get pregnant, they have acne, hair loss, facial hair, body hair, their periods are irregular. They go to the doctor and what do they hear? There's nothing wrong with you. Eat less. You probably need to exercise more. That's all they hear. What do they do? They put them in eating disorder centers when they're a teenager and they feed them pizza and they say, "If you don't eat this pizza, that means your eating disorder is not better." I did a podcast with a patient of mine, Phoebe. She said in this eating disorder center, every day they would put pizza in front of her. And she would say, "I I I eat this pizza, but when I eat it, I get sick. I can't I feel awful when I have this pizza." You know what they would tell her? See, you have an eating disorder. you're not ready to go. No, she had PCOS. But at least if you diagnose and validate them, you can start helping them better. I have several questions. Um you mentioned irregular periods and um I think to most people that means that whatever cycle length they are accustomed to 28 days or 30 days or even you know 22 days that it's regular um and that if it changes by you know plus or minus 5 days or so for you know more than 2 or 3 months out of the year then you would call that irregular. Okay. But if a given how young you're seeing PCOS in your clinic and given that women start menrating at let's say in the in their in their mid- teens early teens I mean I know the age is getting pushed back and but it's going to vary but I could imagine I I've only lived as a male so I'm I'm really uh truly imagining here but I could only imagine that for a lot of women cycle regularity is something that they're still figuring out at the stage when they could already have PCO. OS, maybe not full-blown PCOS, but more milder forms of PCOS. And so this notion of regular periods versus irregular periods, it could be quite confusing for someone to figure out. Um, if it's happening on a backdrop of PCOS, uh, and then that of course leaves aside all the, you know, stress and food induced regulation of of menstrual cycle length etc. So it seems like a very difficult thing to identify. So that's actually you brought up a very good point and I want to make that very clear for teenagers you have to be very careful very cautious diagnosing them with PCOS. Why? As you said when you first start having your periods your periods are irregular and if you do an ultrasound these young ovaries have tons of follicles. So actually the PCOS um uh PCOS morphology does is not used for teenagers. For teenagers to get the diagnosis of PCOS they need to have criteria one which is the irregular period and criteria two which is the high androgen symptoms. You do not use the AMH or PCOS morphology on ultrasound as a diagnostic criteria. Number one. Number two, you want to be very careful diagnosing these patients because you don't want to label them at a very young age. So what I do with these patients, I do a hormone panel and these are patients who usually at a very young age they end up on Accutane for their acne. You give them spirolactone and it's not working. They complain of hair loss. They're gaining weight. They're showing signs of an eating disorder. They're anxious. They're not feeling well. they have really bad I see a lot of PMDD with my PCOS patients. So you look at the big picture and I tend to not label them but I will treat them. And uh you know in uh um 2014 I started using GLP1s on my patients for weight loss for PCOS. 2014 11 years ago. >> I think most people don't realize that these peptides were out there. They weren't as commonly discussed. they were sort of considered a little bit niche, a little bit, you know, was certainly cutting edge. Incredible. Okay. A question that I just um have to ask is because PCOS is diagnosed, if it's diagnosed properly, by this kind of amalgam of different features and and you mentioned by ultrasound, this kind of characteristic lining up of of the follicles. I have to ask what might sound like a politically incorrect question, but I'm going to ask it anyway. Do you think that male OBGYNS more often make this mistake than female OBGYNS or is this an equally distributed problem in the OBGYn community? >> Equal. 90% of these patients, let me tell you, are never diagnosed. A a lot of gynecologists don't do a pelvic ultrasound, which I want to change that in this country. It needs to be part of a wellwoman exam. >> They don't do a pelvic ultrasound. >> No. >> Is there I I'm I'm baffled. what what is the reason for not doing it? >> They're not trained to do it or they have to hire a ultrasound tech to their office to do it. Uh or they but for me in my office, if you come to my office and you say you can't do an ultrasound, it's just like me grabbing your glasses right now and say read how can I how can I diagnose you? Pelvic ultrasound should be mandatory. That's another topic I want to cover with the what wellwoman exam should look like versus what women get when they go to their doctor's office. So one of the issues is because women don't get a pelvic ultrasound. No one knows. One, two, a lot of doctors don't even know what a PCOS looking ovary looks like. They think polycystic ovary syndrome means cysts on the ovary. >> The naming is really a problem. And this is true in science and very clearly true in medicine as well. the what things are named can be it can be very useful but it can also really limit understanding. Yeah. Uh if anything um today's discussion hopefully will maybe even remove or put an asterisk next to the C and in and PCOS. you know, they want to change the name, but I personally am against it because I've spent 25 years saying PCOS, PCOS, PCOS, PCOS. And I feel like just in the past few years, more and more people, you know, like people didn't talk about menopause. Now, everyone's talking about uh menopause. I feel like PCOS is the next topic hopefully. And if you go and change the name, then I feel like I have to start all over again. >> No, but you make a very good point. We don't want that to have to happen. And I agree. >> But they're trying to do it. >> There's this there's a a strange thing in public health where there needs to be a ton of hydraulic pressure over time. Like, you know, I guess today's my day to be only slightly politically incorrect. You know, 5 years ago, if you said the word obese or you said, you know, this person has health issues because they're obese. It was considered I mean, people were losing jobs for for making statements like that. Now, we understand obesity to be a serious risk to brain and body health. It's a medical condition. I think the GLPs have kind of helped shift the view now because there's a medical treatment, but it was always true that obesity was dangerous for people, >> but now you can say it. So, I do think that there need to be a lot of hydraulic pressure behind that. And now, um, you're doing the same for PCOS. So, uh, I have a couple questions about the thinning of of hair, acne, and so forth. I could imagine that a number of women listening to this are thinking, well, you know, I've got a little bit of acne. My hair is thinner than it was 5 years ago, but, you know, is this mild PCOS? Is this indicative of PCOS? I mean, everyone knows that hopefully knows their body best, but how bad does the acne or the hair thinning have to be? How rapid before you might say, you know, it it's maybe just, you know, the the hairs seemingly thinner. Um there's a little bit more acne. It's back acne, but and is it throughout the cycle? >> Yes, it's throughout the cycle. And these are patients who usually come to the office asking for help. They say, "I can't get rid of my acne." I always say, if you're twer than 25 and you're struggling with acne and you come to my office and you're asking for sperolactone and Accutane, something's not right. Right. If you have hair thinning, like you brush your hair and you lose tons of hair. I mean, these are patients you look at, you could look at their scalp and you know they're losing hair. I'm not talking about the hair loss that you get postpartum. Do you know what that's transitional and it recovers in like 9 to 12 months. These are symptoms that persist and as they get these patients get older, it becomes more and more and more significant. But the reason I give that big picture is I always look at other factors. Are they having a hard time losing weight? Do they have mood disorder? Do they have any history of eating disorder? Have they been on Accutane? Do they go and laser their hair like twice a year because they can't get rid of it. It's a pattern that you will know. It's not a little bit of this and a these are patients. Patients who are listening right now to me, they're going to say, "Yes, I have this. >> I have every symptom." And I put a check in front of it. The problem with PCOS is there are four different phenotypes of PCOS. That's why it's so confusing for doctors to diagnose PCOS. The most common classic phenotype is a patient that has all three PCOS looking ovaries on ultrasound. Elevated testosterone symptoms or high testosterone or androgens in the blood or and irregular period and irregular period. The second type B patients have the high androgen symptoms. They do have um dysfunctional ovulation with irregular periods. But these patients have normal ovaries on ultrasound. So you can't in this group of patients you can't do an ultrasound and say your ovaries are not PCOS looking so you don't have it. Then the third phenotype is the ovulatory PCOS. It gets very confusing. this group of uh PCOS patients actually ovulate at least sometimes because you know 70 to 80% of PCOS patients don't ovulate >> 70 >> to 80% do not ovulate even when they have regular cycles. So of the 20 30% who ovulate you need to ovulate to get pregnant this se phenotype these patients are ovulating sometimes with regular cycles. So these are PCOS patients who go to the doctor, they have PCOS looking ovaries on ultrasound, they have acne, hair loss, facial hair, body hair, mood, all of that, but their periods are regular. Even these patients a lot of times are not ovulating. That regular cycle that you're seeing is estrogen withdrawal. It's not from the progesterone of ovulation. And we're going to get into all that if you want to. And the fourth category, these are patients who um basically don't have any uh elevated testosterone or androgen symptoms. They don't have acne, hair loss, facial hair, body hair. They just don't ovulate regularly and they have PCOS looking ovaries on ultrasound. So imagine these four phenotypes, right? And imagine all the insulin resistance and all these other underlying conditions. It makes the big picture, the image of these patients so different. They all present differently to the office. That's why doctors scratch their heads. That's why doctors don't want to diagnose PCOS because they really don't understand all these phenotypes. They don't understand that you can be completely thin and have PCOS. That not all PCOS patients need to have weight issues. That you don't have to have acne, hair loss, facial hair, body hair. That in some phenotypes you don't need to have a PCOS looking ovaries. there's some that have regular cycles. So that's why it gets so confusing. >> It is uh confusing and yet I think when one hears that there there are different um indicators obviously and it sounds like a a skilled practitioner like yourself can can see the contour of which ones fit together. I it's pattern pattern recognition clinical pattern recognition which is very difficult to do from an AI search or from it's impossible really. I mean I think um I have a couple of questions. Uh one is just leap to mind as it relates to the mood disorders. Um I could imagine that some of these disorders are treated or they attempt to treat them through uh anti-depressants, SSRIs and things of that sort. Is there any indication that the drug treatments for these mood disorders interact with the hormones that we're talking about in a way that exacerbates the PCOS? I mean we know that serotonin and dopamine all these things have feedback and interaction with these hormones or do you think that um that's se a separate thing entirely? >> In order to answer that I think it's better for me to tell you the underlying drivers of the symptoms of PCOS and how those can affect the mood. And by treating the underlying conditions, sometimes you can address mood changes without having to give them a zoloft or alexapore. You might have to, right? >> But there's no evidence from what I understand that those drugs are actually causing PCOS. Okay. I just want to essentially rule that out. Right. Okay. Good. I'm relieved to hear that because those drugs are >> not to my knowledge. I've never experienced that. >> My my, you know, not so cursory uh web search on this uh said no, but I I want to verify with you. So, um so what is the cause of the mood disorders? You're talking slightly elevated testosterone. So, all the all the males listening are like, "Oo, sounds great." And of course, um supplementing with testosterone um in women in menopause has now become kind of a trendy thing. >> And you can absolutely do that with PCOS patients. We can get to that. But I is it okay if I discuss the underlying pillars because it's very important and I think that's what people don't understand and I think that's what I've observed in my practice at least over the past 25 years and it's so important to understand it because if you don't understand it then you don't know how to treat PCOS then you don't just throw birth control pill at it and that's why these patients don't feel better so they're underlying pillars that drive the symptoms of PCOS us the number one issue is the brain pituitary ovary access which I'm sure you know it by heart but as you know our hypothalamus releases a hormone called G&R that stimulates in a uh it fires in a pulsatile fashion and basically it stimulates the pituitary gland to release this hormone called FSH which stimulates the follicles in the ovaries as the follicles one follicle per month. As the follicle gets stimulated and starts growing, it starts releasing estrogen. When the estrogen peaks really high for 48 hours, it stimulates that same pituitary gland to release a hormone called LH. And LH is responsible for ovulation. It comes, it basically weakens the wall of the follicle. It causes inflammation. It causes vascular changes, all of that. So the egg gets released. Once the egg gets released, whatever's left of that follicle is the corpus ludial cyst which starts releasing progesterone to basically uh support implantation. This is what's supposed to happen and that's how people get pregnant. >> It's such a beautiful mechanism, right? Very cells that are stimulated by FSH produce a hormone which feeds back to shut down the production of FSH and bring in the LH. I mean it's it's a I mean it's a beautiful molecular set of gears basically. It's beautiful. I mean not to make it too reductionist but it's it's truly incredible when one thinks about it. And as you mentioned that it spans from the brain all the way to the ovary. It's to the uterus. It's it's a it's a spectacular set of of interactions really. >> And you know that estrogen that the follicle is uh stimulating gets the lining of the uterus nice and juicy ready for pregnancy. And then when the egg ovulates and now the progesterone comes, the progesterone stabilizes that lining so the embryo can go and implant and turn into a beautiful baby. And usually that cyst, the corpus ludial cyst during the first 12 weeks of pregnancy is helping release the progesterone to help the pregnancy really stick to that wall of the uterus. In simple terms, >> nothing wasted. >> Nothing. But women are incredible, aren't we? Incredible. >> It's amazing. I mean, it's it it indeed indeed they are. It's it's like nothing's wasted. The the portion of the follicle that that would otherwise be quote unquote discarded is actually a source of critical hormones. It's incredible. >> It's incredible. >> But let me tell you what happens in a poor PCOS patient. That's the problem. The G&RH, remember that secretes from the hypothalamus, it starts pulsating super fast. By doing that, it shifts the FSH LH balance. So FSH goes down and LH goes up. LH stimulates these cells in the ovary. I don't know if you remember the thea cells in the ovary and they start pumping androgens out, right? And it when you have a lot of androgens in the ovaries, the androgens block the growth of that beautiful follicle that's growing to ovulate. So it freezes the follicle and it prevents it from ovulating. The follicle is still secretreting the estrogen, but it never gets to that peak high, right? And it's still stimulating the lining of the uterus, but the ovulation doesn't happen. So when the ovulation doesn't happen, polycystic ovary syndrome, you start seeing these follicles in the ovary. >> So is it um lack of sufficient LH? >> It's too much LH in PCOS. the LH FSH ratio flips. So the LH is twice as much as the FSH. So you have this constant secretion of LH that stimulates these cells to just pump androgens out, right? So the follicle freezes, doesn't ovulate, the follicle stays in the ovary. And one thing that they've noticed with PCOS patients, for whatever reason, their ovary is super sensitive to the LH. It's like adding fuel to the fire. >> It's like a positive feedback. The reason I asked if it's if it's um how LH is adjusted is the the LH surge is what triggers ovulation normally. Correct. >> But there is no LH surge. >> What I'm getting a kind of mental visual of is that um the strong pull of the levers is is it's just a bunch of smaller levers being pulled repeatedly. But but there's still shedding of the uterine lining, right? There's still menses. So it can be. So that's why it's probably very misleading for people who don't have extreme symptoms of PCOS because they think, well, if they're menrating, then they assume that they're ovulating. >> And 20 to 30% of them actually ovulate, right? But they don't always ovulate. That's the problem. >> And of the ones who ovulate, it gets worse. of the ones who let's say you know this uh brain pituitary ovary access is just partially disrupted of the ones who ovulate 40% of them the embryo does either doesn't form because the quality of the egg is bad but also the environment is not ready for it so the progesterone the uterine lining is not ready for it that's why these patients don't get that >> what is thought to disrupt the hypothalamic uh G&RH neurons >> it could be everything it could it comes to all the other pillars yes >> but but is there any evidence um I mean we don't want to attribute everything to psychological stress but the more I learn about the brain and body and their interactions over the years the more I'm convinced that psychological state does impact hormones and brain function anyone listening will say of course it does but 10 years ago there was this notion of psychossematic illness people would say oh they would say it's all in your head we now know that um that stress is a is a powerful modulator of hypothalamic function it actually comes from the hypothalamus in part >> so I is there evidence that this is you know preceded by stress or trauma things of that sort it just comes >> absolutely it yes it's genetic and that's why I want to talk about it this is just the first pillar you saw like just the first driving force is this brain main pituitary ovary pathway that's completely disrupted that some most patients 70 to 80% don't even ovulate and of the ones who ovulate the environment is not really good for the embryo so that's just the first pillar but at its core PCOS has insulin resistance and I'm sure you know all about insulin resistance but I want to explain it >> please remind our audience because you know we we have newcomers to the conversation and I don't think we could hear enough about insulin resistance >> resistance as a gynecologist, I'll explain insulin resistance. So, I'm sure you've had, you know, physicians uh who probably explain it better, but I'm going to simplify it because it's one of the biggest drivers of PCOS symptom and it's extremely common. Even lean PCOS patients can have insulin resistance. So, what is insulin resistance? The simple way of explaining it is when we eat carbohydrates and our body breaks it down into glucose, glucose stimulates our pancreas to release a hormone called insulin. The job of insulin is it goes to the cells in our muscle in our liver and it opens up the channels on these cells and pushes sugar into the cell where it can turn into energy. So basically insulin takes the sugar from the blood, pushes into the cell and turns it into energy. PCOS patients, 80% of them have insulin resistance. It's not their fault. They're born that way. What does insulin resistant do? When they eat carbohydrate and their body breaks it down into glucose, glucose stimulates their pancreas to release insulin, but their cells are resistant. And I'll tell you why. Remember that androgen that I was talking to you about that gets secreted from their ovaries because of the first pillar makes women more insulin resistant. So, their cells don't respond well. I know it's like, let me get there. It's >> do the the question I was going to ask was going to be a facicious one. I was going to say, do androgens do anything good? No, of course they do. But do >> women. No, they do. Well, women need androgens, but they don't need this many androgens coming from the theal cells. Right. Right. >> So, when their cells can't uptake this glucose, glucose bounces in the blood. Well, you can't have blood stay I mean, glucose stay in your blood. You have to clear it. So as glucose goes up, it pushes our insulin to go up. What does insulin do to PCOS patients? Number one, when insulin goes up, insulin stimulates our ovaries to push more androgens out. How about that? And it blocks the ovulation. It freezes that follicle, right? And it causes acne, hair loss, facial hair, body hair, irregular periods, all of that. The other thing insulin does, it blocks the liver from secretreting sex hormone binding globbulin. If you do a blood test on a PCOS patient, a lot of them the sex hormone binding globbulin is low. Sex hormone binding globulin is a protein in the blood that grabs free testosterone from our blood. Right? When the levels go down because of high insulin, our free androgens and testosterone go up. So more acne, hair loss, facial hair, body hair, all those symptoms. >> I see. >> High insulin does one more thing. It basically tells your body, take this sugar, get rid of it from the blood and store it as fat. How does it do that? It pushes our liver to turn it into triglyceride. The triglycerides can a go into our blood as a form of VLDL and go and attach themselves to the heart. And that's why PCOS patients, you have to screen them their lipid panel because of their cholesterol, risk of cardiovascular disease, risk of diabetes, all of that. But what it does, it sends these triglycerides to our visceral organs. So these patients start having visceral fat. Visceral fat is very different than the fat that you have under your skin. Visceral fat actually c releases cytoines inflammatory factors that increases the inflammation. Inflammation makes our insulin resistance worse and inflammation which is the next pillar stimulates our ovaries to secrete more androgens. >> So it's a vicious feedback cycle. And I think maybe if we just double click on uh visceral fat a little bit. We've never talked about it on this podcast really. >> And I'm not a visceral fat expert. >> No. Well, nor do I expect you to be, but I think it's it it's worth um people just hearing twice that visceral fat is not subcutaneous fat. This is why some PCOS patients can be lean. Um indeed, many people, male or female, can be lean and have too much visceral fat. It's important to correct. You can now detect visceral fat and I believe MRI will do it. Not everyone of course has access to MRI. fatty liver they call it. You know what I'm saying? But it gets dismissed. But it's a very dangerous form of fat because of that inflammation. >> We've known for a long time that there are things that we can do to improve our sleep. And that includes things that we can take things like magnesium thrienate, theine, chamomile extract, and glycine along with lesserk known things like saffron and valyan root. 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Some exclusions apply. >> So the next pillar is chronic inflammation. That's why PCOS patients have this chronic inflammation that they complain about. And this chronic inflammation basically stimulates their ovaries to release more androgens. This chronic inflammation makes their insulin resistance worse. This chronic inflammation can affect their gut. That's why PCOS patients come and say, "I don't feel good. I have food sensitivities. I feel bloated." Because these hormonal shifts and these inflammations do affect our gut. Then we go to the next pillar which is genetics. If you look in PCOS families, there's someone who's either diabetic, pre-diabetic, had gestational diabetes, is overweight, there's some form of insulin resistance. A lot of times you see these patients and their dad is diabetic. So you don't have to look in your mom's side of the family. >> This is a very important point both sides. A lot of people just do the direct one to one and they assume, well, if my mother had no fertility issues and she wasn't overweight and wasn't diabetic, didn't seem to have type 2 diabetes, then it's not an issue, but yeah, dad's genetics are critical as well. >> And then the last uh pillar is epigenetics, which I know you talk a lot about it, but it's our stress. How much are we sleeping? What kind of food are we eating? Right? Someone said this to me, and I love this saying. They said, "Your genes load the gun. Your environment pulls the trigger." >> And I love that because even if you're loaded with insulin resistance, all of that, you can suppress these symptoms, but if you start eating unhealthy, if you're stressed out, if you're not sleeping, if you're just not exercising right, you're pulling that trigger. And that's why, Andrew, all these pillars work together. And that's why these patients present so many different ways, right? And when you were talking about mood, why does someone feel bad? Why does a PCOS first of all the androgens do affect disrupt the dopamine and serotonin in their brain? That's a fact. But put yourself in the shoes of a PCOS young girl who lives at home with a thin, beautiful mom or a thin, beautiful older sister. She's overweight. She doesn't eat anything. She's exercising every day. She's already a little anxious. She has acne. Her mom takes her and they put her on Accutane. She's constantly lasering her hair. Her periods are completely unpredictable. She's starting to have an eating disorder because nothing she does is working for her, right? And then you take this patient with everything I told you with all these underlying pillars not working in her. You take her to the doctor and she gets dismissed. That's why I'm here to speak for them. I feel like over the past 25 years their trauma has become my trauma. I literally can cry right now. >> It's clear how much you care about your patients and the ones that are not even your patients. just the women out there that are suffering in this way. I uh perhaps um could we explore the possibility of a different if I say phenotype it may make it sounds so clinical uh but but a different person who um perhaps is only experiencing a subset of those symptoms that you just described um and and on that note I'm struck by the fact that you know what we know from male pattern baldness and female pattern baldness is that when androgens get too high it miniaturizes the hair follicle. It's kind of interesting that when androgens get too high in the ovary, they miniaturaturize the follicle there, too. It seems like that basically excessive androgens are bad for follicle development. >> It >> Yeah. So, two parallel pathways operating in the exact same way. Um, it sounds like we're trying to make high testosterone the issue, but in some sense, unless we think back to the the G&R neurons firing too much, the elevated androgens really seem to be the the kind of tip of the spear in this whole thing. not what initially sets off the cascade, but in terms of of tractable things that good medications and good practices might be able to take hold of. Correct. Is that right? And and certainly insulin sensitivity as well. But um so I'm imagining, you know, a bunch of different uh patient profiles here, but I can imagine women in their 20s, in their 30s who have been told by society, okay, you're still fertile, you're good. You're going to be fine. These are the women that are showing up in clinics in their late 30s and 40s and saying, you know, why is it that, you know, my egg count is so low or why is it that I can't conceive? >> So PCOS patients, their egg count is falsely high because of that, you know, these tiny follicles that are frozen in the ovaries that never got to ovulate, they do secrete AMH. So these patients that's why in 2023 they changed that second criteria the PCOS ovaries to elevated or elevated AMH. >> How high for for AMH? I mean >> sometimes I like a norm let's say >> what's a typical value for someone in their 20s and 30s? >> So I would say up to six is normal >> and people in their 40s >> less than one >> it drops precipitously. Yes. Where is the the the I don't want to say cliff because maybe it's more gradual than that. after probably late 20s it starts declining. >> That's why I always tell patients, especially PCOS patients, to freeze by 28 to 30 even though they have tons of eggs. Listen, I get patients, they come to my office, they're like, "Doctor, new patient." >> I went to my fertility doctor. He doesn't know what he's doing. Why? 40, 41 year old. I put out 30 eggs and he couldn't make a single embryo >> through IVF. Yeah. >> Through IVF. You shouldn't put out 30 eggs at age 40. That's PCOS. This is so important for people to hear because I think egg count and elevated or high enough AMH is is sort of touted as the thing that people go and look at. It makes sense, right? I mean, they'll do an ultrasound, count count follicles. >> It's great as long as you're not missing PCOS because if you're if it's PCOS, then the quality of the embryo is bad, then the ovulation is suboptimal, the environment is suboptimal, and everything else needs to be fixed. And this is perhaps why some people go in in their their 30s, they might be doing IVF or something like that and they actually have relatively low egg count. They'll get, you know, maybe I don't want it's always tricky what what what low correspondence, but you know, three and and two, you know, three on one side, two on the other, but then the IVF works because you you don't necessarily need the quality of the eggs is higher, >> right? So, AMH, antimmalarian hormone, the easiest way to look at it is every uh 0.1 of AMH averages to one follicle. That's an easy way to calculate it in your head. Okay? So, if you have an AMH of one, you you should have about 10 follicles. But if you show up at 40 and there's 30 follicles in your ovaries, something's wrong. That's PCOS. You have to make sure it's not PCOS. have to make sure that you're not missing PCOS because that's why this woman is not, you know, getting pregnant. And can I tell you, Andrew, how many patients come through fertility clinic and they're not diagnosed with PCOS even by their fertility doctor? >> Well, the way you're describing the the sort of standards in the medical profession, it's it's both not surprising and really umad disheartening. Yeah, it's it's really sad. again why one of the reasons you're here today. I think this reframing of AMH and and egg number um or or follicle number is very important for people to hear. uh because um you know I know a number of different people done IVF do IVF and and this issue of of AMH and and follicle number is like kind of held as the thing right and 50 oh my goodness someone still has you know 20 20 follicles at age whatever you know um 41 or something and then and then they have they'll go through rounds of IVF and it's just it's it's >> I'm not a fertility specialist but I can tell you if at age 25 28 every three um eggs make one embryo. At 40, you might need 10 to 15 eggs to make one embryo. So if your AMH at 40 is 0.5, that means five follicles. So you might have to do two or three cycles of egg freezing or embryo freezing before you can hit that normal embryo. So that's why unfortunately insurance companies don't cover egg freezing, right? And I always say this when uh girls are young and they have beautiful eggs and their eggs are young and healthy and you want to freeze them, they can't afford it because it's very expensive and then when they can afford it, they're usually in their late 30s or 40s and the quality is down. So that needs to be fixed. And we had this conversation, I think, in the Bay Area. A lot of these big companies like Google and Facebook and these companies actually pay for their employees to freeze their eggs. They're smart, right? They don't want their employees to get pregnant. They're like, "I'll pay for your egg freezing. Keep working." But most women most women don't have access. And let me tell you, 50% of counties in this country don't have an OBGYn. >> 50% >> 50% of counties. A lot of these women have to drive two to four hours to see their OB/GYN. >> That's crazy. That's why these podcasts are a gamecher because if they don't have access, that's why artificial intelligence AI, these robotic chat bots that hopefully can someday diagnose these patients and treat them, you know, from home without having them have to drive, I don't know, four hours to see an OB/GYN who will then also dismiss their symptoms. >> Yeah, like you said, in some cases, technology may be better than certain physicians. I don't disagree with you there. At the end of this podcast, you'll believe in the robots treating >> Well, I'll believe in in in robots and technologies perhaps doing better than some clinicians and scientists to be fair. >> But I do think that spectacularly good clinicians like yourself and in other fields. I mean, I know people in different fields of medicine. I'm fortunate enough blessed to know people in different fields of medicine for whom you can truly say that there's no world where a robot or even 15 doctors can compare because there's something about you know knowing the principles of something knowing the principles below the principles principles below that and then being a longtime practitioner in a given field. >> Yeah. >> You know like true what we call true expertise deep expertise and lateral expertise. No, I was going to say, you know, most fields of medicine, let's take opthalmology, right? Every single opthalmologist knows about cataract. >> Yes. Most common form of of blindness. >> Thank you. So, it would be rare for you to go to an opthalmologist with cataract and not get diagnosed. Correct. >> Correct. >> So, why is it that the leading cause of infertility on this planet, 90% of women are not diagnosed? Women's health is very different than other fields of medicine. It's very it's a different monster. It's that cataract patient that goes to 20 opthalmologist and she keeps saying, "I can't see." And the opthalmologist says, "You're crazy. There's nothing wrong with you." >> Now, that's an excellent analogy. Not not just because it's vision and that's my home area of science, but because I think humans are so dependent on vision. And just the idea of losing vision is uh for people who are cited is uh so challenging. Oh, I mean the number of of incredibly elegant feedback loops and the way the whole thing works like a beautiful symphony when it works also indicates that like small disruptions in these things are can cause um really downstream consequences. I'm curious why so much more PCOS or is it like so many areas of medicine where it probably was around a long time but uh we just weren't aware and you know I can point to the insulin resistance maybe it's how people are eating and they the downstream chronic inflammation from the traceral fat maybe it's the neuroscientist in me I keep thinking of these G&R neurons in the brain that are suddenly start firing abnormally >> you know I have all sorts of pet theories as to why that could be the case but of course I don't have any any data This affects it for sure. >> Disrupted sleepwake cycles. I would sort of default to that. >> But then you see these young girls who grow up in amazing loving families. They've never had any stress. They're you know they didn't have any trauma. >> They're sleeping well. They're eating well. Yeah. But they they start having these symptoms. The reason I'm saying this, I don't want um people to get this message that stress is starting all this because they really it's a it's a multi-system dysfunction. It's an immune system dysfunction. It's a insulin resistant dysfunction. It's a brain pituitary, ovary dysfunction. It's has a genetic factor. It has an epigenetic. And that's why the treatment plan is so important. That's why you can't throw birth control at all these pillars and say, "All right, see you later." >> Also, birth control means many, many things, right? I mean, there's the >> I love birth control, but you know, >> well, nowadays there's a bit of a push back. I noticed at least on Instagram for what it's worth. Um, sometimes we think Instagram is the whole world and I'll tell you everyone, it's not the whole world. There are a lot of people who are not on Instagram all the time, but many are. Um, and there seems to be a bit of a push back against um, certainly hormone based contraception. A lot of women um, I I hear from are convinced that it somehow they believe it damaged them and and I believe them. >> That's when the topic of endometriosis will come up and I would love to talk about that. But the reason birth control pills work for PCOS patients, it's one of the aspects. I don't like birth control pills for PCOS patients. Remember I told you they're moody patients. they're they have an anxiety, they're depressed. Um it's hard for them to take birth control pills in my opinion. A lot of times they complain of I'm eating more or I don't feel well or I'm more depressed or so I it's not my first go-to treatment, but I will tell you why it works. Remember I told you the ovaries are um the sex hormone binding globbulin goes down because of that high insulin. Birth control pills stimulate that sex hormone binding lobbulin that starts grabbing the testosterone and helps with their symptoms. That's why if you go to the doctor and you say I have acne, they're like birth control. I have hair loss, birth control. My periods are irregular. Birth control. We use it for all everything, right? But it does work to treat the symptoms of PCOS. It makes the periods regular. It helps with the skin. It helps with the hair loss. It helps with all of that. This is estrogen based or progesterine based birth control. You can do both >> estrogen and progesterone or there's a progesterone only birth control pill now called slend that helps with um it's very anti-androgenic that I try for PCOS patients who don't want to you know need a method of birth control but when it comes to treatment you have to hit the underlying um pillars right so we talked about the epigenetics I always start with there with that exercise walking after each meal meal, you know, walk for 10, 15 minutes. Make sure you're sleeping well. Make sure your diet is healthy. You're not eating inflammatory foods. You're avoiding, you know, u processed foods. Um, so lower your stress. So, you deal with that, but that doesn't work for these patients. That's why you need to address everything else. Insulin resistance is one of the main pillars that needs to be addressed. You have to lower that insulin because if you lower that insulin, you're lowering visceral fat. You're lowering inflammation. You're lowering the ovaries from secretreting androgens, right? So that insulin needs to be lowered. That's why a lot of PCOS patients get prescribed metformin, right? What does metformin do? Metformin basically makes us more insulin sensitive. It's opening these channels. So sugar clears the blood and goes into the cells where it turns into energy. >> Is it high dose metformin or low? >> No, high dose. High dose I mean I start patients on 750 twice a day but you have to start slow because uh PCOS patients especially the ones with insulin resistance which is 80% of them. Um I start with 750 because it can cause sometimes GI symptoms like diarrhea and it can also cause nausea. So I start with 750 at night. Then if they tolerate it, I um add the 7:50 in the morning. And for patients who um are tolerating it and they still are not ovulating, their periods are still not regulating and they still have symptoms, I might up it to a thousand twice a day. But you see these patients who come in on 500 milligram of PC uh of metformin once a day. That's not going to touch these patients. So metformin is one. But before Metformin and I don't know if you know this because of my passion for PCOS I actually developed a calculator it's called it's a platform called OV women can go on it obviously I can't diagnose on the on any website but I can tell them that ask them it's my algorithm that I've developed over the past 25 years and I can tell them very closely whether or not they have the likelihood of having PCOS. M >> so that it's there it's ov.com ovi.com it's free >> they answer some questions >> questions and I tell them whether they have the likelihood or you know if they're less likely to have PCOS and if they do PCOS is one of the very few conditions in medicine where supplements make a huge difference and these are for patients who don't have access to the doctor and these are patients who basically go to the doctor and they're not being they're being dismissed these These supplements work amazingly well. Why? Because um the OV supplement I created, I literally did it here. Diagnose yourself and if you're being dismissed, start with the supplement. They make a huge difference for these patients. Why? Because they address the insulin sensitivity. I'm sure you've heard of anacettol, different forms of anacettol that work um to uh to increase sensitivity to insulin. And that's why these patients when they take it, they say, "Oh, my periods became regular or I took it and I got pregnant." Because it does address that when it comes to this insulin resistance. They can either do the metformin, but what I like to do, I like to start them on supplements that has inactol in it and sub vitamin D. Did you know that low vitamin D makes you insulin resistant? Well, I'm convinced that I I was aware, but I think it's it can't be stated enough or emphatically enough because, you know, I know I'm always I'm really bullish about this sunlight thing. I'm always talking about sunlight. I don't want people to get sunburn. That's not what I'm talking about. But we spend so much more time indoors now under artificial lighting where the short wavelength lighting, >> everyone's low. It really disrupts how the mitochondria process energy and the long wavelength light from sunlight, the so-called red and infrared light serves as a protective feature against the short wavelength light. So, we're not getting enough vitamin D and we need that. That comes from the short wavelength light. I do have a question about inositol. Um there are a couple different forms. Uh there's my right. Um and and we can explore those in more depth. Um but um it is a well-known uh regulator and and can improve um insulin sensitivity, which is what you want. Sometimes people hear insulin sensitivity and they think that's the bad thing. You want your insulin to be sensitive. >> You don't want it to be resistant, right? >> Anything that will make you more insulin sensitive will help with symptoms of PCOS. So you want to bring down these pillars, right? without even thinking about birth control pill. You want to lower your insulin resistance. So whether it's metformin or supplements or exercise or low carbohydrate diet or lowering your stress and lowering your cortisol, all of that all of this system. That's why I wanted to explain all this because they all work together. Then you want to bring your inflammation down. You want to bring that visceral fat down. So you have to that's why I don't know if you heard this but you know in 2014 back then I had trulicity as GLP1 and that's what I used to use for my PCOS patients and they would lose 50 60 80 100 pounds and this is 2014. >> What did your colleagues think at that time that you were injecting patients with GLP? >> Um I actually learned it from a cardiologist who I used to work with Dr. Corandi and I used to send because I would screen for lipid panel on these PCOS patients and they were all you know we they had high triglycerides and they were overweight so I would keep sending them send my patients to him and one day he called me he's like listen ta there's this medication called trulicity do not stop sending your patients to me treat them with this medication they will lose weight and their cholesterol everything will get better so in 2014 I started putting these patients on truly and one thing I realized is their periods were getting starting to get regular their symptoms of PCOS would get better and the first thing they would come and tell me is doctor I feel less inflamed why do you think because you put them on these medications first of all PCOS patients chronically they have this insulin firing right and that's why this cascade starts what GLP1s do people think it's It's an appetite suppressant and that's how it works. Well, that's that's a side effect of it. But what it does, it actually regulates that insulin. So when you eat, it spikes your insulin up and clears that sugar out of your blood, right? >> It's like a scavenger, glucose scavenger, >> right? And it also makes you insulin sensitive. So again, clearing it, which is oxygen really for these PCOS patients. That's why I get so upset when patients comment about these GLP ones because in this subgroup of patients with insulin resistance who are overweight, who are not ovulating, and who have all these symptoms, these medications since 2014 have changed their lives in my practice. The push back on GLP1 says there are variety of reasons um probably a discussion for another time but they've clearly helped many many people uh as long as people still engage in the right behaviors muscle resistance training and people still need to take great care of themselves eat properly exercise sleep etc. You mentioned metformin several times. I'm aware of a um of an over-the-counter version called bourberine which I believe comes from a tree bark um which is supposed to be a pretty potent glucose scavenger as well. Is there any reason why bourberine is not advised? >> So I think there are some studies that say long-term bourberine is not uh advised. The problem with PCOS is it's not something it doesn't have a cure. You can't cure it. It's an ongoing issue. That's why you need to be on supplements that long term you can stay on and you know like you mentioned vitamin D uh curcumin uh chromium uh um anacettol there's so many things we can do to increase that insulin sensitivity lower the inflammation in the body I don't usually give bourberine long term but it definitely short term you can use it as pulse uh treatment for these patients >> and metformin it sounds like is a relatively safe drug. Is that right? >> It's very safe. I you know um even for my patients who are not PCOS um I recommend um metformin let's say permenopausal women with hemoglobin A1C's in the borderline range you know 5.7 you fall into the pre-diabetic range. Um, you know, I'm very lean. I've never been overweight, you know, but I have a long family history of diabetes. And, uh, my hemoglobin A1C was, um, 5.6 a few years ago. And I started taking metformin, and now I'm at 4.8. >> What um, dosages for people who are relatively lean or or lean? >> I start with like 500 at night just to see how they do. Metformin does have side effects and >> drops your blood sugar, right? >> And and no, it's mostly like the nausea and some people really get really bad diarrhea with it. >> That's why, you know, um you can I start them on the supplements. If it doesn't work, I go to Metformin. If that doesn't work, then I offer them GLP-1s. I see. But you can abs and I always ask the patients ask me, can I be on the supplement on uh metformin and on the GLP1? Yes. You just don't want to start the GLP ones with the metformin because they both cause nausea and you don't know which one's causing what. So if someone's morbidly obese and they really want to lose weight, I I start with the GLP1s and usually in about four months, my average since 2014, I can tell you four months of GLP1s done correctly, patients lose 24 pounds. That's my that's my uh that's my curve at my office >> of body fat and muscle or >> probably of muscle too. These patients are a lot of them are like >> they need to lose weight >> 300 lb. So it's hard to even assess that. But you know what? As they start losing weight, they become more motivated because it's the first time in their life that something actually works for them because you're actually regulating that insulin dysfunction that they have. And by supporting that, they become more active. They their self-esteem gets better. I had a 26-year-old in my office who I've been treating for many years for PCOS and these GLP1s and she came into my office a few months ago and when I walked in, she was videotaping me. She looked so good. She was so confident. Her hair was done. She had a mini skirt with these boots and she was always like, you know, very shy and she wouldn't talk. She was this different person that walked into my office. And I started hugging her and she started crying and she looked at me. She said, "Dr. This is the first time in my life I know what it means to be happy. >> Wow. Yeah. I mean, it's very clear that these GLP1s can help a lot of people. It's interesting that the the push back on GLP1s now is changing a bit because um a number of compoundingies make them now. So, you know, people tacked the GLP1s to quote unquote big pharma. You was kind of Yeah. Um and I understand people's gripes with big pharma insurance and things. It's, you know, if if everyone has been, you know, boxed out of of access to a drug or something like that and in had insurance issues, it could be very, very frustrating, even deadly. I mean, there's a whole discussion about this recently around cancer and cancer drugs. But to stay on point, I think now that some of these GLP-1 peptides are available through compoundingies, prices have come down. The big pharmaceutical companies don't like that. But it's also the case that people are are quote unquote micro doing them. They're taking the GLP1s at at doses that are below the threshold that would give them nausea. So, they're not losing weight quite as quickly. They're not going gaunt quite as quickly. Um, but nonetheless, they're benefiting from I think the appetite suppression, the insulin improved insulin sensitivity, >> inflammation >> and reduced inflammation. Yes. And it also seems that they adjust something about brain chemistry that make people feel better separate. It's impossible to separate it completely, but separate from a lot of the bodily changes. There's a bit of an anti-depressant function there. >> You know why? Because that noise that says eat, eat, eat, eat, which is an issue like you know that binge eating. I'm just speaking for my PCOS patients cuz I'm not an expert for obesity, but uh they have this voice in their head and it's a constant battle from the minute they wake up to the minute they go to sleep. And it's not like they're crazy. They're not, it's not like they're, you know, being sloppy with food. It's just this this brain disregulation of dopamine and serotonin that stimul that causes this >> brutal >> anxiety, constant anxiety. And every single one of them will tell me my brain is quiet. >> Wow. >> They're not drinking as much. >> Yeah. That's a clear quotequote side effect is people don't crave alcoholics. And I've said it for years. Just use it on alcoholics. Use it on alcoholics. I had a friend of mine who called me and said her son drinks a lot. The first thing I asked is can he tolerate micro doing of ompic because it shuts down their cravings >> because it's in some sense a sugar craving. It's a state craving of being under the influence of alcohol but it starts with a craving of sugar. Those two things are very closely paired. >> But that's why they feel better, right? But even without GLP1s, when you diagnose and treat these PCOS patients, their confidence comes back. They feel better. They know they're not crazy, which is why I'm here today. You are not crazy. If you're gaining weight, acne, hair loss, facial hair, body hair, if you're not getting pregnant, if you can't lose your weight, um none of this, you're not crazy. This this had these are the underlying conditions and these vicious cycles need to be addressed. And for people that want to get pregnant and treat their PCOS, uh, what are the success rates that you've observed in your clinic? >> Very good question. So, as I'm not a fertility doctor, but I'm trying to take these patients out of the hands of the fertility doctors. So, one thing I do, I put them on the supplement uh on my OV supplement. I give them metformin and I have them try and try to see if I can regulate their period. two things you can do easily and doctors can do it in their office. One is a medication called let and the other one is Clomid. Both of those basically um regulate that hypothalamus pituitary ovarian axis and pushes these patients to ovulate. With letol 60 70% of them I think ovulate and with Clomid it's a little bit less. So you can try those in the office for someone who wants to get pregnant. What I usually do, I have them try on their own for 6 months to a year depending on their age. If they're above 35, I say 6 months. If they're less than that and they're not in a hurry and their egg count is good and I've regular and I know I've dealt with their PCOS and their inflammation and their insulin resistance, then I have them try for a year, right? Because if you take um 100 couples regardless of age um and you have them have sex I don't know three times three to four times a week 50% of them get pregnant in the first 6 months and 90% of them get pregnant in the first year. But for patients with endometriosis or PCOS I usually have them try for like about 6 months and then check back in with me. you know if letol clomit uh trying on their own everything fails then you can send them to fertility doctors. Uh one thing that I want to bring up here which is my observation and it's nowhere in the literature but I'm saying it today and I know it's going to be published someday. I strongly believe that over 50% of PCOS patients also have endometriosis. Over 50%. And I've always said this, if you have a patient with PCOS, think about it. PCOS is already one of the leading causes of infertility. And in my opinion, 50% of them, because I I've seen it in my office, have endometriosis. And I have a path report and I've done laparoscopic surgery to prove it. If you only address PCOS and you're dismissing their painful period, then they're not getting pregnant. That's why you have to make sure you put a check in front of all these underlying conditions. I'd like to take a quick break and acknowledge one of our sponsors, Element. Element is an electrolyte drink that has everything you need and nothing you don't. That means the electrolytes, sodium, magnesium, and potassium, all in the correct ratios, but no sugar. Proper hydration is critical for brain and body function. Even a slight degree of dehydration can diminish your cognitive and physical performance. It's also important that you get adequate electrolytes. The electrolytes, sodium, magnesium, and potassium are vital for the functioning of all cells in your body, especially your neurons or your nerve cells. Drinking element makes it very easy to ensure that you're getting adequate hydration and adequate electrolytes. My days tend to start really fast, meaning I have to jump right into work or right into exercise. So, to make sure that I'm hydrated and I have sufficient electrolytes, when I first wake up in the morning, I drink 16 to 32 ounces of water with an element packet dissolved in it. I also drink Element dissolved in water during any kind of physical exercise that I'm doing, especially on hot days when I'm sweating a lot and losing water and electrolytes. Element has a bunch of great tasting flavors. In fact, I love them all. I love the watermelon, the raspberry, the citrus, and I really love the lemonade flavor. So, if you'd like to try Element, you can go to drinkelement.com/huberman to claim a free Element sample pack with any purchase. Again, that's drinkelement.com/huberman to claim a free sample pack. Well, I definitely want to talk about endometriosis. Um, before we move to that, it sounds like going after the insulin resistance first with metformin and oitol, the other things in uh OV. Well, first people should go to the uh OVI site. We can put it in the show not take the quiz as it's a zerocost platform. You get some feedback there about what might be happening, what's likely happening. Um and then take care of the insulin resistance which presumably also includes things you mentioned trying to get best possible sleep, limit stress, exercise. >> Yes. And start with supplements first if your symptoms are not bad. You know, I've had like 50some patients get off OV because they got pregnant. All you're doing is addressing their hormone and metabolic health. That's all we're doing with it. But if it doesn't work, ask for metformin. If it doesn't work and you're you're having a hard time losing weight, ask for GLP1s. Ask your doctor for Clomid if you're trying to get pregnant. Ask your doctor for let first, Clomid second. And if all that fails, go see a fertility doctor. But before that, even if you're single and you don't have a partner and you're in your late 20s and you have no one uh and you know having a baby is something that will probably happen few years down the line, consider freezing eggs. Not because of the count, because of the quality of the eggs because PCOS patients again have tons of eggs but the quality is not that good. Endometriosis is opposite. endometriosis destroys your egg count and quality. >> I've seen a few papers um that suggest that co-enzyme Q10 and Lcarnitine might be beneficial for egg quality. Yes. And in males sperm quality, but we're talking about eggs here. Um do you include that? >> Yes. And I would say it's probably because of inflammation, right? >> We don't really have great tests for inflammation yet. like the number of tests, you know, that are coming online for um evaluating biomarkers is is quite quite impressive, but we don't really have a good test for inflammation >> as we don't have a test for PCOS. >> Wouldn't that be wonderful? But but it sounds like there's no single blood test that would do it because it's a constellation of things. >> That's why patients say, "My doctor said I don't have PCOS because my testosterone is normal." False. My doctor said I don't have PCOS because my uh I don't have any cysts on my ovaries. False. My doctor said I don't have PCOS because I'm not overweight. False. My doctor says my periods are regular so I'm not I don't have PCOS. False. There's so many myths that that's why it's important to understand the four phenotypes and how they differ. Understand that 70 to 80% of these patients don't ovulate. understand that that the 20 30% who ovulate ovulate sometimes, not all the time and that's why they're not getting pregnant. And understand that inflammation, insulin resistance, and this brain ovary axis are the main drivers. And then you add genetics and epigenetics, it starts a big chaos in the body. And that's why as a clinician, that's why it takes so much time, right? In this health care system, when you get 10 minutes with your doctor, do you think your doctor everything we talked about? I'd say I teach all of this to my patient, new patients with PCOS. How can you do that in 10 minutes? And on top of that, do their papsmear, check their hormones, talk about STD, talk about birth control, rule out endometriosis. How are you going to do that? A, patients don't have access to doctors. B when they have access either the doctors are not well trained or they don't have time to send spend time with these patients and they get you know even when they get diagnosed they get prescribed a birth control pill >> and off you go. >> Yeah. the thin end ed end of the wedge in this case really seems to be going after the insulin resistance um at least in terms of what people can do for themselves without you know because people can't start injecting androgen blockers without you know the assistance and and guidance of a physician so take care of your insulin sensitivity incur you know enrich it encourage it so >> sunlight limit stress sleep etc but these tools of inocl co-enzyme Q10 lcarnitine and these are in OV supplement. >> It is amazing. And not speak not because I don't even have time, but I really created it for women who are at home who don't know if they have a PCOS and they don't know what to do. This is the least you can do. Eat healthy, exercise, sleep well, lower your stress, take the OV supplement, but before you do all that, take the quiz. >> And if you want future fertility, freeze, freeze, freeze before 30 and know your egg count. What about for women who are older than 30 who want to freeze eggs? Does it make sense for them to freeze at 35? It seems to me the answer would be yes. >> Oh, always. I always freeze because you need one good egg. >> Mhm. >> And you don't know if you're going to get it or not, but freeze. And PCOS patients, the beauty of it is they have all these follicles, so we can pull out a lot of eggs. Now, the quality might not be good, but keep pulling it. So for my PCOS patients, generally speaking, we I always tell my patients, freeze 20 eggs because 20 is safe. But as you get older, especially if you have PCOS, I might want 40 eggs. You know, the more you have because I know the quality is not that good. >> Well, and considering that you're going to get more the younger the patient is um and that freezing eggs is not a zerocost endeavor, it starts to get more expensive as you get older essentially, >> right? So the incentive to do it younger is that it's going to be less expensive in the long run. Um I mean there are women in their late 30s, early 40s who still try to freeze eggs. I think in in the state of California after age 42 you can only freeze embryos, not eggs. I think it um >> and I mean it doesn't even make financial sense at that point to do it to pay 10, 15, 20,000. I think in Northern California it goes up to like 35,000. I mean imagine for one cycle to get two eggs out. >> Yeah. the probabilities are exceedingly low but you can understand why people feel you know this this kind of information even just podcasts in general weren't so prominent you know six seven years ago I mean they were podcasts were around but these sorts of discussions weren't happening >> no this is amazing what you're doing I don't think you'll see this podcast will make such a huge difference and I want your male listeners to listen for the sake of their daughters their sisters their girlfriends because are wise because this is so common and so dismissed and you know I've always said this you're going to laugh but you know what my dream is you'll see I'm going to get to my dream is I've always said it I want the president of United States to call for 15 minutes of silence in this country and I'm really serious and I want him to hand me the mic so I can tell women what they deserve to know to tell them that their symptoms are real that their pain is real, that they're not crazy, that it's not in their head, that there is something really wrong that needs to be addressed. And if they're being dismissed, they need to listen to podcasts like yourself. Come on, GMD podcast. I literally, just like you, I take every single condition and I teach them what to do with it. They don't need to go to like literally they don't need to come to my office to see me. I'm telling them what to do. But you have to teach them to become their own health advocate. >> Well, this is the the new movement is for people to advocate for their own health is a big shift. I think since the pandemic really and um I hear you loud and clear and and also uh folks at AHS um health and human services do listen to this podcast. Um about 50% of our our listenership is is male. The other 50% is female. Uh it you know distributes differently across platforms but that's that's basically the contour of things. And I have a feeling uh you'll get your 10 15 uh hopefully more minutes. >> I know this is my mic today. I feel like I'm getting to my dream. >> Yeah. Well well hopefully it's it's a um a large vertical step toward your ultimate dream of of doing that at the um national level although you know we are now translated into other languages. So there there is uh the potential for this to go extremely uh far. Thanks thanks to the information you're sharing. Okay. So, I definitely want to talk about endometriosis, but before we do that, I just want to give people a summary reminder of the two dues. Women basically, regardless of age, should go take this OVI test, the self test. Yes. Zero cost. Get some answers. Um, get some feedback and then really take control of their insulin sensitivity. This is true for everybody, but especially for the people we're talking about here, women that might have PCOS, might not interested in their fertility or just broadly interested in their hormone health regardless of age, even if they're pmenopause, menopause. Great. >> The actionables of limit stress, excellent sleep in no particular order. limit stress, get the best possible sleep, eat a low inflammation diet, limited processed foods, maybe even cut back on starchy carbohydrates >> to improve insulin sensitivity for make sure you're getting enough protein. This kind of thing, exercise, including high intensity and resistance training. And then supplementation. You've designed a supplement. I have no relation to it. So that know this isn't a a designated like, you know, collaborative promotional, but the point being that it has all the things in it that one would want. It's inositol, co-enzyme Q10. >> It has vitamin D. It has actually um wild malberry leaf in it, which believe it or not, if you take it before your heaviest meal, it blocks the absorption of carbohydrates in that meal by 40%. So all the things that PCOS patients um really need for that insulin resistance, for their inflammation, um you know, we've had so many patients get pregnant on it. So many patients I had a patient who called me and said, "My mood is better." Going back to what I was telling you, uh, instead of just starting these patients on Zoloft and Lexapro, sometimes when you fix their underlying condition, you might make them feel better. Not to dismiss their symptoms, but you can at least start with the more natural ways and then prescribe them anti-depressants or anti-anxiety medication. >> Yeah. Amen to that. And it's interesting uh this mulberry um you know I think some people who are more from the uh traditional medical orientation um think oh supplements this and that we've had a couple of scientists on this podcast serious laboratory scientists who work on things every everything you can imagine from painkillers to things that are uh you know active in the brain to improve mood regulate appetite pharma and the drugs they make are derived D almost always from plant compounds initially, right? They actually do what's called bioprospecting. They go out and find plants. We rarely hear about this. They find plants, then they isolate the alkoids from plants that have potent effects on blood sugar, potent effects on on mood, potent effects on pain. And so what we end up with when we talk about pharmaceutical drugs, you know, most of them are derived from plants >> in the first place. >> In the first place. So when you hear malberry, you think, oh, is this like a berry? Is this some magic berry from the jungle? No, this is these are the these uh plant compounds contain uh very bioactive elements within them. So that will also reduce uh these uh the business of improving insulin sensitivity will uh lower inflammation, >> right? >> Very very important. And then of course we can't control our genetics but we've been talking about epigenetics. And then if one is poss if one can they should really evaluate their egg count AMH with the understanding that high egg count and AMH and regular shedding of the uterine lining aka menses menrating does not necessarily mean that everything is reproductively normal. >> Bravo. >> Okay. Did I get it right? All right. >> You're the best. >> Oh yeah. Well, I just I just want to make sure that that the audience really understands because these are things that people can really take control of and do. Oh, and one other critical thing is um listen to Dr. Aliabati's podcast because uh >> she MD there's a because there's a lot more information there as well. >> Okay, let's talk about endometriosis. What is it? What problems does it create? And what can people do about it? devastating devastating condition that affects you know they say 10% I think it's north of 20% because they're not diagnosed it's a condition where uh tissue similar to the lining of the uterus is outside of the uterus around the tubes and ovaries on the bladder on the bowel or inside the ovary right what happens is in a simple terms when every month our ovaries are trying to get us pregnant, they secrete estrogen and estrogen stimulates the lining of the uterus. When we don't get pregnant, this lining breaks down and comes out as a form of period. 10 to I think 20% of women have these cells similar to the lining of the uterus outside of the uterus. So once a month when the follicle is secretreting estrogen, these cells on the outside get stimulated. And when we don't get pregnant and the lining breaks down, these guys uh break down and bleed, but they're bleeding outside of the uterus. >> Oh, so it's a form of internal bleeding. >> Correct. >> It's e it's ectopic formation of uterine lining. It's in the wrong place. >> Correct. Correct. We don't know why people have it, but it's extremely common and as I was telling you, I think 50% more than 50% of my PCOS patients also have endometriosis. The problem with endometriosis is in this country it takes doctors 9 to 11 years to diagnose endometriosis. On average patients see 5 to 10 doctors and that's not an exaggeration. I've had patients who've seen 50 doctors in this country to get the diagnosis. Majority of them go undiagnosed. A lot of them end up in the fertility clinics. And I my heart if you spend a day with me in my office, you go home with a broken heart because these patients travel from all over the country to come. They already know, right? Because a child had GPT, they already know they have endo. They just want a physician to validate them. So they will fly to come because they want someone to say, "Yes, you're not crazy. you have endometriosis and yes, there's a treatment and it's not in your head. The problem is these patients talk about dismissal. I can't even tell you the devastating side effects of this prolonged dismissal because no one wants to sit down and just listen to them. You do not need a fancy blood test. There's no blood test for endometriosis. You don't need an ultrasound. You don't need anything to diagnose endometriosis. You just have to listen. I met this gentleman in Paris who told me he has this blood test that's 95% accurate that he's going to release it. This is was few years ago. And I was like, great, that's great because we need a blood test. But then when I, you know, was um flying home, I was thinking to myself, my accuracy is 99.9% just by listening to the patient. You don't need any fancy tools to diagnose. You can self diagnose yourself at home. How do you diagnose? The first thing I want to teach your listeners is painful periods are not normal. You know, one time for my 50th birthday, I wanted to get um uh what do you call it? On the freeways, uh I wanted to get like 10 billboards for my birthday and just put painful periods are not normal # endometriosis. That was my birthday gift for myself. I wanted to do that. But then my daughter, my second daughter came up to me. She's like, "Mom, okay. So you tell them painful periods is not normal." They go to their doctor and the doctor says, "Yes, it's normal. Don't worry about it." Then what? I'm like, "So maybe going down the freeway, the next one will say, if you have endometriosis, check your egg." And if you have endometriosis on the third, and I was, you know, I was going to just treat them as they drive down the freeway. That's how bad it is. So painful periods are not normal. Could you distinguish between painful periods and premenstrual cramping? >> Correct. So, what do I mean by painful period? If the pain disrupts your life, if you're skipping school, if you're calling in sick and you can't go to work, if you're staying in bed, if you change your social plans around your periods, if you're ending up in the emergency room or an urgent care because your periods are painful, that's not normal. If sex with deep penetration hurts, that's not normal. If you're constantly bloated, even during the month when your periods are painful and after your periods you eat and you're constantly bloated, that's not normal. If when you have a bowel movement, your bowel movement hurts, that's not normal. If you constantly end up in your gyn or primary care's office complaining of UTI or bladder symptoms, recurrent bladder symptoms, and you're getting antibiotics three, four, five times, six times, 10 times a year with a negative culture, that's endometriosis until proven otherwise. So because these patients present differently, majority of these symptoms are chronic pain though. It's the top cause of chronic pelvic pain in women. It's the leading cause of infertility. Right? Over hundred years ago they knew about endometriosis. 100 years later we're still not diagnosing these patients correctly. 100 years later, these women go through life. They can't have children. They have chronic pelvic pain. They stay home. They get anxious. They get depressed. They get addicted to opioids because when they go to the doctor, they end up in these pain clinics and someone starts prescribing them uh Norco or Percoet. I have 25 year olds who come to my office, they're like, I know Percoet is not going to help me. I don't want to take this, but this is what the urgent care gave me. That sounds like malpractice to me. >> But it is. But it is. And you know what? I I I think people think I'm crazy, but you know what I wanted to do, which I'm never going to do, but intent to sue letter to send to all the doctors who've dismissed my patients because if you get one of those letters, maybe you maybe it'll wake you up. We have to do something. How, you know, can I tell you something, Andrew? If men, think about this, had a condition that would cause them to have severe pain during sex. It would scar their scrotums. It would lower their sperm count. It would be the top cause of their fertil infertility that they would stay home 2, three days out of the month in bed. They would end up in emergency rooms few times a year, right? They would get bloated, anxious, depressed from the pain. Do you think majority of them would go undiagnosed? >> No. The the problem would be dealt with very differently. And I say that with um with certainty because if you look at the just even the speed with which certain uh drugs have been approved uh in the medical community like Viagra for instance, one of the fastest approvals for new uses. I mean some of those drugs like were developed for other purposes but male specific health has uh does um receive a sort of acceleration um and and we know that the in the research community it started about 10 years back there was a requirement actually to get grants funded that um that people evaluate both sexes. So believe it or not, it was all done on male mice for large largely male uh done. That changed um now with changes in the way that you know um science is being done and funded. This is this issue has become prominent again. But everything I'm saying here is just in in uh total agreement. Yeah, it it would have been um it would have been considered a national emergency. >> It would have been right. I saw a patient I mean I have thousands of these stories. I have literally I have trauma from it. I have PTSD from it. I saw a patient last week in my office, 50 years old. Um, the first thing she said when I walked in, she said, "I asked you a favor." I said, "What?" She said, "Don't call me crazy. I'm not crazy." And I didn't mark anxiety because I didn't want you to blame my symptoms for my anxiety. And I looked at her, I'm like, "This is the last office I would I would be the last person standing on this planet that would do that to you." as as I started listening to her classic endometriosis patient. She's 50 years old, painful periods. She said, "I've been to hundred emergency rooms. I know every emergency room in every country I've ever visited. I've um she never got married cuz she had painful sex. She couldn't have sex. She had severe pain. She would stay at home. She would lose her jobs, right? Um never had children. Just chronic pain. completely anxious, guarded, right? Shows up to my office. I'm probably the hundth doctor she's seen. And all she wanted to hear me say is, "You have endometriosis." This is the story of these patients. I you can't even make these stories up. >> It's unbelievable and yet believable. And I don't want to sound like somebody who's super suspicious of of the medical community or pharma. I think most physicians have good intentions. I think that like you said they they the culture and climate within the field, the way insurance is handled, all these things I think railroad people into a kind of a conveyor belt type of of practice. But I can also say that because I know some excellent physicians like yourself and some people I've known for for um a very long time in other fields that really good physicians read the literature. They integrate what they know from their clinical practice. They talk to other physicians. They they're part of a community that's trying to evolve itself, but that's usually a subculture within the culture. And most people don't know how to find the right people. Although with podcasts, they're starting to. >> The problem with endometriosis is it's so common and we don't have enough doctors diagnosing it. And like I said, a lot of these women don't even have an access to an OB/GYN. And when they go there, 95% of the time they're not even diagnosed. And if they're diagnosed, they're not even treated correctly. So what happens these ectopic implants, right, that are in the pelvis. It's very strange because I mean, we don't know why some women have endometriosis and some don't. It could be. There's so many hypothesis, but the most common one is probably retrograde menstruation, which a lot of women uh get, which means when we're having our period, some of that blood goes through the tubes and out into the pelvis and implants there. In a regular healthy immune system will get rid of those implants. But for whatever reason in this subgroup of patients their inflammatory their their immune system doesn't work well. It actually helps start an inflammatory process around these implants that make it stick to the wall of the pelvis. >> May I ask? So, um I think I have the picture right where the the the uterine lining either heads up the fallopian tubes as opposed to being shed uh of outward out of the body basically um and then it actually gets out into the extracellular space. So would it be cleared by the lymphatic system? >> Yes. And by their immune system >> they come they're eat Yes. But in in these patients, not only they don't take them away, they stimulate them to stick to the walls of the pelvis. That's number one. Then these little implants need estrogen to grow. Right? Remember I told you the ovaries are secretting estrogen. So they start making their own estrogen, >> right? So locally they support themselves without needing systemic estrogen. Right? And then they start, you know, they increase vascularity to the lesion and then they start um growing nerve uh fibers around them each lesion. >> It's almost as if they're like everything you're saying resembles tumor formation. >> It's just I always say it acts like cancer, but it's not. >> Let's say you have a patient with colon cancer. You go and you reect the colon cancer. You never tell them, "Okay, sir, I'll see you in 6 months. he'll be back with colon cancer everywhere. You have to give him chemo. Endometriosis is not cancer, but you have to treat it the same way. What I mean by that is once you go in laparoscopically and cut these lesions out, you have to give it hormonal suppression. Otherwise, it comes back. >> I see. >> So, we can get to that. But these implants are self-limited, right? They basically have vessels that's feeding them. They make their own estrogen. they start an inflammatory process in that area and they start growing right every month they get more and more uh they progress more as we age that's why these patients average age of diagnosis for endometriosis is 32 and it takes doctors 9 to 11 years to diagnose these patients because it can start with oh my periods are painful then they get more painful then you start staying home then you have to call your mom to pick you up from school then sex starts hurting Then you realize a week before it starts hurting. Then you realize now a week after the pain is still there and eventually it turns into chronic pelvic pain. But these patients jump from doctor to doctor to doctor until a they have chronic pelvic pain and someone says wait a minute you have endometriosis or b they can't get pregnant and they end up where in the fertility clinics for something that could have been suppressed years prior to that. >> Let's say they end up in an IVF clinic. they're able to create healthy embryos they implant. How does endometriosis impact the uh probability of carrying that embryo to successful? >> So it depends on the age on the quality of the eggs. One thing endometriosis does so endometriosis is an inflammatory process. It causes inflammation in the pelvis. That's why as it progresses it causes scarring in the pelvis. It can cause scarring of the tubes. That inflammation can affect your egg quality. can cause bowel adhesions, bladder adhesions. If it's inside the ovary, we call it endometrioma or a chocolate cyst that can destroy a woman's egg count and quality. That's why sometimes you get a 30-year-old endometriosis patient who has zero eggs or you can have a 14year-old who has the egg count of a 40year-old. So, it is absolutely crucial crucial for endometriosis patients to know their egg count. If they have no pain, get a baseline at age 18. If you have painful periods and you're 14, get an egg count. Rule out endometriosis. You can have an eight-year-old with endometriosis. Now, it's very rare, right? But as soon as women start menstruating, they can start complaining of these pains. Now, it's common for patients to have some cramps. You they might take a couple of Advils and it's fine. But if pain becomes recurrent and it starts progressing and it's disrupting the their life, then it's absolutely not normal. It's endometriosis until proven otherwise. Which takes me to my other discussion. We're discussing doctors don't do ultrasound. Not that you can diagnose endometriosis on ultrasound, but if you have an endometrioma or a chocolate cyst, which takes you to approximately a stage three out of four endometriosis, you can see it in two seconds on ultrasound. So if you do an ultrasound and you see an endometrioma, I don't care how small it is, don't ignore it. It's just like me saying, "I see smoke here, but I'm going to ignore it because I don't see the fire." Well, if you see smoke, you know there's fire. Go check it out. And that's exactly what happens with endo patients because they go dismissed. They show up at age 30. They have no eggs. Their tubes are scarred. And to answer your question, once you a lot of these patients because of that inflammation, the environment is hostile. So the reason it's one of the top causes of infertility, yes, your tubes can get blocked. Yes, your egg count and quality can drop. that the environment is so hostile for the sperm, for that little egg that's getting released that needs to be picked up by the tube that can get attacked by these inflammatory cells. The embryo sometimes doesn't form. If it forms, it might get stuck in the tube and you might end up with an ectopic pregnancy or if it goes into the uterus, all that inflammation increases the risk of miscarriage. And on top of that a large percentage of endometriosis patients have adenomiiosis which is the sister condition to endometriosis which is very common. You don't not all adnomiiosis patients have endometriosis but a lot of endometriosis patients have adinomiiosis and adnomiiosis is when these ectopic tissue the uh lining inside the uterus are in the wall of the uterus. So they do get stimulated and they can cause heavy periods. They can cause recurrent miscarriages. They can cause um painful periods and it also gets dismissed on ultrasound. A lot of doctors depend on MRIs to diagnose adnomiiosis where if you've done enough ultrasounds, you can start seeing it on a pelvic ultrasound. But the problem is a lot of radiologists don't know how to diagnose it. I'd like to take a quick break and acknowledge one of our sponsors, Function. Last year, I became a Function member after searching for the most comprehensive approach to lab testing. Function provides over 100 advanced lab tests that give you a key snapshot of your entire bodily health. This snapshot offers you with insights on your heart health, hormone health, immune functioning, nutrient levels, and much more. They've also recently added tests for toxins such as BPA exposure from harmful plastics and tests for PASES or forever chemicals. Function not only provides testing of over 100 biomarkers key to your physical and mental health, but it also analyzes these results and provides insights from top doctors who are expert in the relevant areas. 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As a consequence, I decided to join their scientific advisory board and I'm thrilled that they're sponsoring the podcast. If you'd like to try Function, you can go to functionhealth.com/huberman. Function currently has a wait list of over 250,000 people, but they're offering early access to Huberman podcast listeners. Again, that's functionhealth.com/huberman to get early access to function. >> Can I ask a naive question about ultrasound and and diagnosis and just women's health in general? And forgive me for not knowing the answer to this, but I don't. So I'm going to you know um swallow my pride and just ask what is the current state of of of medical care in this country for women such that let's say a woman is in her doesn't matter 20s 30s 40s 50s whatever and wants to go get a pelvic exam with ultrasound a blood draw to look at AMH and let's say have a short discussion with with a let's say marginally qualified physician about um hormone Is that the sort of thing that is just impossible for people to access who don't have insurance? Um, if they do have insurance, does insurance cover it? Do they need to do they need to have a major problem to get a referral for that? I have no concept of this because as a as a man, we don't think about this, right? >> Insurance will cover it. The problem is, so there's a lot of issues. One, patients don't know that there's something wrong. They think irregular periods are normal. They think painful periods are normal. They think it's just their nerves because people around them, including their parents, their aunt, sister, everyone dismisses them. Oh, it can't be that bad. Why are you being so weak? Take some Advil and get up. No, the this this is really debilitating. >> This is not premenstrual cramping. This is pain. This is abnormal levels of pain. >> And they don't have anything to check it against because it's in some cases all they ever knew. >> And it sounds as if people are very dismissive of women's pain is what I'm hearing. >> Period. >> Yeah. It's minimized, dismissed, or normalized. And there's no other way around that. Those are the three options right now in the health care system majority of the time. So then this patient goes to the doctor not knowing what's going on. The doctor doesn't have time. You have 10 minutes with your doctor. He comes in, he's like, "Maybe she has endometriosis. Maybe he he or she is even thinking about this." But what do they do? They give birth control, right? And the patient doesn't know why. She goes home and someone tells her, "If you take birth control, you're going to be infertile." So she doesn't take it because her grandmother tells her that and then she continues to have pain and starts bouncing from doctor to doctor. A lot of these do patients, believe it or not, end up in GI uh offices getting colonoscopies at a young age. Like if you have to do a colonoscopy for pain in a 22year-old, make sure you're you're not missing endometriosis. So it's like you have to teach all these doctors. So doctors don't have time. They don't diagnose these patients and they start bouncing from doctor to doctor. How can we fix this? And insurance will pay for these visits. But you need to be empowered. You need to be educated and you need to be your own self health advocate when it comes to endometriosis on top of every other diagnosis. Why? If I'm telling you all the symptoms of endometriosis and you have them, you already know you have endometriosis. Go on chat GPT. it will confirm it for you. >> So, painful periods, UTI, >> painful sex with deep penetration, >> GI pain, >> GI pain, bloating, chronic pelvic pain, leg pain, just pain, pain that con it's comes with your period and eventually takes over your life. Now, educate yourself. Write down the questions. I'm telling you, a you need if you're young and you want a family, you need your egg count checked. So, write AMH on your to-do list before you go to your doctor's office. Two, ask for a pelvic ultrasound. You know, I have a physical therapist. He said, "Every time my daughter goes to a doctor, I tell her to exaggerate her symptoms by 50%." So, if she has a five out of 10 pain, I say, "Go tell your doctor it's 10 out of 10 so they minimize it to five out of 10." So, you can get your pelvic ultrasound. But don't do that. Just ask your doctor. say, "I have pain and you need to give me a pelvic ultrasound order and if you don't, I'm going to go do it somewhere else or I'm going to go to another doctor." Most doctors want to help. They're not there to hurt you. They're there to help you. Sometimes if they don't think of of it, maybe reminding them that this could be an endometriosis is the first step. They're your advocate. They want to help you. So, guide them in the right direction. Ask for that pelvic ultrasound. Ask for that egg count. And when it comes to endometriosis, a normal ultrasound does not mean you don't have endometriosis. A normal pelvic MRI does not mean you don't have endometriosis. Endometriosis can be minimal, mild, moderate, or severe. And we stage it 1 2 3 4. The higher the stage, the more uh involvement, the more aggressive the endometriosis is. Endometriosis can be superficial. These implants can be superficial in the pelvis. They could be in the ovary called endometrioma or they can be deep infiltrating where they go deep and as I told you they make their own nerve fibers. And what happens eventually these nerve fibers start shooting and our central nervous system starts going in overdrive and exaggerating those pains. That's why the pain is so real and so debilitating because their body they get sensitization to this new nerve pains that are forming in their pelvis. The gold standard way of treating this is a laparoscopic resection of endometriosis. >> Surgery. >> There's no like VEGF inhibitor or something of that sort. >> So let's talk about that. So you don't have to jump to surgery, but surgery is the gold standard way of diagnosing a to be 100% if you're not confident and b cutting these excising these lesions. We used to burn them, but as of like for the past 15 years, we've learned that you really need to cut them. You don't want to burn them, right? Because burning them is just a band-aid and the pain comes back. >> Peripheral nerves grow back very readily once they're there. I mean, this is reassuring to anyone that has a peripheral nerve injury, it'll grow back, unlike a brain injury where it's variable outcome. But when peripheral nerves want to grow, they grow. >> They grow. >> Yeah. They're very stubborn. >> They're stubborn and they're painful. Here's the problem, Andrew. Surgery is not firstline therapy, but it's gold standard. If you have a patient in severe pain who's not responding to hormonal suppression, which we we're going to talk about. But here's the problem with surgery. Do you know that out of 100 gynecologists, one is trained to do laparoscopic endometriosis surgery and then it gets better. If you give 100 laparoscopes to 100 gynecologists, half of them will wake the patient up and say you didn't have it. Endometriosis, the typical endometriosis implants are glandular endometriosis. So when you look at it, they're blood filled, right? There are these black spots, purple spots all over the pelvis. But sometimes you really need to look for them. You have to lift the o lift the ovary, look underneath, look at the bladder. Like with the laparoscope, you have to go really close to find them. The problem is a small subgroup of patients have stromal endometriosis who's actually, you know, this stromal endometriosis is not as rare as what you read. It's actually very common in almost every end endometriosis surgery that I do. My path report shows at some stroal endometriosis implants. So stromal endometriosis, imagine those cells in the uterus, they have the gland, but they also have the stroma, the connective tissue around it. Stromal endometriosis doesn't have the glandular uh lesions with it. It's just these fibers that have nerve endings and the the nerves get squeezed and actually patients with stromal endometriosis tend to have more bloating, more inflammation and more deeper pain. But when you put a laposcope, you only see these thin lines. >> Sometimes it takes me 15 minutes to find it. So if I put a camera and I look for these purple spots, I'm like, "No, you don't have it." So imagine here you have a patient who's had 15 years of pain, ends up in the hospital, goes home, she lost her job, she's on narcotics, she's halfway addicted to these medications. She's depressed. She's anxious. And finally the doctor says, "I think you have endometriosis. Let's take you to surgery." And then they wake her up and say, "You didn't have it." >> Oh my goodness. >> But that's what I see. >> And they missed it. In many cases, >> they missed it. But you want to vomit. You literally I want to pass out sometimes when these patients tell me these stories. I can write a thousand stories like this for you. >> Sounds like the field of which you're trying to fix is badly flawed in some sort of like central structural way. >> It is. >> It just sort of feels like and and we could explore the reasons for that. Um but that comes clear in what you're saying. Do we know what causes endometriosis? The first one is this retrograde uh flow of the menstrual uh flow. Second is an immune system issue, right? Which I told you for whatever reason the immune system cannot their immune system cannot clear out this um these implants which goes to the PCOS, right? Remember I told you PCOS patients have so much cytoines released from their viseral. It's my hypothesis that that's why I see so much endometriosis with PCOS that this chronic inflammation that is caused in PCOS patients is fueling these implants from not being cleared. Right? That's why I see so much. That's my hypothesis. Someone needs my problem is I don't have time to do all of this. There's so much I want to do. >> You're too busy saving all these families and women and kids. >> I would have done so much. I love women. I would have done so much for them if I could multiply myself to five more or 10 more. But anyways, so inflammation is another theory. Um then it's the uh metiplasia of this malarian duct you know the malarian duct that forms the uterus and the fallopian tubes. Maybe embryologically these cells are left somewhere in the body. That's why we see implants sometimes by the diaphragm or so you can find it in people's lungs or very rarely in their brain. So you can't say that's retrograde menstruation, right? >> The other hypothesis is through blood vessels from the uterus that these cells get picked up in the vessels and implant in distant uh organs like the lung or the brain. >> But was it always this common or you >> It's always been this common. >> Okay. So it's not as if in the last you know 20 years we're seeing a huge increase in I mean it's difficult to say because as you said the diagnosis it the whole system is faulty you know >> but you can't really study. That's why I'm telling you it's not 10%. I get so upset when people say 10%. I'm like it's not 10%. Cuz it's, think about it, 15% of women have PCOS, which I think it's more. And I think half of those patients have endometriosis. So that's just the PCOS group. >> And then I think in the general population, if I had to guess, I would say north of 20% have endometriosis. And I feel like >> that's a huge number. 20% is an enormous number. >> Enormous. That's why I'm here to tell you this is not some zebra diagnosis. This affects every family in every every single person can think of someone in their life who either has PCOS, PCOS and endometriosis or endometriosis. There's no way if you close your eyes and think that you cannot think of someone like that. There's no such human because they're everywhere. There are millions of these women, but they are all dismissed and they are told for years and years that they're crazy. And that needs to stop. If I hear one more doctor or health care provider or physician assistant or anyone call a woman crazy, I want like literally I want to turn this world upside down. Well, it seems like a, you know, grounds for malpractice to call a patient crazy, even if they're a psychiatrist calling somebody who has a severe mental condition crazy. I think that what what's becoming increasingly clear as we have this conversation, is that for these issues surrounding women's reproductive health and hormone health generally, because I I realize not everyone wants to have kids. Many many women do, but many women perhaps don't. the core component seems to be that there's kind of like a lot of overlap in the ven diagram. And so while I'm I'm not trying to get any physician a pass, it seems like the only people who really understand this are the clinicians like yourself who spent a lot of time with people with these conditions and the patients themselves. I think that one thing that I'm hoping will happen as a consequence of this conversation as well as just the general theme around podcast and public health communication is that in general patients are dismissed as having important knowledge about their own health. And I I think that you know we we put doctors on a pedestal because they are incredible healers potentially incredible healers. No one knows more about their own body than oneself. I will make >> especially women. >> Especially women. I was going to say yes, absolutely. And and you know, it's going to sound like I'm trying to grab, you know, political correctness points now, even though earlier I was saying politically incorrect things um by saying this, but I I firmly believe that, you know, and again, I've only lived as a male, so I I only know my own my own situation, but by menrating, by having hormone cycles that across the month are more extreme typically than male hormone cycles. I think it's fair to say that that women are much more in tune with changes in their underlying physiology and how they relate to their underlying psychology and back and forth. From a scientific perspective, you'd say, "Oh, they they've experienced more variables and more outcomes. They've run more experiments, right? It's being it's happening internally." Again, not to make it reductionist or or overly uh you know uh intellectual, but I think that >> the the first thing to do is to really give the statements that patients make even if they're not technical, you know, perhaps especially if they're not technical, to give them an an enormous amount of merit. Who knows more about their own body than the person experiencing something? And women are in a position to know far more about their own changes within their body because they're always undergoing changes across the month. >> Yeah, that's that's coming uh coming through very clearly. >> And I will tell you, 30 years in women's health, 25 years in private practice, when a woman tells you something's wrong, >> 99% of the time something's wrong. Take them seriously. The last thing they are is crazy. The last thing they are is stress related or hormone related. It's not in their head. I had a patient once who told me every time I go to the doctor, uh, my doctor tells me it's my problem is between my ears. >> Oh goodness. I mean, unless they're a psychiatrist, and even if they're a psychiatrist, we now know that metabolic health impacts brain health. Yeah. That that's that's criminal. I mean, honestly, what you're describing is criminal. It's it's not >> It is criminal. That's why I'm here, though. But it is. And it has to change. It really Why do you think I want President of the United States to give me that mic? that you did today. I don't think you're going to understand the impact of this podcast today. I don't think I mean I'm sure you do cuz you're amazing and you have millions of followers. >> But the information is coming from you. I mean >> I know but but women's health is very different than any other field in the medicine. Let me tell you what my solution is. You know what my solution is? You literally need to separate OB obstetrics from gynecology. You need to separate it. >> Tell me more. I think for doctors who want to deliver babies, great. Go learn how to deliver babies. Take care of those women like they're your family member. Give them the time. Have the energy. Don't run from your office to deliver them last minute. Hold their hand. Don't dismiss them. And just focus on giving them the best experience they can possibly have, which women are not getting that right now in this healthcare system. and then separate the residency and for whoever does not want to deliver babies, teach them gynecology, teach them how to recognize PCOS, teach them what endometriosis is, teach them how to do a laparoscopic hysterctomy without cutting the patient from their belly button all the way down. Do you know that in Los Angeles there's maybe two of us that can do a laparoscopic hysterctomy and take a uterus out this big and I think I'm the only one that does it outpatient. That's >> you laparoscopic for those of you who don't know. So small small incisions. So you're not talking about you know major scar incisions, right? So coming in laterally and and essentially doing everything from uh the camera from the camera. >> So literally a uterus the size of a watermelon. I take out laparoscopically outpatient. Patient goes home the same day. >> Amazing. >> Yeah. But but that should be standard of care. >> So these patients are still getting cut because it's so big from their belly button all the way down vertical incision which is traumatic in you know it would be traumatic to me. And these patients have six to eight weeks of recovery have to stay in the hospital for 2 three days. I lost my outpatient privileges at Cedars because I haven't done surgery at Cedars. I do it in the outpatient Cedars. So, it's because you really if you train these doctors uh well, they don't need to um take their patients in the hospital and quality of care will go up. The problem right now is when you're busy running around delivering babies all night. I used to deliver 80 babies a month. >> 80 babies a month. When I was pregnant with my first daughter, Delara, who you met at Stanford, I delivered 82 patients when I was 34 weeks pregnant until one night my husband used to drive me to the hospital. I had my pillow and a blanket in the car. One time when I was running at 1:00 in the morning, I fell on the lawn and my husband was like, "You can't do this anymore." And that's when I started cutting back. But my point is take that doctor who's I was up all night. Then I would come to my office the next day like nothing happened at night and now I had 30 40 patients on my schedule. Gyn patients. How can you catch that endo patient? How can you diagnose that PCOS patients? And let me tell you, you can't just diagnose in your head and throw a medication at them. Patients compliance goes down when they don't know why they're taking a medic certain medication. But if you take the time and explain it to them, they're going to go home and say, "This medication I'm going to take." So if you separate OB from gyn, then you empower gynecologists a to spend more time with their patients to not be exhausted, not run from the hospital into their office just completely burnt out. And then you can focus on women's health. And then we can also talk about well woman exam. I mean, I can sit here until tomorrow morning and talk to you about what a wellwoman exam should all be about. >> I love it. Well, we can do multiple podcasts, but uh but you're also giving us tools to understand uh for women to understand for themselves if they likely have endometriosis. Um you know, the painful periods, UTI issues, GI pain, um >> bloating, >> bloating. You mentioned earlier that with AMH, whatever units it's measured in, 0.1 of the typical units it's measured in corresponds to one egg. Typically, um, ultrasound can be informative, but often even with high resolution ultrasound, it's not exhaustive. You can it can be missed. Laparoscopic surgery in and out the same day, no major scar is the ideal way to go. Very, very few doctors are actually doing that. But a number of the things we just listed off are actionable. People can think about them at any age. I think that's one of the big themes coming through today among others is that if a woman is 19, 22, 42, 14, >> yeah, 14. Okay. As I that if some of these symptoms are occurring, they need to take them seriously. I know we talked about surgery when it comes to endometriosis, but endometriosis implants in general, not the stromal type. Uh they grow with estrogen, but their growth slows down with progesterone. So if you have a young patient who you suspect they might have endometriosis and you can't really prove it, right? you don't have the experience, but you know they're complaining of painful periods. And I'm talking to clinicians right now or patients, then there's nothing uh wrong with prescribing them some form of birth control or hormonal suppression that will suppress their symptoms of endometriosis. What do I mean by that? You can use progesterone only birth control pills, which that's what I would remember. We talked about birth control and I said I want to circle back with endometriosis. Birth control pills in endometriosis patients can be the difference of fertility and not having children. That's how amazing birth control pills work for suppression of endometriosis. Would you recommend against estrogen birth control pills because these these I want these implants right tissues these ectopic tissues meaning sorry ectopic it's the the scientist in me the these tissues that are essentially in the wrong place they've migrated their form there they are sensitive to estrogen in the sense that they grow in response to estrogen does that mean that in the in the first half of the ovulatory cycle the menstrual cycle that there's more pain at that time >> no they actually have more pain with the shedding of the lining with the period. But some patients do complain of chronic pain because remember these implants eventually cause scarring cause nerve pain and those nerve pains are start you know they start firing all month and that's why chronic pelvic pain now so you want to give it progesterone you can give this progesterone in a form of birth control right so if I have a patient who also has PCOS and has acne hair loss facial hair body hair irregular periods painful periods and their mood disorder is not that bad. I'm like, maybe I give her a slint because I can kill two birds with one stone. I can suppress her PCOS symptoms and I can suppress her endometriosis. But most PCOS patients, which is the crowd I see with endometriosis, have mood disorder. So, one of the um methods that I use to suppress endometriosis is actually a proesterine IUD like Kylina or Merina IUD. Morina IUD is the most common progesterone IUD used in this country. um if you use it for you know it's a method of birth control and it can last for eight years sometimes we use it for heavy period and you use it for 5 years but I use it very often in my patients with endometriosis or adnomiiosis for young girls who haven't had children I tend to go with the smaller IUD because Marina IUD is slightly larger than the Kylina IUD so I love the Kylina IUD and I'm not advertising for it I'm just saying it because it really works. So for patients who have a lot of mood disorders, then I might go to these IUDs which are more local in suppressing the endometriosis in the pelvis. So I start with either a progesterone birth control or a progesterone IUD. And by the way, I always check egg count. Always, always, because I want to make sure we're not low because if you have low egg count and you're 17, you're going to go freeze eggs. I'm not going to wait for you to be older to freeze. Waiting for that patient to be 30 or 35, you're done. You know, they will have no eggs left. So, suppressed with progesterone birth control, progesterone IUD. Then we have u G&R antagonist. I don't know if you've heard of these pills or Alyssa or my famry. These are medications. is remember I told you you either um give it progesterone or you take the estrogen away to treat endometriosis. So giving it progesterone you can do the progesterone IUD or the progesterone birth control. I don't like the implants because of the weight and irregular bleed that comes with it but you can also take the estrogen away. These medications work amazing especially for women who have painful sex and usually by 2 months they get a relief from that painful sex and painful period. The problem is anytime you take estrogen away, what happens? You can have hot flashes. You can have all the symptoms like a pseudo menopause. >> Correct. These pills are great because they're reverse reversible. So if you don't like them, you can take them for a couple of days and stop it and it's out of your system in a couple of days. So it's not a big deal, but it does make a difference. The problem with these pills are because of the effect on the bone and the bone loss it causes, you can take him up to two years. So you can't take him beyond two years. Usually if I do a progesterone suppression and the patient has pain, I recommend surgery because during surgery, I resect the endometriosis, I cut all the adhesions if they have it, and then I put a progesterone IUD and I send them home. For patients during surgery who have severe disease, stage three or four, then I also add these G&RH antagonists after surgery depending on their stage or symptoms from 6 months up to two years >> to suppress estrogen >> suppress it and to just kill the endometriosis because when it's advanced stage, even with surgery and IUD, let's say stage four, it can come right back. So, I really want to knock it out. So that's what I would um I would do for endometriosis patients and very important point the stage of endometriosis has nothing to do with the degree of pain and this is very important for patients to understand. You can have stage one endometriosis and you end up in the emergency room every month because of pain or you can have stage four endometriosis and you just have mild pain. So pain you can't say oh you're there's not much in your pelvis I'm not going to worry about it. So that's one. The other thing is remember I told you stromal endometriosis that doesn't have the glandular aspect of the tissue is missing. The glad glandular aspect is mostly the fibrous part of it. These lesions are almost always missed on laparoscopy. they tend to cause more inflammation and they they tend to be more resistant to progesterone in my opinion. >> So those are the ones that you really need to cut out. But then if you've never seen stomal endometriosis, you will not remove it during surgery and you will wake your patient up and say you didn't have it. >> So stage does not equate to pain and vice and vice versa. >> Absolutely. These days it seems at least in the United States that women are opting to have children later or not at all. We know that having children before age 40 is protective against certain cancers and he breast cancer in particular and if and if women have uh the BA mutations >> then that number goes way way up. So um is there any indication that pregnancy at before a given age, successful pregnancy or maybe just pregnancy in general before a given age is protective against PCOS and endometriosis? >> For endometriosis, yes, because during pregnancy your endometriosis is at bay. Patients have no pain, right? It all starts when the menstrual cycle starts again. But what I do for these patients, as soon as they deliver, I put a progesterone IUD in them. when they come postpartum, six weeks postpartum, and they're discussing birth control, I always recommend a progesterone birth control. >> Do you think that um well, these days we hear a lot more about postpartum depression? >> Yes. >> Um and I'm very intrigued by this. >> Yes. Like any medical discussion, when you hear about something more often, you get two very polarized arguments. One is it's been limited diagnosis, and this has been around a long time, and people have just been suffering in silence. You hear this about psychiatric conditions, childhood neurologic conditions. You hear about this about gut issues. And then on the other end of the spectrum, you often will hear, well, people are just sort of like they're just kind of fanatic about these terms and then now people are paying attention for to it. Um, do you think that postpartum depression is on the rise and does it have any correlation with things like endometriosis? Postpartum depression I think in is we see more in patients with anxiety, trauma or PTSD. So to answer your question uh endometriosis and PCOS patients have anxiety, have depression and have PTSD. When you live their experience in their life and everything they've gone through in their life, they all have PTSD. So anyone with any history of anxiety, PTSD or depression or PMDD, a severe form of PMS, all of these patients are at a higher risk of postpartum depression. And to answer your question, because anxiety is on the rise, because depression is on the rise, um postpartum depression is very common. It is very difficult honestly to navigate the different stages of life being a woman. You know, imagine when you're young, some of them with endometriosis and PCOS, they have all that struggle. Then they try to get pregnant. They don't get pregnant. They need to sell everything they have to pay for an IVF to have a baby. Then they have a baby. They their body changes. There's this giant drop in estrogen that puts them into this, you know, postpartum blues and then postpartum depression. And that goes dismissed by family members, by everyone. Oh, you're not sleeping well probably. Oh, it's normal. It's because you haven't had a child. No. These patients, even with PMDDD, they completely dissociate themselves from their environment, from their child. It's it's really heartbreaking. And then once they're done with all this in their early 40s, per menopause comes, late 30s, early 40s, right? >> It's like wave after wave, >> wave after wave, and then pmenopause, which is again not diagnosed, right? Average age of menopause is 51 and a half, 45 to 55 is the range. Seven to 10 years before menopause, women go through perry menopause. And during that pmenopausal time, their mood can go. They're not sleeping well. They have hot flashes, night sweats, irregular periods, they're gaining weight, their uh sex hurts, their joint, they have frozen shoulder, they start having hair loss, they have skin thinning. And all these things are happening and no one's diagnosing them. No one's treating them with hormone replacement until they go through menopause. And then that's another chapter of life that just turns your body and your life upside down. And most men don't even know what menopause is. So imagine just the story of this one woman through her life. And then look how many times there are opportunities for this patient to get dismissed in the health care system. That's why I have a broken heart. >> And you're also doing a ton of healing for people. >> But I hear you loud and clear. what you describe would uh cause most men, including me, to dissolve into a puddle of her own tears is my only response. Fibroids, >> there's hope, though. I don't want to be all negative. No, that's why we're here. We're here. >> I feel like I'm ne I it might come out negative because that's what I see. Do you know what I'm saying? I see I say my office, my waiting room is the waiting room of dismissed women in this country. So maybe so I have a skewed view, but it's so real and it's so painful to watch that, you know, that's why I sound a little negative, but I'm not a negative person. >> I don't I don't think you sound negative if I'm honest. I think you sound very passionate about um your empathy for the pain that you observe. And it must be in I'm realizing right now it must be incredibly frustrating to know that there are solutions and to see so many people suffer. >> Yes. >> Like I can think of almost nothing worse than having the solution to somebody's suffering and not being they don't know and because they don't know they they can't access that solution. Um, and as you mentioned, it's a very tangled web of of medical infrastructure and things like that, but uh, what comes through is your your your passion and your care for people, for women, >> for women. >> For women. >> Yes. Specifically women. And also your desire to give them useful information that they can act on and and u better their lives and their health. Fibroids. I hear about fibroids. Where does that fit into this picture if at all or is that completely separate? Fibroids are very common. >> Mhm. >> By age 50, 80% of women have some form of fibroids. Like if you stand at the side of the street and pull out 100 women, you know, a lot of them will have fibroids. When it comes to fibroids, the location of the fibroid is very important. You can have a small fibroid in the lining of that cavity that we talked about that can cause you to have heavy periods, blood clots, you become anemic, um fertility issues, all of that. Or you can have a 10 cm fibroid outside of the uterus that can make you look like you're pregnant, but it doesn't do anything to your bleeding. So, when it comes to fibroids, the location of it is very important. For patients who have small fibroids, it's away from the cavity. they don't have any symptoms. We just watch them. Uh, as they grow, you're more likely, you know, women in their 40s are very likely to have fibroids or develop fibroids. But if it doesn't bother them, we don't do anything. We operate on fibroids for several reasons. Number one, if it's inside the cavity and it causes causes anemia, infertility or heavy periods. We operate on fibroids if they're extremely large and they cause bloating after like you know we go by weeks of pregnancy and uh let's say you have a 16 week size fibroid uterus which is equal to a 16 week size uterus pregnant uterus. It starts putting pressure on the urers that drain your kidneys. So then you have to talk about either a myomectomy for women who want to get pregnant when you go in and you remove the fibroids or hysterctomy for women who are done having children. So fibroids are extremely common but then again if you don't do a pelvic ultrasound just doing a bmanual exam will never tell you that the if these patients have fibroids. >> Can a woman insist that she get a an ultrasound? Can you walk in and just say uh maybe not have to exacerbate the pain from a five to a 10, unless she's already at a 10, of course, but can she come in and just say, "Listen, I absolutely want ultrasound. I want you to look at fibroids. I also want you to do everything you can to determine if I have endometriosis. Here's what endometriosis there is. I heard uh a podcast where an exp a true expert in this describe these things." How how do you think a physician would respond to that? Um I like to think that they would say, "Wow, this person knows a lot. I better do everything. >> There you go. Bravo. Empowered, right? That's why I called my um podcast she MD. Strong, healthy, empowered. If you empower the woman to be her own health advocate and she has that list and she takes that to her doctor's office, nine out of 10, like I said, doctors are amazing humans. They they're there to help you. But if that doctor doesn't have a pelvic ultrasound in his office, which is probably very common, then ask them for an order to go to a radiology center to the hospital near you. But you should, every woman should have a pelvic ultrasound. I think it should be part of wellw women exam every single year. >> Yeah. Why isn't it just part of the standard exam? >> It should be >> every male that goes in for a general exam has his uh testicles grabbed and told to cough over the sink looking for a hernia. So it could be the the equivalent of of that. Well, I mean, they just do it. They do it no matter what. >> It takes me less than a minute to do a pelvic ultrasound, but then I've done it for 30 years. >> But this is not an hourong procedure. >> And you know what? Let me tell you, I had a patient with a uterine septum. Do you know what that is? when the uterine cavity is actually divided in two because of this septum that was supposed to be absorbed, you know, but it never did. Unless you do a pelvic ultrasound and unless you're a good ultrasographer, you will miss this septum. And these are patients who have recurrent miscarriages. They don't get pregnant. They sometimes come from fertility clinics and they're like, "My doctor said I fall into the unexplained category. There's nothing unexplained. So if you want to assess your fertility, I have buckets of it. One, female factor. What is female factor? Check your hormones. Make sure your egg count is normal, right? Make sure your prolactin, thyroid, everything's normal. Do an STD check, gorrhea, chlamydia, all of that. Next bucket, male factor. What's the sperm like? Is your partner smoking weed every single day? Um, has he had radiation because of testicular cancer? Whatever. Has he had fertility issues with his previous partner? Make sure the semen analysis is normal. It takes one minute to check that. The third bucket is uh tubal factor or anatomy. Is the anatomy normal? Do we have fibroids in the uterus? Is there a septum? Are the tubes open? Have you had chlamydia? Do you have, you know, any kind of adhesions? But you know that's the next bucket. The fourth bucket is endometriosis. Are you missing endometriosis? Do you have painful periods, painful sex, bloating, everything we talked about? Rule that out. The next bucket, PCOS. Do you have irregular periods? Do you have PCOS looking ovaries on ultrasound? Do you have symptoms of high testosterone? If you do, you're 70 80% chance you're not even ovulating. Boom. That's your problem, right? If you have PCOS then you have in my opinion that's aliabody diagnosis you have a 50% chance of having endometriosis then go back to the other bucket and make sure you're not missing endometriosis and the last one is autoimmune for me which is very important these are patients who can't get pregnant or when they get pregnant they lose the pregnancy especially my endometriosis patients endometriosis is a form of autoimmune and I always say if you have one autoimmune condition you probably have a 30% chance of having some other autoimmune condition. Run this autoimmune bucket because if someone has let's say antifhospholippid syndrome and they're hypercoagulable and pregnancy make you more hypercoagulable you can actually make blood clots in the placenta and these are patients who keep having miscarriages and they don't know why. What about other autoimmune conditions like uh psoriasis, not even mild psoriasis, it's suggestive of overactive interlucans and things of that sort. >> Any autoimmune I do a full autoimmune panel. And for patients who I go through all these buckets. So these buckets I told you your your listeners can do it at home. You don't need your doctors because some doctors don't know what these buckets are and they're not really putting a check mark in front of it. You can do it yourself. You can ask for the first one, first bucket, female factor. Ask for your hormones, ask for a semen analysis, second one. For the third one, ask for a pelvic ultrasound. Make sure there's no septum in that uterus. Make sure there are no fibroids. Make sure there are no ovarian cysts or anything that would cause any problems. For the fourth bucket, ask for testosterone levels. Rule out to see if you have PCOS. The next one, endometriosis. Make sure you I taught you today what to do to make sure you don't have endometriosis. And if you have any family history of any autoimmune condition, if you have psoriasis, if you have shoggrans, if your mom has lupus, if you had recurrent uh pregnancy losses, if you have endometriosis, which is autoimmune, ask for a full autoimmune panel because for patients who have autoimmune panel, you can give them blood thinners like Lovenox in pregnancy and it'll help uh bring that flow. And it's I mean, you know, I have patients who come in, I haven't even gone into the room, and my medical assistant says, "Oh, this patient has had five miscarriages, but there's nothing wrong with her." I'm like, "There's no way this woman doesn't have an autoimmune condition." But that's pregnancy. But can I say something, >> please? >> I want to talk about breast cancer. Can I? >> Absolutely. You know, my passions in life are PCOS, endometriosis, and the breast cancer calculator. Do you know what that is? Do you know Tyra Cusk? Have you ever had an episode on it? >> No. >> You're going to love this. So, I always say for women listening to this podcast, if you know your first name, your last name, and your date of birth, you need to know your lifetime risk of breast cancer. It's mandatory. >> Lifetime risk of breast cancer. >> Yes. Have you heard of that? >> I've heard that term. Good. So, why is it so important? I'm sure you've you know of someone in their 30s who end up with stage four breast cancer or advanced stage breast cancer and they die way before they get to their mamogram age, right? So, the first message I want to say on this podcast is that the message of mamograms should start at 40 is misleading and it needs to stop. Mamograms start at 40 for very low-risk patients. An average American has a 12.5% chance of getting breast cancer. >> 12.5%. >> Average American >> for women specifically. >> Yes. So pick your finger, go to a party in a room with 100 women, 12.5 of them, just average will get breast cancer. If I That's incredible, right? That's a huge number. Now the problem is if you have family history of breast cancer or if you have a biopsy that shows atypia at some point in your life that will significantly increase your lifetime risk of breast cancer. Why is that important? Again there are three buckets for breast cancer risk. Low risk is less than 15%. Intermediate risk is 15 to 20%. And high risk is 20% or more. Why am I bringing this up? If your lifetime risk of breast cancer is 20% or more, you can start breast imaging at 30, not 40. How about that? >> What does a doctor need to hear um in order to put someone in that category? >> It's a very simple formula. Patients can do it at home. See, you don't need your doctor to do this for you. Empowered. That's why women can do this at home. It's a formula called tireus risk assessment tool. I have it on GMD. It's free. You can literally go on there and calculate your lifetime risk of breast cancer. It asks you for your age, height, weight, density of the breast, which you can only get the density of the breast from your breast imaging mamogram or your MRI. Usually the radiologists make a comment of whether or not you have uh you know fibro glandular fatty breast uh heterogeneously dense or extremely dense breast. The higher the density the higher your lifetime risk of breast cancer. Patients who have children after age 30 are at a higher risk. Women who haven't had children. Women with family history. Women with genetic mutations. So you answer these questions and at the end of it it will calculate your risk of breast cancer over the next 10 years or over your lifetime. If that number is 20% or more, you can go to your doctor's office for your wellwoman exam after you ask for your egg count and your pelvic ultrasound. You ask them for breast imaging. Especially if you have a firstderee relative, mom, sister, daughter with breast cancer, that significantly increases your risk. If that risk is north of 20%, you need to ask your doctor for breast imaging as early as 30. That's why I had a girl in my um on my podcast at 34. She has stage 4 breast cancer. Had she been treated and diagnosed and and I'll tell you her story. It's it's really devastating. So, it's important to know your left-term risk of breast cancer. Patients who fall into the high-risisk category, 20% or more, in addition to mamogram, if they have dense breast tissue, they need to ask for ultrasound of the breast. And for high-risk patients, 20% or more, in addition to mamogram and ultrasound, they need to ask for a breast MRI. Now, if your doctor writes for a breast MRI, it's probably not going to get covered by insurance. But if your doctor writes patient is high risk, lifetime risk is 28%. Then your insurance company has to cover, right? So that's how they test doctors. They want to see that lifetime risk on the prescription order in order to approve it, but they can still not approve it, but that's another discussion. So it's important to know your lifetime risk of breast cancer. For any woman with family history of breast cancer, ovarian cancer, pancreatic cancer, prostate cancer, and the list goes on and on, they can ask their doctor to see if they qualify for genetic cancer testing. The company I use in my office, I've used for I don't know over 10 years, is Marriott. And um the reason I use this specific company, there are a lot of companies that check for genetic cancer testing, right? They check 80 90 genes. I think Marriott only checks 63 genes which is fine. But so not only Marriott checks you for the cancer-causing genes, they also calculate your tire cus for you so the doctor can see it. But in addition to that, Marriott takes your tire and also looks in the DNA for tiny little markers. These are not main genetic mutations. They're tiny little markers that individually don't have that much power, but some women walk around with tons of these uh markers and they add the tire with these markers and they give you a risk score. Sometimes I have a patient whose tire is 19% but when you calculate uh their risk score it jumps up to 34%. So for patients who fall into the very high risk category north of north of 35% those patients have the choice of um either doing imaging every 6 months alternating mamogram ultrasound with MRI or asking their doctor for a medication called temoxifen >> estrogen receptor blocker >> that reduces the risk of breast cancer by 50% in the next 10 years of their life or ask for a double mastctomy which is exactly What I did, and I'm just going to end it by this. I have I was 48. I had no family history of breast cancer. 85% of women who get breast cancer don't have it in their family. Less than 5% have a genetic mutation. Most Americans who get it are just like me. I had no family history. I had no genetic mutation. I was never on hormones. I was never overweight. I never smoked. I never I don't drink. I've never done drugs in my life. Um, so I was the perfect example of someone did everything. I did everything right. At 48, I had a breast biopsy that showed atypia and I asked my uh, obviously I had to go in and do an excisional biopsy. They removed it >> and my doctor said, "Everything's good. Go come back in 6 months." I went to my office and I calculated my lifetime risk of breast cancer. And it was the first time I did that because I had no reason to do it before cuz I had no risk factors. But when I calculated my lifetime risk, it showed 37%. So I called my doctor and I said, "You tell me I'm okay, but this lifetime risk says 37%." And back then I had three daughter, my three daughters. I had not adopted my little one. If you told me this plane had a 37% chance of crashing, I would never board that plane. I'm very conservative. Please take my breasts off and put implants in. I already had implants. I had augmentation. They called me crazy, paranoid. um uh anxious. Uh they told me uh I was told that because I didn't have family history or because I looked the way I did and I was so healthy that I was very low risk. Yet my number was 37%. Until I found the surgeon who was willing to do it. She did it and the day before surgery she was very annoyed with with me and she said, "Why are you doing it?" I'm like, "Well, I don't want it." I said the, you know, boarding the plane. >> Is that what you want your surgeon to say to you the day before surgery? >> She was because she really didn't want to do it. She She really thought I was crazy. And I said, uh, why why is it so why do I fight? Why do I have to fight so hard to remove my breast? This is my body and I don't care about my breast. It's just it's very personal, but for me it really didn't matter. You know what she told me? We have really good chemo for breast cancer. >> Oh my goodness. >> I'm a women's health advocate. Do you understand? This is how I'm being treated in the health care system. Right? So she did it. They gained her advice and a week later I get a call that they found breast cancer in my tissue. That's how I diagnosed my breast cancer. So all this time they were digging in the left. My breast cancer was sitting on my right breast at 6:00. Why am I saying this? I'm not saying this to scare people, but I'm saying this that as a woman's health advocate, as a gynecologist, as someone who's I feel like I'm extremely competent in my field. If I had to fight so hard for someone to take me seriously, do you think other women have a chance? That's why they show up so late. That's why their genetic test is not done. That's why if you don't know your lifetime risk of if I didn't know my lifetime risk of breast cancer, I would have never known to ask for these options. That's why you have to empower women to be their own health advocate. Go calculate your lifetime risk of breast cancer. That's non-negotiable. And if that number is 20% or above, ask your doctor for breast imaging. I don't care if you're 34 years old. You need it. And if you have family history, ask your doctor for genetic cancer testing. That's not optional. And if you do this, that's why, you know what, Andrew, I don't want to jinx myself. I've practiced for 25 years. I've never lost a patient under my care to cancer. >> That's a wonderful thing to be able to say, >> right? But it's not because I do some magic in my office. I'm hyper vigilant with these patients. When you come for your wellwoman exam to my office, I'm assessing your fertility. I'm ruling out endo. I'm ruling out PCOS. I'm checking your egg count. I'm doing a pelvic ultrasound looking for cyst, fibroid, septum. If you have PCOS, if you're young, I'm checking your APO. I'm checking your lipoprotein little A status. If you're pmenopausal, I'm checking your ApoE4 to see if that increases your risk of dementia. I talk about hormone replacement early uh during pmenopause. I talk about bone density. I talk about colonoscopy. I talk about genetic testing. Depending on your lifetime risk of breast cancer, I order different things, different imaging for different patients. I check your hormones. I check your thyroid. I check your prolactin. So, I talk about anxiety, depression. I talk about eating disorder. So, right now, a wellwoman exam for a patient is go to the doctor's office, get your papsmear, get an STD check if you're asking for it, right? Ask for birth control, do a breast exam. If you're 40, you get an order for mamogram, and then you go home. That's not a wellwoman exam. That has to stop. And pelvic ultrasound should be on top of the list. >> I greatly appreciate you telling us this. I I do believe that what you're saying will lead to change. It's going to take some time, but I'm going to encourage all the women listening to not just do what you suggest, but to also echo what you're saying to all of their friends and to all of their family members, uh, the women they know, because I do think that that's the way things change, frankly. Um, you know, I I've never beat the drum of one particular um health ailment or health practice, although morning sunlight. I what I do is I give people information and I try and distribute it so people can distribute it to one another. But um if ever there was a a batch of information to come through on this podcast where it was absolutely critical that people do what the guest is talking about and share that information and just keep pushing and pushing forward with this. Um, it's the information you've been sharing. So, um, and I can't say that enough times or emphatically enough. I do have a couple more questions, even though you've been incredibly generous with your time. No, of course, but there are questions that come from the the audience on social media that I've solicited for prior to the podcast. So, I'm going to just take a moment, grab my phone, which I keep out of the room for our discussions, but I'm going to grab it now and see if any of the questions um touch on things that we haven't talked about uh this far. Okay. Okay, some excellent questions from the general public. This first one is, are there any non-invasive methods for the diagnosis of endometriosis like tests within the men from the menstrual blood itself? >> They're doing a lot of research right now. We don't currently have it right now. Non-invasive is well, listen to your patient. That's like 99% accurate. Do a pelvic ultrasound. Unfortunately, if you see it on pelvic ultrasound, it's already advanced disease. Or do a pelvic MRI because MRI can actually with a experienced radiologist, they can look at these specially infiltrating lesions, they can see those on MRI. >> Is endometriosis an autoimmune disease? >> Yes, it is. We talked about this. Absolutely. And that's why if you have endometriosis and you're trying to get pregnant or if you've had a miscarriage, ask your doctor for a full autoimmune panel because when you have one autoimmune, you have a 30% chance of having another autoimmune disorder. >> Is cognitive impairment in menopause an absolute occurrence. Like does it necessarily happen as what they want to >> not always but it's extremely common. I call it brain fog. You know, women lose their uh concentration. They don't remember things. you go into a room, you're like, why did I come in here? And a lot of that is because of the fluctuations in the hormones and uh the drop in the estrogen. So by replacing um by hor giving these patients hormone replacement, they feel like oh my god, I'm alive again. I can see again, I can think again. So it absolutely happens. It you know most symptoms of menopause, different women experience menopause differently. They all don't share the same exact symptoms, but a lot of women complain of brain fog. Is inositol useful for PCOS? >> Yes, absolutely. Gonna have it in OV. >> What do you think is the most overlooked missed cause of infertility by doctors? >> Everything we talked about endo and PCOS hands down a lot of these patients who are unexplained are undiagnosed PCOS and endometriosis patients. suggestions for PMDD relief >> for somebody in their 40s. >> And could you explain PMDD? I don't think we've defined that acronym. >> PMDD is a severe form of PMS. Very, very common. Devastating for these girls. The best way to describe it is these girls, two weeks out of the month, they're perfect. Two weeks out of the month, they destroy all their relationships. They're depressed. They're crying. They're unmotivated. They don't want to go to school. they completely decline. They don't want to go out and two weeks after, so I always say two weeks out of the month, you destroy all all your relationships and then you spend two more weeks fixing it. And then the vicious cycle happens over and over again. So PMDD is a severe form of PMS. And what happens, it's not an abnormal hormonal u condition. It's actually the brain's reaction, extreme reaction to normal hormonal changes in the body. So PMDD, the symptoms usually start 10 days before the period and goes away 2 3 days after the period. And this vicious cycle happens. Believe it or not, suicide is really high in these patients during those weeks. I'm actually seeing a patient from out of state on Friday after my surgery because her family's flying her because she's not feeling well and her diagnosis is PMDD. How do you treat it? If you want to use birth control, there's one form of birth control. Yas, I don't usually go to it. It helps with the symptoms of PMDD, but these patients actually they do really well if you put them on uh SSRIs or anti-depressants just 10 days during the month. For these patients, you can prescribe 20 milligrams of Prozac 10 to 14 days before their period. So, they only take it 10 to 14 days per month after ovulation. They start taking it once a day and they stop at the onset of their period. You can also treat them with 25 milligrams of Zoloft. For some reason, their brain responds really well to this pulsatile treatment and it's a gamecher for these patients. PMDDD patients, you do want to make sure they don't have a chronic underlying anxiety depressive disorder. So, I always refer them to uh a psychiatrist, but you can absolutely treat it. For pmenopausal women, you can also treat them with hormone replacement. So, someone in her 40s, I want to make sure if she didn't have it and suddenly she has, it's not like she hasn't had PMDDD and suddenly she has PMDDD, it's probably it could be pmenopause. So, you don't want to miss that. >> Great. It's the first time I've heard such a thorough description of what PMDDD is and what one can do about it. Uh I think you just helped a ton of people. Uh a lot of questions about fasting and about low starch aka low carbohydrate diet. >> I 100% say yes. A lot of us are eating, you know, like if you're waking uh in the morning and having bread and pasta for lunch and then you're having ice cream and then you have uh rice and I don't know, pizza for dinner. Of course, it'll start that process. Diet is extremely important. One thing I try to stay away from is limiting these patients or telling a 22year-old you are not to have any carbohydrates. That's not sustainable. What I believe is if you fix their underlying condition and address their insulin resistance and help them exercise and um have healthy habits, you can fix these symptoms. Just cutting carbohydrates out. A lot of these PCOS patients are already doing this. They're literally starving themselves and they're exercising and they're not losing weight. It's because their underlying condition has not been addressed. So I I would say like anything else at moderation. But you don't want to tell someone don't eat carbohydrates. It's not sustainable. >> Someone said that their estradiol patch is causing some hair loss. Is there another option? >> I don't think it's the estradiol patch causing the hair loss. Women who use estradiol patches um are going through pmenopause and menopause. One of the issues with pmenopause and menopause is that drop in estrogen does cause hair thinning. So for that reason I would say you know I usually treat these patients with minoxidil. You can either do like ro gain on your scalp or you can take oral minoxidil. Uh the prescription is 2.5. You can start as uh little as.5 every single day. The problem is hair thinning is very common in menopause and you want to hit it quick. So if you start noticing that you're losing hair. Take the minoxidil. It doesn't work overnight. You will probably start seeing results in about six months, but in two years it you'll see a huge difference in your hair. But hit it early. And it's not the estrogen patch. I doubt it. >> A number of questions about how to improve quality of eggs after age 35 presumably by doing all the things that we talked about for the past. lower end intramaler fat, lower inflammation, um improve insulin sensitivity, >> uh suppress endometriosis for sure because endometriosis will go after those egg count and quality. PCOS will go after your quality. >> Does endometriosis pain start to wayne with pmenopause? >> Yes, it gets better. The problem is women in their 40s have a lot of adenomiiosis which mimics the symptoms of endometriosis. So these women actually do extremely well with the progesterone IUD. We talked about the Marina IUD because it suppresses their pelvis and their endometriosis. And once they go through menopause, this is a very important point and I'm so glad you brought it up because doctors don't realize this for patients with endometriosis. Menopause will make the pain go away, right? Because what happens in menopause are ovaries are not functioning and the estrogen levels drop. However, you come and give these women estrogen, what happens? You can stimulate these endometriosis implants all over again. And this is what happens. So, endometriosis patients in general have a slightly higher increased risk of ovarian cancer, especially the ones with endometrias or advanced disease. And post-menopause hormone replacement, the estrogen, can still stimulate these implants. Now a lot of women in the health care system who have undergo a hyerectomy meaning they remove their uterus the doctor says you don't need progesterone cuz you know we think we give the progesterone to protect the lining of the uterus from unopposed estrogen causing uterine cancer. Well that's not true. In patients with endometriosis, even when they undergo a hyerectomy and they're using estrogen patches, you always want to give them the progesterone because otherwise you stimulate this these implants again because of unopposed estrogen. That's one reason. And also we use the progesterone micronized progesterone in hormone replacement for patients who are anxious, who are not sleeping well, regardless of whether or not they have uter they have a uterus. But endometriosis patients their hormone replacement should always be with progesterone. >> Are there any natural ways to increase progesterone? >> So one reason uh our body doesn't uh you know when we don't ovulate we don't make that corpus ludial cyst and we don't have that progesterone being secreted. So in PCOS let's say by lowering your weight by lowering that visceral fat but reg by regulating your insulin resistance you can increase your chance of ovulation and by ovulation then you start releasing the progesterone. So that's the best way of describing it but for pmenopausal women then you need to um prescribe them the micronized progesterone. >> You already answered this earlier but I think it's worth just briefly repeating. uh how does diet affect female hormone health? >> As we get closer to menopause, we become more insulin resistant regardless of whether we had PCOS or not. So dealing with insulin almost all of us women, we deal with insulin resistance at some point in our life at different degrees. But that goes to the uh you know what I was telling you when you load the gun with your genetics and you pull the trigger with epigenetics, your diet, your exercise, your sleep, your stress, all of that will affect it long term. >> What can women do to prolong their fertility? I suppose everything you've already talked about, >> but you see, but now you know how to answer it. Don't dismiss your endometriosis. Don't dismiss your PCOS. Know your egg count. Make sure you freeze your eggs early if you can afford it. You know, I mean, all the steps we talked about for the past four hours. >> I could listen to you for many, many hours and I know the the audience can too. Um, several things. First of all, thank you for coming here today to share with us a true treasure trove of information. I mean, I have to imagine that most of what people heard, they have not heard before, and certainly not with the depth and rigor and actionable items that you've suggested. So, just thank you. Thank you. Thank you for taking the time. You you're very busy. You have four children. You you're happily married. You run a a a very active clinic and your uh story about running off to deliver babies at a rate of 80 or more per month while pregnant um says it all. but that you would take the time to come here and share with our audience, the general public, that is um I'm immensely grateful. I know they are immensely grateful. We will put links so that people can find you and the various resources discussed as well as um another call to action to listen to shemd uh your podcast. I also just want to thank you for being you, you know, which is a sort of a funny statement on the surface, but truly I mean your passion for what you do, your passion for women's health and just the again the depth and rigor with which you approach these things that I think for most people they you know look up one or two things see a few symptoms you know this age to this age group and you're giving people tools to potentially diagnose their own endometriosis PCOS and breast cancer extend fertility live life with far less pain, ideally no pain, and perhaps most importantly to give them clarity and the sense that they are indeed sane in a world that basically is sending back >> the opposite message because it just doesn't understand what they're going through. So, um, you know, words really can't say enough for how grateful I am to have you here and to share this knowledge and that the audience is sure to glean from you. I would really like to have you back again to talk about where these things are going because it sounds like the field is advancing very quickly too. And everybody out there um head to the various resources that Dr. Aliabody shared and um and please share with me and thanking her uh through her social media channels, her podcast and and all the rest. And just you know really truly thank you. Thank you. Thank you so much. >> Oh, you're so sweet. Thank you for having me. Thank you for giving me this opportunity, this mic so I can take, you know, so I can take this time to talk about women and women's health. I love women. I'm surrounded by them. I have four daughters. I do this for them, for the world, and this world will be a better place if we take care of our women. >> Well, God bless you for doing it. Thank you. >> Thank you. >> Thank you for joining me for today's discussion with Dr. Tais Aliabati. 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