#9 What is PMOS (PCOS)?

In this episode, we are joined by Dr. Cheung to discuss Polyendocrine Metabolic Ovarian Syndrome (PMOS), formerly known as Polycystic Ovary Syndrome (PCOS), a condition that affects approximately 1 in 8 women worldwide. We explore the hormonal and metabolic factors involved, common symptoms, challenges with diagnosis, and evidence-based approaches to management. Dr. Cheung shares expert insights to help listeners better understand this complex condition and its impact on women's health, particularly on fertility.

Episode Resource: 

PMOS Tool Box: https://pcos.together.ualberta.ca/resources/

Dr. Cheung's Clinic: 

https://www.fertilitywithgrace.com/

Chapters: 

00:00 Introduction

03:00 What Is PCOS?

07:16 Diagnosis of PCOS

18:42 Why Is PCOS Difficult to Diagnose?

21:35 Treatment Options for PCOS

24:30 Supplements for PCOS (Inositol)

26:05 Is PCOS Reversible?

29:40 Fertility and PCOS

32:10 Common Misconceptions About PCOS

32:27 PCOS: True or False?

33:32 What Women Want to Know About PCOS

38:30 Conclusion

Transcript

SPEAKER_00 0:01

So a lot of people get frightened. Oh my god, I got cis. I've told that I got cis in the ovaries. Don't be. They are not cis. But initially, the criteria for PCOS, the syndrome now, basically based on two things. In clinical practice, there are people being labeled at PCOS when they are thick.

SPEAKER_02 0:22

Is there any specific birth control recommendation for people with PCOS?

SPEAKER_03 0:27

We often hear that it takes a long time for people to get a diagnosis and you speak to why. Is PCOS reversible?

SPEAKER_02 0:58

So we wanted to make a quick note about an important name change for PCOS. So researchers have officially proposed renaming polycystic ovary syndrome, so PCOS, to polyendocrine metabolic ovarian syndrome, PMOS. So this change matters because the term polycystic ovaries has long been considered misleading or inaccurate, which Dr. Chung explains really well in this episode. PCOS involves far more than just the ovaries, and a new name better reflects the true complexity of this condition. Since this episode was filmed before the name change, we will be referring to PMOS as PCOS throughout this episode. On that note, we really hope you enjoyed this episode. And we are very excited to be joined today by an expert, Dr. Anthony Chung.

SPEAKER_03 2:00

So Dr. Anthony Chung is a reproductive endocrinologist and infertility specialist with 35 years of clinical research and teaching experience. He's the founder and medical director of Grace Fertility and a clinical professor in the division of reproductive endocrinology and infertility at the University of British Columbia. Dr. Chung completed subspecialty training in menopause in Sydney, Australia, and training in reproductive endocrinology and infertility in California, USA. His areas of specialty include polycystic ovarian syndrome, which we're very excited to talk about, ovarian physiology, assisted reproductive technologies, female infertility and menopause. He's always keen to share his knowledge, and Dr. Chung is known for being thorough and taking the time to answer patient questions. So, Dr. Anthony Chung, welcome to the Volvolution.

SPEAKER_00 2:55

Thank you. Thank you for inviting me. We hope that we can share some information in this session. Exciting.

SPEAKER_02 3:00

Okay, so now we're gonna talk about PCOS. So I think a lot of our listeners probably heard of it in a lot of different videos or online. We talk a lot about PCOS, but what is actually PCOS? What does it stand for and what's what is it?

SPEAKER_00 3:15

So the term PCO or PCOS, S is a syndrome. If you look at PCO itself, we stand for polycystic ovaries. So a lot of people get frightened. Oh my god, I got cysts. I've told that I got cis in the ovaries. Don't be. They are not cysts, they are just physiological follicles. Follicles are the normal structure that you see on outer sound and in a normal menstrual cycle. So the eggs are microscopic, you can't see them. But there's a small group of these eggs evolving to the next stage of development, such that each one of them is housed in a cystic structure, we call them follicles, is watered by very specialized cell layers. Those are the ones that will respond to the hormone during the menstrual cycle. So in the beginning of the cycle, let's say you got, depending on the age group, you got a bunch of them, but only one will be selected so that about two weeks into the menstrual cycle, an ideal normal menstrual cycle, that follicle would have grown from, let's say, four millimeters to about 20 uh millimeters. Around the time ovulation will occur, it means that an egg will be released, and then an estrogen will be going up during that part of the cycle. But after the eggs is released, the structure called a follicle collapses, but it doesn't go away. It actually converted to a very important structure called a copper solution, or in plain English, yellow body. Why is it yellow? Because it's producing a lot of uh steroid progesterone. So basically, if you look at the menstrual cycle, the first half is estrogen predominant, the second half you have progesterone in addition. Progesterone stops the estrogen from dividing, so the cell layer will not become becoming too much hyperplasia occurring. Later on, we can talk about the risk of why women with PCOS don't overlay the risk of abnormal endometrium, precisely because there's no progesterone secreted naturally or regularly to protect the lining. So the endometrial progesterone actually stops the endometrium from the cell division, make the cells conducive for implantation. And if the woman is pregnant, it actually will then produce a progesterone to continue on with the pregnancy until the placenta is better developed by about 10 weeks from the last menstrual period. So it's a very important function. So in PCOS, the for ovaries just have all these background photocodes available. Somehow, whatever reason, they are not regularly developing to the next day. So the term was coined in the 1950s or before. So even before before, in fact, and they we didn't understand as much. So it's called cis. So people got scary or polycystic kidneys, that sort of thing. We got kidney cysts. No, it's not the same category. They're just follicles. So always tell them that don't be worried. It's actually in modern day 21st century. If you do have PCO, it may be an advantage because age for age, you actually will have more follicles to work with if you're going to stimulate the ovary. More eggs as a result. Of course, you run the risk of the other side effects. You will have overstimulation if you're not careful, and run the risk of a condition called ovarian hyperstimulation syndrome. But that's a different story. But at least rather than struggling, like someone who's 40 years old with few follicles to work with, think of fewer eggs from the one oversight pickup, you may have way better than someone who's 37. That's that's the advantage of that. But of course, the age-related chance of the embryos with normal chromosome number can still be affected. That's the H effect, you can't change that. So that's a polycystic ovarian. So initially, the the criteria for PCOS, the syndrome now, basically based on two things. Because before ultrasound wasn't available to the extent that we can do it now, it's really based on two criteria. One is irregular or no periods, reflecting ovarian dysfunction.

SPEAKER_02 7:24

When you say irregular or no period, what is irregular?

SPEAKER_00 7:28

Generally speaking, the cycle length is around 28 days, but the range can go from 21 to let's say 34, 35 days. So you are over that 30 over 35 days, it would be oligal, ovulation, oligo means fewer. Ovalation still over if you're still having a menstrual cycle. Some people remember 36-day cycle, but an ovulation will occur later. So typically, the normal menstrual cycle, the variable phase is, or I should say the other way around, the constant phase is more the luteal phase. Luteal phase means from ovulation to the onset of the next menstrual cycle. That's usually fixed, 12, 14 days, depending on how you have the onset of bleeding. The variable part, how the follicle, the time takes for the dominant follicle to develop and to ovulate can be variable. For some people, it may take two weeks typically, other time it may be three weeks or four weeks. So when that happens, the cycle length is longer. So that's reflected in either uh delayed ovulation. So when they do the ovulation prediction kit, they can't get it, keep doing it, nothing, nothing. And then they realize that by the time they stop, forget about it, that's the time when they when they show. So so that's it. So if the cycle is over 35 days, not just occasionally, as you know, stress, whatever reason, can sometimes cause that, but if it's persistently or more commonly, even though in between you may have seemingly regular cycles, then you still will have that situation. Yeah. A short end of that can be tricky. Generally speaking, as a woman entering into the late 30s, early 40s, the cycle length, even though she still may be overlating, the cycle length is actually shorter. Instead of 28 days may shorten to 26, 25, and 24 days and so forth. That's a physiological reason for for that. If within that it's still overating, that's fine. But the main concern is that if the cycle gets very short, like 19 days or so, then the question is that are we and training ourselves to think that it was a period, but it's actually bleeding, but not followed by ovulation. So it may be actually irregular bleeding, which can occur because if you don't ovulate, you just got estrogen, not high, but lower dose of estrogen, keep on stimulating the lining, the lining or endometrium, the endometrium may outgrow the blood supply. Then it starts having breakdown, irregular spotting or bleeding. But unlike the menstrual cycle, when all the hormone profiles are acting in concert in a certain sequence, whether you come as a vingens with heavy flow and then very quickly stop. That is really related to the hormonal changes. But with irregular bleeding due to breakdown, haphazard irregular breakdown of the lining, you can have starting, stopping, starting, stopping, and for a prolonged period of time. Those are the ones that you're worried about.

SPEAKER_02 10:22

Okay, and that wouldn't be PCOS, that would be maybe.

SPEAKER_00 10:25

That would be one criteria. Okay. Because think about it, if you don't overly regulate, you only got estrogen alone, then we have that situation, and that is a manifestation. So a classic example with someone who has no period for six months, and not the marathon runner type theme, low BMI, hardy enhancer fat, those are the different scenarios. This would be uh just no period for six months, and then suddenly you have bleeding, and the bleeding doesn't stop for weeks and so forth, requiring actual treatment to stop. That's a classic example of an ovulation, no period, followed by irregular as a prolonged bleeding that also needs to be treated. And particularly endometrium in terms of potential pathology also need to be looked after. Okay.

SPEAKER_02 11:11

So that's one criteria. Yeah, so irregular period can be a lot of different things. That's right.

SPEAKER_00 11:16

But typically it would be prolonged interval before a period occurs, or irregular bleeding or no period. So we can group under that category. So that's one criterion. The other one is increased androgen manifestation, be it clinical. So some people may have increased facial hair, hair under the chin, more terminal hair, not facial, sort of sort of stunny type of fine hair. And or midline hair like the man's distribution, midline of the of the chest, or a band between the navel to the pubic hair, or fan out like a uh triangle type of thing. Increased hair around the inner aspiral thighs and so forth. So there's actually a paper score, you can self-score your own uh herzwatism score. Herzutism means increased abdominal hair. Okay. So that would be one criterion. Acne is more tricky because exactly during puberty, a lot of situation or androgen changes can cause that. So it's not necessarily a strong feature, but it usually can come hand in hand with the hesitation. So that's uh that's that one. And or they may have may not have manifestation because family history or ethnic group can be different. Like East Asians, for example, they have fewer uh hair photos per square area, so you may not show. But on the other hand, someone in the different areas may have geographic areas, may have that predisposition anyway, and it may be harder to detect any changes. Yeah, but it's more the individual perception of what she feels. Yeah, and then of course, if you do your blood results, you can blood test hormones. You may find that typically the male hormones will be a bit higher, not like male uh levels, but higher than normal cycling women. And the ones that we're interested in will be testosterone, and uh androsin diol and 17 hydroxypogesterone. Those two are relevant because sometimes patients with late onset adrenal hyperplasia can mimic PCOS, and these two hormones are relevant in deciding whether they got that adult onset or occult adrenal hyperplasia. Then the other one, the adrenal hormone, to reflect increased androgen from the adrenal gland would be DHEAS.

SPEAKER_02 13:39

Okay. Okay.

SPEAKER_00 13:40

So that would be those are the two main criteria. But then the uh European school didn't like it. They said, well, no, you haven't included ECO in your uh criteria. So that's why the Rotterdam criteria have become popular. Include these three criteria uh irregular, no cycles or few menstrual cycles, and uh increased androgen manifestation, biochemical, as in hormone testing or clinical, and then PCO morphology of nutrition. So what does it mean by PCO morphology of ultrasound? So typically when you do the ultrasound, see, as I mentioned, the background follicle present. And so it's basically the number. So initially in the early 1980s or so, when we were still using majority of the cases during abdominal ultrasound, resolution not as high, then when we use a criteria, maybe above 13 follicles per ovary will be PCO. But if you now tell me that someone got PCO 20 years old, 13 follicles, hmm, I would say, really? Because with vaginal ultrasound, the resolution has increased. That 13 folticos is commonly seen in a woman in her 20s. So it may be overdiagnosed as a result. So again, we can touch on that. It's PCOS, overdiagnosed or underdiagnosed. Most people think it's underdiagnosed, but also in clinical practice there are people being labeled at PCOS when they are nothing. Yeah. Okay. So those are the ones.

SPEAKER_02 15:10

Because they saw more follicles on the ovaries.

SPEAKER_00 15:13

Or because they don't have menstrual psychos, uh, they uh at a younger age should say, oh yeah, you're PCOS. That's okay.

SPEAKER_02 15:20

Oh, okay. So you need to fit in the three criteria?

SPEAKER_00 15:24

You need two out of three. So precisely because of now adding the follicle number included PCO in into the diagnosis, we suddenly increase women that may not necessarily have the classic definition of PCO and the prevalence have changed from maybe six or seven percent to now 13%. And the in terms of prognosis and how you look into that, probably there's a gradation of who will respond better in terms of fertility medications and ovulation. So if you have all three criteria, increased androgen levels, um PCO, morphology on ultrasound, and irregular or no ovulation, those are the patients that probably be more resistant or more severe. And they typically will also the metabolic concern, because metabolic concern is one uh important factor tied in perhaps with uh insulin resistance and compensatory hypoinsulinemia or increased insulin secretion and obesity, and the two can fuel one another. So one gets worse, the other one would get worse as well, and then when this one gets worse, the other one will also keep going worse and worse, that sort of thing. Then the second group would be uh still got increased androgen levels, but have irregular cycles. So they may be better, but it's still got a metabolic syndrome concern. The third group would be perhaps you have uh PCO and uh irregular cycles. So that would be the group that is quite easy to treat in terms of fertility. And then one other group would be with the increased androgen levels and PCOS. Any anytime when you have increased androgen levels, probably worse. If you have just PCO and irregular cycle, that's probably the easiest to treat. Does it make sense?

SPEAKER_02 17:19

Yeah, yeah. What are some of the most common symptoms people experience with PCOS?

SPEAKER_00 17:24

Right. I perhaps because of the practice that I have, I got more people coming wanting fertility. So that is one of the major concerns. So typically they have three clinical features that are commonly uh want to seek help. One, they are not overting regularly, not in the reproductive age or not wanting to pregnancy. Related to that, of course, if you don't overturn it, you can't get pregnant, then you would need fertility treatment. And the third one would be uh cosmetic, increased facial hair growth, or hair thinning and so forth. So those are the three categories regulation of psychos, contraception, included there as well, uh fertility, ovulation inducing ovulation, and cosmetic. So those are the three main ones. So depending on your practice, you may get a jaundice field. Mine is essentially more related to uh not able to get pregnant. Yeah, but if you're an internist only seeing those people with increased hair growth, then you're gonna have that group of people. Or if you you know that in the hyperandrogenic group, they have about at least 50% chance that they can have prediabetic situation, obesity, and or just diabetes. And so that will be need to be taken care of as well.

SPEAKER_03 18:41

Okay, so then we talked a little bit about how you actually diagnose PCOS or the diagnostic criteria. We often hear that it takes a long time for people to get a diagnosis of PCOS. Can you speak to why that might be sure?

SPEAKER_00 18:55

If someone typically coming in with irregular psychos, you check the hormones. She has not been on any hormones just before she's come to see you. And uh ultrasound show that a lot of follicles, uh, 20 in each ovary, for example, in a good age group. Yeah. And then that would be PCOS for sure. You don't need any further. So for someone like me, where we can do ultrasound on site and do the blood work and know the history, that's easy. The tricky ones would be that they have been on the birth control pill. So you eliminate one criteria already. So you have to go back in time. Oh, what were your periods like before you started the birth control pills? Some people will remember that my period is always irregular. That might be the reason why I'm on the birth control pills to regulate the cycles. Some will say, Well, I really don't know. So those are the more tricky ones. Then sometimes when they when you do the ultrasound, and you may not necessarily see the full hand of the follicles as such. So I've seen it in both ways. Sometimes the birth control pills don't make the PCO go away. You still see a lot of follicles. But every now and then you may have seen some people on the marina IUD, progestion IUD, which is a good way to treat uh irregular bleeding to protect the endometrium. Okay, the follicle may be a little bit quieter in some cases, so it can be tricky. So those are the ones you don't have any evidence. You just purely go by by scenario. But what I've seen is that quite often the patients that I have PCOS. I thought, oh, how did you know? Oh, because I didn't have irregular cycles at the time, my OBE told me that, oh, you have PCOS. So that's not not a true diagnosis as such. Yeah. So in general, those are the criteria. So if I don't know the irregular cycles, but the patient added to the situation, then you got one criterion. I'll just have for sure. Androgen levels can also be an addition. Unless they've been on birth control pills long enough, the increased androgens are not too high, subtle enough, they are actually suppressed. Then you again eliminated that uh criteria. So for those ones that's fine until they are ready. Stop the pills, want to get pregnant, then you know what happened. Uh but they're already on the good track anyway, because one, they are they really had PCOS, they got irregular psychos on the piece on birth control pills to uh regulate the psychose and also protect the endometrium. In addition, if you choose the right birth control pills, the components with the progestogen with more anti-androgen component, then they also may help with their acne and/or hesitism. So that that would be the advantage. Yeah. Okay.

SPEAKER_03 21:35

And you mentioned a little bit about using the birth control pill somewhat as treatment. Could you expand upon what the general treatments look like for people with PCOS?

SPEAKER_00 21:45

As I mentioned, there are three presentations depending on what their major issue. I have also seen patients who are fine, everything is okay, they don't need contraception, but they're just worried about weight.

unknown 21:59

So

SPEAKER_00 22:00

Those are the parts that we becoming lifestyle modification. And quite often you hear them, I uh exercise as much, if not more, than my skinny friend, and uh eat not as much as she does, and yet she has no problem, and I keep on gaining weight. So those are common uh scenarios. So so that's tricky one. Those are the ones that you have to also look into the lifestyle scenario. And once you get into that, it you it's a more variable. So it's not a one single uh protocol for everybody, it's more work with that person how it works. So be it diet combining with exercise, what type of exercise, for example, what type of diet.

SPEAKER_03 22:42

And there are medications that you can use as well.

SPEAKER_00 22:45

Yes, yes. So it's I'm sure you're aware of the very popular for the Ozampic and those uh uh medications to reduce weight. So it's certainly for the very high BMI, those are very useful in addition to beneficial effect on glucose control and so forth. Uh and the severe one, even BMI 51, sometimes, from what I understand, that's the one, the category that the internists would see more than I do. They would probably give them the ozampic or equivalent medications and then prepare them for uh barometric uh surgery to improve it. So those are the extreme ones. That's not the patient that I see. Uh, but the borderline one are typically the BMI would be under 40. And then we work with them on how to improve their general metabolic parameters and uh what their major concern, uh if ovulation is the main thing, then we may treat earlier if they're already 39. That's how I think.

SPEAKER_02 23:43

Okay. So someone that's not trying to get pregnant, um, then we would focus more on diet and lifestyle first. Absolutely.

SPEAKER_00 23:50

If someone like what we mentioned about irregular psycho, how they define it. If someone has 36 psychos, but if you do timed progesterone and confirm that she overlaid, I wouldn't necessarily think that she needs birth control pill. So those are the ones that uh may not be, and those are the ones that perhaps try to improve her uh metabolic factors. So they may be just fine too. So when you check the insulin level, glucose and lipid there, perhaps perfect. Yeah. But the ones that are borderline, then yes, you can then tinker with the uh diet and or uh exercise. Yeah. But we all know that exercise is good for you anyway.

SPEAKER_02 24:30

Yeah, yeah, yeah. What about supplements? So we hear a lot about different supplements, and I was just doing my own little research on this, and I saw a lot of research actually looked at inocol. Yes, yes, yes.

SPEAKER_00 24:43

Inocito had been in in in their original study suggests that it actually can help women to overlay regular more regularly. And but the pure randomized control trial as such still lacking. So it's still people think it's still experimental. But I think it's a lot of of factors involved. I'm a bit skeptical about it, but having said that, you have to group into the four subtypes of PCOS that I mentioned. If you are the borderline one, you probably overlay every now and then yourself anyway. So those may be the ones that just giving a little bit of innocito may help you to achieve the goal one or more times more frequently. But if you're looking at the hyper androgenic that group, maybe enough. Nothing. It's just a waste of time. So I think that's where the individual thing occurs. I wouldn't be completely uh write it off, but I also wouldn't endorse it completely. So if you want to try for a little bit, that's fine. But I wouldn't keep going until oh, I want to be natural. I want to be natural. What is natural in osido is also something that you take.

SPEAKER_03 25:54

Yeah.

SPEAKER_00 25:54

Uh letrozole or clomophene is a medication, but it's way cleaner. I know what I'm giving you, and I know that you're over it or not overlay, so it's way faster rather than prolonging it.

SPEAKER_03 26:04

Yeah. So is PCOS reversible?

SPEAKER_00 26:09

Short answer, no.

unknown 26:11

Okay.

SPEAKER_00 26:11

But the symptoms may get better or worse depending on the aggravating or improving factors.

SPEAKER_03 26:19

Okay.

SPEAKER_00 26:19

So why did I say that? I always wonder, for example, if you got PCO PCO first, and you got pregnant, what happened to the PCO appearance when you're pregnant? If you look at the ovaries, I do find that they're still there's still a lot of follicles. Okay. Now I'm the only one to look at that because I'm interested in see what happened to them. And what happened to them when they get older? They still get more. They still got more follicles, age for age, but then you also have the natural age decline in follicles. So they may not have the same complement, same number of follicles as when they were in their 20s, but age for age is still got quite more.

SPEAKER_01 27:01

Okay.

SPEAKER_00 27:02

And then the next question that I've got in mind, okay, so if that's the case, follicles produce estrogen, right? Are they going to have later menopause? Subjectively, for the patient that I've been following up, I think they do. And if you look at the other side of the story, like people have one ovary removed, do they have earlier menopause? They do. So I think again, it reflects the follicle number that you've got your menopause maybe earlier or a bit later. So I'm treating I'm still treating some uh patients who are still having uh withdrawal bleeding from progesterone. In other words, uh they have irregular or no periods. Now, in that situation, around a menopause scenario, PCOS can be similar. Because but you what you don't know is that is she not having ovulation or no periods related to ovarian uh insufficiency or failure, menopause, or she still has that reproductive access that she doesn't ovulate. So that is a group that you still have to track because if she is not menopausal, she's still producing estrogen. The estrogen may not be high, but it's enough to make the lining to proliferate. So the lining can get overactive and the cells can become abnormal, and if still not corrected and she's still producing estrogen rather than going through menopause, then she runs the risk of endometrial cancer.

SPEAKER_02 28:31

Would there be a timeline, like a if someone doesn't have a period for let's say three months, then that's where we would like start to be concerned, or would it be more of a year?

SPEAKER_00 28:41

Sure. The three months is on a one-time event or intermittently over the years. So that's a big difference. If just three months every now and then, then we just check. Uh for me, I got the two to look at endometrium correlated follicles. So the follicle, if it's enlarged, getting closer to ovulation, then the metrium got a certain pattern. But if there's no follicle, then the metrium is thick and there's no evidence of ovulation, be it from the hormones or carpus luteum seen or nervous, then yes, that one I may start worrying about for three months because that duration may be enough time for the endometrium to go into the next phase of hyperplasia. Yeah, then I would consider doing endometrial biopsy. So it's more the chronicity, how long it's been going on. It's only a one-time event, or irregular cycles interspersed with no periods, or seemingly regular cycles is not really related to ovulation. Those are the traps that we fall into.

SPEAKER_02 29:40

Yeah. A lot of people with PCOS are really, really concerned with fertility. And you mentioned something that I thought was very interesting that you were like, oh, it's actually it could be good because you have more follicles. So then if you you want to conceive that it's maybe better. Yes. Um, and I thought that was very interesting because what we see online is just PCOS is very much like linked to infertility, and a lot of women are very stressed with it. So would there be anything reassuring that you can do that?

SPEAKER_00 30:07

I have no problem because the ovaries mean that you got good endowment of photos you work with. However, having said that, then they are dependent on the subtypes, depending where they got obesity and the metabolic parameters. Those also to be good. Because otherwise, you can induce ovulation, but with with side effect complications for pregnancy, those are not good. I may be sympathetic, I'd like to help them to get pregnant, but my colleagues will criticize me. Wait a minute, why are you helping this person to get pregnant, not have to deal with uh obesity, risk during pregnancy, diabetes and control, and so forth. So you have to look at in the overall picture. So in general, jokes aside, is really to be healthy. But yes, I agree. If they got PCO, which got a good AMH level, which is a screening marker for people with uh PCOS, not one-to-one, but at least if the AMH level uh in the range that we expect it to be good, then it's a good sign, at least. But then generally speaking, if you are certain subtype, you need to improve your parameters as much as possible. So you balance age, balance your metabolic uh BMI and ovulation induction and other factors. Yeah, but I don't think they should feel that they can't get pregnant. But there may be some work that needs to be done for some some of them.

SPEAKER_02 31:31

Okay. And should they try naturally first to get pregnant and then come see a doctor?

SPEAKER_00 31:36

Or is it uh again, depending on their situation. If they routinely haven't had any periods, then I would say no, definitely no, because that needs to be dealt with because otherwise you would have thought that over the years, intermittently, you probably have a period. Right? If you routinely having three or four months without a period, that's a sign it needs to be checked to find out what's going on. That net naturally it wouldn't work because you may have other things blocking you, like uh insulin levels may not be good, glucose may not be good, and so forth. Yeah.

SPEAKER_03 32:11

So are there any other misconceptions that we haven't talked about today about PCOS that you want to address?

SPEAKER_00 32:17

Um I think not to think that they got cis is the most important thing. It's not abnormal. They're not like cis you have to be worried about having surgery.

SPEAKER_02 32:27

So now we're gonna go to our true or false section. Like a rapid fire, true or false. Yes, great. So the first one is cardio can help with weight management and hormonal balance, but strength training is not recommended because it may increase cortisol or stress levels.

SPEAKER_00 32:43

Force.

SPEAKER_02 32:44

Okay.

SPEAKER_03 32:45

Hair loss or thinning is uncommon with PCOS.

SPEAKER_00 32:49

Force with a quadifier depend on the types that I mentioned. Yes.

SPEAKER_02 32:53

Okay. Okay. PCOS always causes significant weight gain.

SPEAKER_00 32:57

Force, but again, adapted to the subtype that I mentioned.

SPEAKER_02 33:02

PCOS only affects the ovaries.

SPEAKER_00 33:05

Force.

SPEAKER_02 33:07

Birth control is a treatment for PCOS.

SPEAKER_00 33:10

True. For people with irregular psychos or contraception.

SPEAKER_03 33:14

Um people with PCOS always have ovarian cysts.

SPEAKER_02 33:20

People with PCOS who have irregular periods may be at higher risk for decreased bone density over time.

SPEAKER_00 33:27

False. Again, depending on the subtypes and the psychos. Yeah.

SPEAKER_03 33:31

Okay. And then we have a couple of questions that were directly submitted by our listeners about this what women want to know.

SPEAKER_02 33:38

Okay. Okay. Is there any specific birth control recommendation for people with PCOS?

SPEAKER_00 33:44

Yes. You pick the one with lower estrogen and the progestogen with higher anti-angigen components. Okay. So Diane is an example. Essentially it's the most hypo hypoteron acetate component that may work better. Okay.

SPEAKER_03 33:58

So maybe they can take that information to their physician. Okay. Why is fatigue a symptom of PCOS? And is there anything to help manage it?

SPEAKER_00 34:07

I don't know that can be said uniformly.

SPEAKER_03 34:11

Yeah.

SPEAKER_00 34:12

They do have inflammation for those people with metabolic syndrome, so any time when you have sort of chronic inflammatory makes you feel sort of not yourself, right?

SPEAKER_02 34:22

Okay. The last one is how often should people with PCOS follow up with their doctor? So let's say they've been diagnosed. I think a lot of people get diagnosed and then they just get out of the doctor's office and they don't know.

SPEAKER_00 34:34

Uh generally speaking, depending on the end goals. For me, the patient would be if for fertility they practically on a monthly situation, if they're not pregnant, then the question should you use the same uh uh medication, the dose, uh, or should you change it? Or at least you find out even if they overlaid it, but a cycle length would take about 40 days that you know that the dose need to be treated. So that's obvious. And then once they're pregnant, they don't see me, right? Then we've after follow up to 10 weeks, then they're they will be pregnant, then they will come back the next one. Yeah. For irregular cycles, you do need to have a follow-up to make sure they are, in fact, regulated. So if they you've done your endometrial biopsy, given her the progesterone to induce a period and start on the birth control periods, then probably it's good to follow up in a few months' time to see whether everything is on target. Then whether she's still got other metabolic concerns, if that's the case, then you can follow up with those. But people who are already on the right trajectory, they're doing the right thing, diet, exercise, and aware of the situation, and they want to just check their metabolic scenario, they're already on the birth control pills or cyclicopesterant regular cycles, then I think once a year is not a bad idea to check the metabolic screen and so forth. Yeah.

SPEAKER_02 35:55

Okay. Okay. And just a follow-up question. For people that get pregnant, let's say they have PCOS, they try naturally, they got pregnant. Is there any increased risk of pregnancy outcomes?

SPEAKER_00 36:07

Yes. Compare the general population, the typical that's a situation, hospital data or a database, let's say in the province, they'd look at people labeled with PCOS, people with uh just uh the control would be all province or the births, assuming they're all normal. You do find a the relative risk of, for example, uh preterm birth or low birth weight, pre-clampsia, hypertension, diabetes a bit higher. But be aware that relative risk means that I can say that this thing is twice the size of the other one. That's a relative risk. But the original size is very small. So twice twice the size is still very small. So the absolute risk is actually not as high as we worried about that. Oh, 100%, you shouldn't get pregnant. No. Let's say preterm birth or low birth, we may be 6% in the general population. It may become 10%, 12%, for example. But in terms of the absolute risk, it's still good. Otherwise, we say you better not get pregnant. No, I don't think so. A lot of people think that is the case and then worried about it. But it's yeah, you're talking about it's become a personal risk taking. 5% can you live with that? Your chance will become 10%. Are you okay with that? As long as the other parameters, any hypertension beforehand treated, diabetes optimized, then the risk will be just monitoring by very uh specialized specialists who know what they're doing. Okay.

SPEAKER_03 37:37

Yeah, I think that's important to compare relative risk to absolute risk. So we're not saying these people are absolutely gonna have issues. Absolutely. Maybe a slightly increased risk.

SPEAKER_01 37:45

Yeah, yeah.

SPEAKER_03 37:46

Okay. So if anyone has listened to this episode and wants to learn more about PCOS, do you have any resources that you would recommend?

SPEAKER_00 37:54

Um I just look at different sources, and the best thing is that learn about it, but don't get over worried about it. And if it's any concern, talk to your doctor. And one doctor may not have time or have a full um understanding of the area. That's okay. He or she will help you if she can work with you. So we are we are not, even though I think I'm a specialist, but I'm learning all the time. So if you give me some information, instead of being threatened, I should say, interesting, I haven't heard that before. I want to look it up and then we'll learn it together. So I think that is the way, the best way to do it because the experts or the doctor have resources that they can tap into that can help you.

SPEAKER_03 38:34

And our very last question: what is one change you hope to see in women's health in the next 10 years?

SPEAKER_00 38:40

Oh, that one that's interesting. And it's not necessarily medication or medical treatment, it's more how society views women's profession, health, resources, and so forth. So basically we are having equality, but biologically we're actually disadvantaging women from what I can see from reproduction perspective, right? Your education longer, your training longer, so that would delay your timing to starting a family. Then when you start a family, you're worried about I'm losing my rank. When you go back, how do you get into it? So if you ask you to change, I would say how as a society actually have a system that truly equal in the sense that allow women to have a baby at the right age and able to still continue the education, training, and for career without because of that, we're not gonna hire you. I love that. That is what I think is a really good one. Yes, best one. Yeah, because the pressure shouldn't be on the woman to get it all done in a timeline, it should be a societal absolutely, absolutely, because it's it's a tough thing for family building in some way. In your early 20s, it's supposed to be the best years, but that's also maturity-wise, what you want to do is also the worst years. Yeah, you haven't even seen the world, and how are you gonna do that? So, how do you balance all these things? And and I think both men and women need to understand to create a system that can be coexisting and help one another to grow that way. That's my wish. I love that. That's wrapping up on that.

SPEAKER_03 40:29

That's perfect. Well, thank you so much for joining us on the podcast today.