WEBVTT - Ep 181 PCOS: Beyond the cysts 0:00:01.240 --> 0:00:04.440 Hi, my name's logan. I'm a transgender man. I use 0:00:04.519 --> 0:00:09.160 he hymn pronouns, and I have PCOS. My symptoms first 0:00:09.240 --> 0:00:12.479 started really appearing when I hit puberty. My periods would 0:00:12.560 --> 0:00:15.680 last a week on average, and they were very heavy. 0:00:16.320 --> 0:00:18.560 The cramps would be so bad that I couldn't walk, 0:00:18.920 --> 0:00:21.680 I couldn't sleep. I would just lay awake at night 0:00:21.680 --> 0:00:26.239 in agony, despite taking pain medications. I also had very 0:00:26.280 --> 0:00:28.960 severe acne, and I had a lot of excess body 0:00:28.960 --> 0:00:32.600 and facial hair. If I didn't shave or pluck my hair, 0:00:32.720 --> 0:00:36.160 I could actually grow like this scraggly little chin beard, 0:00:36.240 --> 0:00:38.480 which was very affirming to me as a young trans 0:00:38.520 --> 0:00:42.760 masculine person. That was probably the only benefit of having 0:00:42.920 --> 0:00:47.240 PCOS was the masculinizing features. By the time I was nineteen, 0:00:47.479 --> 0:00:50.519 my periods became even more painful, if that was possible, 0:00:50.720 --> 0:00:54.280 and even more irregular. At one point, I went ten 0:00:54.320 --> 0:00:57.720 months without a period. December twenty eighteen is when I 0:00:57.760 --> 0:01:01.040 first experienced assist bursting. I was sitting in a college 0:01:01.040 --> 0:01:03.320 math final at the time, and I remember being in 0:01:03.440 --> 0:01:06.440 so much pain from my abdomen that I could barely breathe. 0:01:06.959 --> 0:01:09.480 I managed to finish the final, but I could hardly 0:01:09.560 --> 0:01:11.960 walk because of the pain, so I was rushed to 0:01:12.000 --> 0:01:15.880 the er. When we got there, I was not treated well. 0:01:16.520 --> 0:01:19.240 They started off by accusing me of faking my pain 0:01:19.280 --> 0:01:22.160 to get opioids, but soon after they thought that it 0:01:22.200 --> 0:01:26.039 could be appendicitis. I had to get blood drawn and 0:01:26.080 --> 0:01:28.920 a cat scan. They actually ended up bursting one of 0:01:28.959 --> 0:01:31.399 the veins in my arm like trying to do the 0:01:31.480 --> 0:01:33.680 die for the cat scan, so that was also not 0:01:34.080 --> 0:01:37.720 a fun experience. When the doctor finally came in to 0:01:37.720 --> 0:01:40.119 give me a diagnosis, or so I thought, all he 0:01:40.240 --> 0:01:44.080 really told me was your appendix is fine, but you 0:01:44.160 --> 0:01:47.360 have multiple cysts on both your ovaries, so just go 0:01:47.440 --> 0:01:51.280 on birth control, and then I was dismissed right after 0:01:51.520 --> 0:01:55.360 with no diagnosis. The next year that followed, I had 0:01:55.360 --> 0:01:57.680 to get a lot of blood work and scans done, 0:01:57.800 --> 0:02:00.680 but no one seemed to understand what was wrong with me. 0:02:01.400 --> 0:02:05.960 I started birth control but immediately became extremely depressed and suicidal. 0:02:07.000 --> 0:02:10.600 My body reacted so poorly that I had to quit 0:02:10.720 --> 0:02:15.079 after like a month. It was actually very terrifying how 0:02:15.120 --> 0:02:18.200 it changed my mental state. And once I stopped the 0:02:18.240 --> 0:02:21.240 birth control, I really wasn't given any other options. For treatment. 0:02:22.240 --> 0:02:24.519 At some point, a doctor pulled me to the side 0:02:24.560 --> 0:02:27.280 and said, I looked at your records and I'm going 0:02:27.320 --> 0:02:31.639 to formally diagnose you with PCOS. You have elevated testosterone, 0:02:31.680 --> 0:02:35.440 facial hair, irregular periods, and multiple cysts on both ovaries. 0:02:36.440 --> 0:02:39.079 I'll never forget her telling me that I was lucky 0:02:39.120 --> 0:02:43.480 that I had lean PCOS, which basically meant you have PCOS, 0:02:43.600 --> 0:02:47.320 but at least your skinny. Once again, I was told 0:02:47.400 --> 0:02:51.000 my only options for treatment were birth control, which did 0:02:51.040 --> 0:02:55.080 not work before, or to get pregnant. Much to my horror, 0:02:55.760 --> 0:02:58.399 By this time, I was aware that I was transgender, 0:02:58.600 --> 0:03:03.120 and I told her birth makes me suicidal, so she said, 0:03:03.120 --> 0:03:06.160 in that case, I should just go to therapy and 0:03:06.440 --> 0:03:09.919 go on a diet. I was twenty years old and 0:03:10.000 --> 0:03:13.560 one hundred and twenty five pounds at the time. Needless 0:03:13.600 --> 0:03:16.959 to say, the diet didn't help. I lived in chronic 0:03:17.040 --> 0:03:19.919 pain for the next few years, with both my physical 0:03:20.000 --> 0:03:23.400 and emotional states causing me a lot of harm. It 0:03:23.440 --> 0:03:26.440 wasn't until I decided to start testosterone for my gender 0:03:26.480 --> 0:03:30.280 dysphoria that I actually felt like myself again. As a 0:03:30.320 --> 0:03:35.240 result of taking testosterone, my period stopped. My mental state stabilized, 0:03:35.400 --> 0:03:38.440 and I was happy and pain free for the first 0:03:38.480 --> 0:03:42.120 time in a very long time. I remember bringing this 0:03:42.240 --> 0:03:45.200 up to my new doctor and her telling me some 0:03:45.440 --> 0:03:49.880 bodies just function better on different hormones. I've now been 0:03:49.920 --> 0:03:53.400 living without PCOS symptoms for the past three years, and 0:03:53.560 --> 0:03:57.560 the quality of my life has greatly improved. I'm a bioengineer, 0:03:57.640 --> 0:03:59.920 and it really breaks my heart that this is the 0:04:00.200 --> 0:04:04.160 state of medical care for people who menstraight. I experienced 0:04:04.200 --> 0:04:06.800 a lot of sexism and a lot of transphobia throughout 0:04:06.800 --> 0:04:10.360 the whole process. All the assumptions doctors made about me 0:04:10.400 --> 0:04:14.200 at the time were made through these heterosexual cisgender lenses. 0:04:14.720 --> 0:04:17.640 They assumed that I didn't want to look masculine, that 0:04:17.880 --> 0:04:21.520 I'd eventually get pregnant, and that only birth control and 0:04:21.720 --> 0:04:25.080 estrogen based pills would work for my body. But this 0:04:25.240 --> 0:04:28.240 was never the case, and I suffered so much as 0:04:28.240 --> 0:04:32.520 a result. Transgender people are often left out of these conversations, 0:04:32.560 --> 0:04:34.719 and I think it's important for people to know just 0:04:34.800 --> 0:04:37.839 how distressing it can be to have your pain and 0:04:37.920 --> 0:04:40.360 your identity dismissed by the medical field. 0:05:26.720 --> 0:05:30.640 Logan, thank you so much for sharing your story with us. 0:05:30.400 --> 0:05:36.320 It really is so meaningful and important to get to 0:05:36.440 --> 0:05:39.680 hear these stories of like what it is actually like 0:05:39.800 --> 0:05:42.560 to live with PCOS. I think, really it really helps 0:05:42.600 --> 0:05:43.040 so much. 0:05:43.320 --> 0:05:47.000 Yeah, it really provides so much context for us, for 0:05:47.080 --> 0:05:51.200 everyone listening. And thank you so much for sharing your 0:05:51.240 --> 0:05:51.840 story with us. 0:05:52.600 --> 0:05:56.320 Hi, I'm Aaron Welsh and I'm Erin Allman Updike and. 0:05:56.400 --> 0:05:58.240 This is this podcast will kill you. 0:05:58.640 --> 0:06:01.360 Welcome to PC long awaited. 0:06:01.560 --> 0:06:05.240 I feel like so long awaited. I mean, I wonder 0:06:05.480 --> 0:06:07.880 I didn't do this search, but I wonder if you 0:06:08.000 --> 0:06:11.760 like searched our email. Oh gosh, what the first suggestion 0:06:11.880 --> 0:06:13.040 for PCOS would be? 0:06:13.200 --> 0:06:16.039 It had to be years ago, and probably probably even 0:06:16.080 --> 0:06:19.160 before we did endometriosis, which was how many years ago now, 0:06:19.279 --> 0:06:19.760 long time? 0:06:19.800 --> 0:06:20.760 Twenty nineteen? 0:06:21.040 --> 0:06:21.240 Was that? 0:06:21.920 --> 0:06:26.560 No, No, I don't remember. I later, I don't remember either. 0:06:26.680 --> 0:06:28.080 It's fine, and it's been a minute. 0:06:28.160 --> 0:06:28.919 It's been a minute. 0:06:29.160 --> 0:06:32.120 And PCOS has been on our radar since then and before. 0:06:33.240 --> 0:06:39.520 And I am thrilled for this episode and also honestly 0:06:39.640 --> 0:06:43.520 embarrassed by how little I knew. When I thought that 0:06:43.680 --> 0:06:48.440 I knew, I I was diagnosed with PCOS in twenty thirteen, 0:06:49.120 --> 0:06:52.440 I remember, Yeah, and I went through all of med 0:06:52.440 --> 0:06:54.599 school and all of residency. So I thought that I 0:06:54.680 --> 0:06:57.240 had a pretty good handle on PCOS. I learned so 0:06:57.400 --> 0:06:58.320 much Aarin. 0:06:58.400 --> 0:07:02.800 Yeah, I same, same. I mean, I do not have 0:07:02.960 --> 0:07:05.960 PCOS as far as I know, But I thought I 0:07:05.960 --> 0:07:07.720 thought I was like, oh, yeah, I know what this is. 0:07:08.000 --> 0:07:10.080 Yeah, my gosh. 0:07:10.280 --> 0:07:13.240 Yeah, And so like I'm just so I think that 0:07:14.080 --> 0:07:16.800 this was a moment where I was so I'm so 0:07:16.880 --> 0:07:18.760 grateful that we get to do this podcast. 0:07:18.920 --> 0:07:21.800 Same where because part of it selfishly is like, oh 0:07:21.880 --> 0:07:24.360 I feel like I know more about this now, Like 0:07:24.480 --> 0:07:27.000 I there were I had all these misconceptions. 0:07:27.040 --> 0:07:28.960 There were things that I finally realized. But I think 0:07:29.000 --> 0:07:33.840 also like this is so many people have similar misconceptions. 0:07:33.920 --> 0:07:36.600 I know exactly, Like it's never just us. 0:07:36.480 --> 0:07:41.640 It's never just us. Yeah, so we're really excited. Yeah 0:07:41.880 --> 0:07:42.920 maybe sometimes it is. 0:07:42.880 --> 0:07:45.840 Just maybe it is just us. But in any case, 0:07:45.960 --> 0:07:49.640 in any case, I'm excited. But before we get into 0:07:49.800 --> 0:07:54.640 the full picture of PCOS, it's quarantin any time time, 0:07:54.880 --> 0:07:55.760 who are we drinking? 0:07:56.720 --> 0:08:01.600 We're drinking under revision. Those are Brackett. 0:08:03.200 --> 0:08:08.720 Watching us listening, Yes, under revision Because truly, like I 0:08:08.760 --> 0:08:13.000 feel like our our perception of this is constantly changing 0:08:13.240 --> 0:08:16.440 and needs to change in many ways to deliver better 0:08:16.520 --> 0:08:18.840 care and better empathy and awareness. 0:08:18.920 --> 0:08:22.920 So we'll get into So tell us first, are what's 0:08:23.000 --> 0:08:24.120 in under Revision. 0:08:24.640 --> 0:08:29.480 It's it's it's a place Brita version and it's so good. 0:08:29.640 --> 0:08:34.520 It's lavender syrup and lemon juice and club soda and 0:08:34.559 --> 0:08:38.320 it's like a little lavender lemona fresh and relaxing. 0:08:39.679 --> 0:08:42.320 Yeah, we'll post the full recipe on our website, This 0:08:42.400 --> 0:08:44.679 podcast will kill you dot com. We'll post a video 0:08:45.000 --> 0:08:46.400 of Aaron Welsh making it. 0:08:47.200 --> 0:08:47.760 Sorry. 0:08:47.960 --> 0:08:53.479 Yeah, we're gonna try on our social media's like Instagram 0:08:53.520 --> 0:08:56.720 and the TikTok and the Facebook, et cetera. We're on 0:08:56.760 --> 0:08:59.040 Blue Sky as well. So if you're not following us, 0:08:59.360 --> 0:09:03.320 you should consider doing that. If you haven't yet rated 0:09:03.400 --> 0:09:08.319 and reviewed and subscribed to our podcast on your favorite podcatcher, 0:09:08.600 --> 0:09:12.240 iHeart Podcasts, Apple Podcasts, Spotify, we'd love it if you 0:09:12.320 --> 0:09:14.560 do that. If you're not yet subscribed to the exactly 0:09:14.640 --> 0:09:18.200 right YouTube network channel, consider doing that. 0:09:20.400 --> 0:09:23.760 We're there just a gentle recommendation, a nudge. 0:09:23.520 --> 0:09:27.240 A nudge in the right direction, and. 0:09:27.280 --> 0:09:32.160 We have it exactly right direction. Sorry, thank you, thank you. 0:09:33.720 --> 0:09:35.880 And Finally, we have a website. It's called this podcast 0:09:35.920 --> 0:09:37.360 will Kill You dot com and on it you can 0:09:37.360 --> 0:09:40.000 find merch you can find Patreon, you can find bookshop 0:09:40.040 --> 0:09:43.040 dot org affiliate accounts, and a Goodreads list, and Bloodmobile 0:09:43.040 --> 0:09:45.600 who does our music, and all of our sources, and 0:09:46.360 --> 0:09:47.720 so much more, so much more. 0:09:49.480 --> 0:09:52.960 And that was great, and I think there's nothing else 0:09:53.000 --> 0:09:57.200 to cover except PCOS. So let's take a break and begin. 0:09:57.520 --> 0:09:58.400 Okay, can't wait. 0:10:14.960 --> 0:10:21.080 PCOS stands for polycystic ovarian syndrome, which really makes it 0:10:21.120 --> 0:10:23.200 sound like it's a disease where you have cysts on 0:10:23.200 --> 0:10:27.920 your ovaries. This should be pretty straightforward. It's not that, Arren, 0:10:28.160 --> 0:10:30.080 not that, not that. 0:10:30.080 --> 0:10:32.920 That was my misconception Number one. I was like, surely 0:10:32.960 --> 0:10:35.400 the name must be a clue as to what's going 0:10:35.440 --> 0:10:36.120 on here. 0:10:36.360 --> 0:10:38.480 Not even really a good clue at all. 0:10:38.640 --> 0:10:44.760 Actually, Yeah, what PCOS really is is an endocrine disorder, 0:10:45.360 --> 0:10:48.320 which means it's a disorder of our hormones. And not 0:10:48.559 --> 0:10:51.960 just like one or two of our hormones. No, no, 0:10:52.679 --> 0:10:54.880 today we're going to get to talk about almost all 0:10:54.920 --> 0:10:57.079 of the hormones that we use and have in our 0:10:57.120 --> 0:11:03.719 bodies and their effect on all of our body systems. Okay, Yeah, 0:11:04.360 --> 0:11:07.280 there is not a single test that we can do 0:11:07.400 --> 0:11:12.680 to diagnose PCOS, but rather there are a list of criteria, okay, 0:11:13.120 --> 0:11:15.680 and you have to fulfill two of three of these 0:11:15.720 --> 0:11:20.480 criteria to earn I guess the diagnosis of PCOS. And 0:11:20.600 --> 0:11:26.240 this list underscores some, though not all, of the possible 0:11:26.480 --> 0:11:29.560 And I'm going to put this in quotes symptoms because 0:11:29.559 --> 0:11:31.520 we're going to get into it, but some of the 0:11:31.559 --> 0:11:34.560 possible symptoms of PCOS. And so I thought that that's 0:11:34.600 --> 0:11:37.520 where we would start, is how we actually diagnose PCOS. 0:11:38.080 --> 0:11:40.480 And then we'll talk about what we know about what 0:11:40.600 --> 0:11:45.280 PCOS means in terms of the risks of various chronic diseases. 0:11:46.440 --> 0:11:49.280 And then we can get as deep or stay as 0:11:49.280 --> 0:11:51.200 shallow as you want in terms of what we know 0:11:51.360 --> 0:11:54.199 about the nitty gritty path of physiology of what's causing this. 0:11:54.480 --> 0:11:56.920 How much do we actually know about the nitty gritty 0:11:56.920 --> 0:11:58.920 of the path of physiology that's causing. 0:11:58.559 --> 0:12:02.200 This, Aaron, we know both a lot and so little. 0:12:02.559 --> 0:12:04.800 I mean, that's typical, Yeah it. 0:12:04.640 --> 0:12:06.920 Is, isn't it. And then we'll talk about how we 0:12:06.960 --> 0:12:07.320 treat it. 0:12:07.360 --> 0:12:09.440 And my goal is to do this in twenty minutes, 0:12:09.480 --> 0:12:10.600 so we'll see if that's gonna happen. 0:12:10.640 --> 0:12:13.680 I think, ah, it won't. It's quite a lofty goal. 0:12:14.040 --> 0:12:14.360 I know. 0:12:15.280 --> 0:12:18.400 You should see all the words on a page. So 0:12:18.480 --> 0:12:22.440 there has been fluctuation over the years over these diagnostic criteria, 0:12:22.480 --> 0:12:25.080 but at this point there's pretty well established guidelines on 0:12:25.120 --> 0:12:28.040 how we diagnose PCOS. So to make this diagnosis, you 0:12:28.080 --> 0:12:32.319 need two out of three of the following criteria. One 0:12:32.640 --> 0:12:35.440 is hyperandrogenism, and we'll talk about what that means. And 0:12:35.480 --> 0:12:38.400 this can be either clinical so symptoms that you can 0:12:38.480 --> 0:12:42.480 see on a person or biochemical, so looking at lab tests, 0:12:43.600 --> 0:12:46.560 you have to have a ligomenorreea or a menorrhea so 0:12:46.960 --> 0:12:50.480 few periods or not having any periods at all, and 0:12:50.880 --> 0:12:54.600 polycystic ovarian morphology. So you need two out of three 0:12:54.640 --> 0:12:57.600 of those. So let's talk about what those actually mean, 0:12:57.840 --> 0:13:01.800 like what they would look like right right, English. So, 0:13:02.000 --> 0:13:06.160 hyper androgenism means an elevated amount of androgens, which are 0:13:06.320 --> 0:13:10.400 steroid hormones. We often think of testosterone, and testosterone is 0:13:10.480 --> 0:13:13.360 one of the androgens, but there's a lot of others, 0:13:14.520 --> 0:13:18.560 DHA andristino, dione, there's a whole bunch, okay, and so 0:13:18.720 --> 0:13:22.400 you can determine whether a person has what is considered 0:13:22.520 --> 0:13:27.360 hyper androgenism by measuring the levels of those hormones in 0:13:27.400 --> 0:13:31.120 a person and comparing that to what we see in 0:13:31.200 --> 0:13:34.480 typical females. And this is again we're talking about people 0:13:34.480 --> 0:13:38.840 with ovaries here, and that is entirely the focus of 0:13:39.080 --> 0:13:40.600 PCOS at this point. 0:13:41.400 --> 0:13:42.439 Asterix abound. 0:13:44.320 --> 0:13:48.600 Quick question. Okay, when you are let's say you are 0:13:48.640 --> 0:13:52.120 being tested for these hormone levels, what does that test involve? 0:13:53.160 --> 0:13:55.400 Those are If you're testing for hormone levels, it's going 0:13:55.440 --> 0:13:58.480 to be blood tests. What exact hormones people are going 0:13:58.520 --> 0:14:00.680 to test for can vary depending on who is doing 0:14:00.720 --> 0:14:04.000 that test. One of the important things is to make 0:14:04.040 --> 0:14:06.720 sure that you're doing enough testing to rule out other 0:14:07.440 --> 0:14:11.959 androgenic disorders. Because your adrenals produce androgens. There's other like 0:14:12.200 --> 0:14:14.320 known disorders where we know, like, oh, you have a 0:14:14.360 --> 0:14:17.800 deficiency in say this enzyme that produces a specific clinical 0:14:17.840 --> 0:14:21.520 syndrome that's different than PCOS. Okay, and so you have 0:14:21.600 --> 0:14:23.680 to do enough of the blood tests to make sure 0:14:23.680 --> 0:14:25.680 that you're ruling out these other things. And then if 0:14:25.720 --> 0:14:30.280 you see still an increase in androgens, and again this 0:14:30.360 --> 0:14:32.920 is already where we can get some variation, because you 0:14:33.040 --> 0:14:36.200 might have an increase, you might not have an increase. 0:14:36.240 --> 0:14:39.120 But this is just one possible criteria, and you can 0:14:39.160 --> 0:14:40.600 look at a number of different androgens. 0:14:40.640 --> 0:14:43.720 So that's one. I already have so many questions. I know, Okay, 0:14:43.760 --> 0:14:46.440 so that like where it where? What is the source 0:14:46.520 --> 0:14:48.720 of the excess androgens? 0:14:50.280 --> 0:14:54.640 You're jumping so far ahead? Okay, Okay, there, we'll get there. 0:14:54.720 --> 0:14:55.400 We'll get there. 0:14:56.760 --> 0:14:59.720 Ultimately, the main source of the extrass androgens is the 0:14:59.760 --> 0:15:06.160 over but the question of why is yeah, okay, but 0:15:06.240 --> 0:15:09.440 ultimately the ovaries are producing excess androgens. 0:15:09.560 --> 0:15:12.360 And I just I swear two more quick questions because 0:15:12.360 --> 0:15:15.600 I'm trying to get a sense of what elevated means. Yeah, 0:15:15.640 --> 0:15:19.600 so is this how how much do hormones fluctuate during 0:15:19.680 --> 0:15:21.840 the day, during the range, during the year, et cetera. 0:15:22.240 --> 0:15:27.280 And so then how much is excess? How is excess determined? 0:15:27.400 --> 0:15:29.800 Or like how is greater than average determined? What's is 0:15:29.800 --> 0:15:31.920 there a standard deviation? Like what's the vibe? 0:15:32.160 --> 0:15:33.360 This is a great question here. 0:15:33.760 --> 0:15:37.400 There's not like a number cut off necessarily, So every 0:15:37.520 --> 0:15:40.800 lab that you do a lab test at is going 0:15:40.840 --> 0:15:43.280 to have there. What is called like normal range or 0:15:43.280 --> 0:15:47.640 typical range, and for hormones like testosterone or DHA or 0:15:47.760 --> 0:15:50.400 estrogen or progesterone or any of those, they're going to 0:15:50.440 --> 0:15:52.160 have a normal range for females and they're going to 0:15:52.200 --> 0:15:54.840 have a normal range for males. And so if it 0:15:54.960 --> 0:15:59.240 is higher than that normal range for females, then that 0:15:59.280 --> 0:16:01.920 would be consideredhyperandrogenism. And that could be if you're looking 0:16:01.960 --> 0:16:04.360 at free or total testosterone, or it could be one 0:16:04.400 --> 0:16:08.640 of these other hormones. I don't have like exact numbers, 0:16:08.680 --> 0:16:11.040 and you're right that it can vary day to day. 0:16:11.080 --> 0:16:13.000 It can vary during the time of day as well, 0:16:13.640 --> 0:16:17.720 So again this can get quite complicated. Okay, it doesn't 0:16:17.760 --> 0:16:20.400 have to be bio It's okay, don't all. I love 0:16:20.440 --> 0:16:24.720 your questions. It does not have to be biochemical evidence, though. 0:16:24.720 --> 0:16:29.720 We also can see what's considered clinical evidence of hyper androgenism, 0:16:29.800 --> 0:16:32.400 and that usually there's three main things that we think of. 0:16:33.120 --> 0:16:37.840 Acne usually more severe acne, sometimes cystic acne but not necessarily, 0:16:38.680 --> 0:16:45.640 androgenic alopecia aka scalpel like male pattern hair loss, and hersitism, 0:16:45.960 --> 0:16:47.840 which I always have to look up how to pronounce 0:16:47.880 --> 0:16:48.360 because I'm. 0:16:48.280 --> 0:16:50.400 Glad that you said that first, because I would have 0:16:50.400 --> 0:16:51.080 gotten it wrong. 0:16:51.640 --> 0:16:56.760 Hersaitism, which is hair growth like coarse, thick hair growth 0:16:57.200 --> 0:17:00.840 that specifically grows to longer than five millim so not 0:17:00.960 --> 0:17:05.439 just tiny tiny little hairs in androgen dependent areas, So 0:17:05.480 --> 0:17:07.680 that means places like the under arms, the pubic area, 0:17:07.760 --> 0:17:10.879 the face. And this is a kind of tricky one 0:17:10.920 --> 0:17:14.840 because there's a grading scale that in theory one should 0:17:14.920 --> 0:17:17.959 use to determine how much would be considered excess or 0:17:18.320 --> 0:17:22.359 like hersaitisms truly, and there's also going to be like 0:17:22.480 --> 0:17:26.600 racial and ethnic variation in hair patterns to begin with, 0:17:27.080 --> 0:17:31.320 but that is also one of the possible clinical criteria. 0:17:31.520 --> 0:17:34.800 So that's all just hyperandrogenism. That's one thing that someone 0:17:34.880 --> 0:17:38.399 might have to put them on this list of possible pcos. 0:17:39.000 --> 0:17:42.760 The second is ovulatory dysfunction, which means people either aren't 0:17:42.840 --> 0:17:46.639 ovulating at all and then therefore they're not having any menses, 0:17:47.880 --> 0:17:51.440 or they're ovulating infrequently or irregularly, and so they're having 0:17:51.520 --> 0:17:57.119 very infrequent or irregular menstrual cycles. Exactly how infrequent or 0:17:57.160 --> 0:17:59.080 like how far apart they have to be or how 0:17:59.119 --> 0:18:02.000 irregular depends in part on how far you are from 0:18:02.040 --> 0:18:06.040 menarch or that first menstrual period, because it's quite typical 0:18:06.119 --> 0:18:09.679 in the first few years to have irregular menstrual cycles. Okay, 0:18:10.280 --> 0:18:13.000 but if you are more than three years after your 0:18:13.000 --> 0:18:16.200 first menstrual cycle, than anything less than eight per year 0:18:16.480 --> 0:18:18.840 or greater than thirty five days apart would be considered 0:18:18.880 --> 0:18:24.840 a ligomin arehea or having few menstrual cycles. But that's again, 0:18:24.960 --> 0:18:28.719 so that's that's one, so ovulatory dysfunction. And then the 0:18:28.760 --> 0:18:32.879 third and final is polycystic ovarian morphology, which does not 0:18:33.240 --> 0:18:35.679 really mean that you have a bunch of cysts on 0:18:35.720 --> 0:18:39.320 your ovaries, but means that if you look on ultrasound 0:18:39.480 --> 0:18:42.400 in the ovaries, you see a bunch of and by 0:18:42.440 --> 0:18:46.240 a bunch, I mean twenty or more visible follicles that 0:18:46.280 --> 0:18:50.040 are arrested in an early stage of development, so we're 0:18:50.080 --> 0:18:53.800 born in with all, if you have ovaries, your ovaries 0:18:53.840 --> 0:18:56.120 have as many eggs in there as they're going to have. 0:18:56.720 --> 0:19:01.399 And typically, in response to these hormone cycles, every month, 0:19:01.880 --> 0:19:05.240 one like multiple follicles start to mature, but then one 0:19:05.359 --> 0:19:09.560 takes over matures completely and then is released during ovulation. 0:19:10.480 --> 0:19:14.720 And what happens in PCOS is that multiple follicles start 0:19:14.800 --> 0:19:18.240 to grow and then grow to a certain point, but 0:19:18.320 --> 0:19:22.200 then are arrested in their development without ever having one 0:19:22.600 --> 0:19:25.000 that takes over and is released, which is why you 0:19:25.119 --> 0:19:28.800 have a lego or a menoreea because you're not ovulating. 0:19:28.880 --> 0:19:31.800 And then it's also why you have so many of 0:19:31.840 --> 0:19:34.840 these kind of follicles that are arrested at a stage 0:19:34.840 --> 0:19:37.480 in development, that is, before they get to ovulation. 0:19:37.640 --> 0:19:39.560 Okay, So you've got a bunch of these like not 0:19:39.720 --> 0:19:45.960 fully uh developed, developed follicle matured follicles just hanging out 0:19:45.960 --> 0:19:49.520 at the ovary and causing like little grape clusters. 0:19:49.680 --> 0:19:51.560 Yeah, they look like little grape clusters. Okay. 0:19:51.840 --> 0:19:55.040 Sometimes on ultrasound you might not see specific follicles, but 0:19:55.080 --> 0:19:57.760 you would have an overall larger volume, like greater than 0:19:57.760 --> 0:20:02.000 ten millimeters volume without having one dominant follicle, because if 0:20:02.040 --> 0:20:04.840 you have just one that's burst or ready for ovulation, 0:20:04.960 --> 0:20:06.520 that you can get quite large large. 0:20:06.520 --> 0:20:07.320 Okay, Okay. 0:20:08.000 --> 0:20:10.560 Now, one thing that's new in the most recent guidelines 0:20:10.600 --> 0:20:12.840 from twenty twenty three is that you don't necessarily have 0:20:12.920 --> 0:20:15.760 to do an ultrasound to look for those polycystic ovaries. 0:20:15.800 --> 0:20:20.520 You also could diagnose polycystic ovarian morphology by looking at AMH, 0:20:20.680 --> 0:20:23.159 which is another hormone that you would check via a 0:20:23.160 --> 0:20:26.160 blood test that we've talked about I think in our 0:20:26.240 --> 0:20:30.639 infertility episodes or n menopause. Not sure, Yeah, I know 0:20:30.680 --> 0:20:33.159 we mentioned it in menopause as well, But this is 0:20:33.200 --> 0:20:37.280 a hormone that relates to like how many follicles are 0:20:37.359 --> 0:20:40.479 still in existence in your ovary kind kind of a thing, 0:20:41.800 --> 0:20:45.800 and having an elevated level of AMH is suggestive of PCOS. 0:20:45.800 --> 0:20:48.760 But again here there's not like an exact cutoff value 0:20:48.880 --> 0:20:51.240 yet for this, which is interesting in and of itself. 0:20:52.960 --> 0:20:54.679 So that's how we diagnose it. You got to have 0:20:54.680 --> 0:20:55.520 two out of those. 0:20:55.359 --> 0:21:03.160 Three, Okay, so either you have this hyperandrogenism infrequent or 0:21:03.560 --> 0:21:04.840 no periods. 0:21:06.400 --> 0:21:10.159 And polycystic Yeah, psychology, Yeah, in the name, yeah, in 0:21:10.200 --> 0:21:10.480 the name. 0:21:10.640 --> 0:21:11.760 I was like, what's the third? 0:21:12.880 --> 0:21:15.639 And so because there are these three different criteria and 0:21:15.640 --> 0:21:18.840 you only need two out of three to have a diagnosis, 0:21:18.920 --> 0:21:23.480 it leads to four different what are called phenotypes of PCOS. 0:21:24.440 --> 0:21:26.920 So one of the options is that you have all three, 0:21:27.000 --> 0:21:29.200 You meet all three of these criteria, and that would 0:21:29.200 --> 0:21:32.760 be called phenotype A. The second option is that you 0:21:32.960 --> 0:21:37.400 have evidence of hyper androgenism and evidence of ovulatory dysfunction 0:21:38.119 --> 0:21:40.440 without having polycystic ovaries. 0:21:40.960 --> 0:21:41.679 We'll call them. 0:21:41.560 --> 0:21:45.080 Polycystic ovaries, they're not sis, and that would be phenotype B, 0:21:46.200 --> 0:21:50.600 and those two together are called classic PCOS, and they 0:21:50.640 --> 0:21:53.920 account for an estimated two thirds of people with PCOS. 0:21:54.080 --> 0:21:56.880 So two thirds of people with PCOS will have evidence 0:21:56.920 --> 0:22:02.359 of hyper androgenism either clinical or online tests, and they'll 0:22:02.359 --> 0:22:07.040 have ovulatory dysfunction with or without having polycystic ovarian morphology 0:22:07.040 --> 0:22:11.639 on ultrasound. The third phenotype phenotype C, someone will have 0:22:11.840 --> 0:22:17.680 hyper androgenism and on ultrasound polycystic ovarian morphology, but without 0:22:17.720 --> 0:22:21.240 necessarily having any issues in terms of their ovulation, so 0:22:21.359 --> 0:22:27.200 not having aligomin area. And then phenotype D is ovulatory 0:22:27.280 --> 0:22:32.680 dysfunction and polycystic ovarian morphology but no evidence of hyper androgenism. 0:22:33.560 --> 0:22:38.560 All right, Okay, Okay, why it's a great question. 0:22:38.800 --> 0:22:42.520 Okay, So just looking at all of those that there's 0:22:42.520 --> 0:22:44.840 a there's a y question, and then there's a huge 0:22:44.960 --> 0:22:49.760 part that's missing already, okay in these diagnostic criteria, because 0:22:49.800 --> 0:22:52.600 those criteria give us a lot of insight into some 0:22:52.680 --> 0:22:56.200 of the symptoms as well as some of the consequences 0:22:56.320 --> 0:23:00.879 of PCOS. Right, So, an ovulation, which can happen very 0:23:00.920 --> 0:23:04.840 commonly in PCOS, can result in infertility or reduced fertility, 0:23:05.520 --> 0:23:08.960 and PCOS is the major cause is estimated to be 0:23:09.000 --> 0:23:12.320 like the number one cause of an ovulatory infertility. So 0:23:12.359 --> 0:23:15.120 if you're not ovulating and you can't get pregnant when 0:23:15.119 --> 0:23:17.720 you want to be pregnant, PCOS is the number one 0:23:17.760 --> 0:23:22.800 cause of that. In addition, this an ovulation also leads 0:23:22.880 --> 0:23:26.600 to an increased risk of endometrial cancer down the line. 0:23:27.040 --> 0:23:30.680 And that's because your uterus, because of the hormones that 0:23:30.720 --> 0:23:35.000 are floating around, is out here like getting ready to 0:23:35.320 --> 0:23:38.000 have an egg implant. It's getting ready, it's getting ready, 0:23:38.000 --> 0:23:41.159 it's getting ready. That egg never comes. You never menstrate. 0:23:42.119 --> 0:23:45.920 Your uterus lining is proliferating this whole time, and that 0:23:46.000 --> 0:23:51.200 proliferation increases the risk of cancer in this continually proliferating tissue. Okay, 0:23:52.480 --> 0:23:56.199 the hyperandrogenism that we see in PCOS that we can 0:23:56.280 --> 0:24:00.040 see may or may not be associated with symptoms that 0:24:00.119 --> 0:24:03.679 are undesirable, right, It depends on someone's perception of what 0:24:03.720 --> 0:24:07.280 those symptoms are. Male pattern hair growth or hair loss 0:24:07.400 --> 0:24:09.760 may or may not be something that is distressing to 0:24:09.800 --> 0:24:15.320 someone acne. Most people are not a fan of acne. 0:24:15.600 --> 0:24:18.320 But this, all of. 0:24:18.280 --> 0:24:23.600 These definitions are missing one of the huge, very clear, 0:24:24.000 --> 0:24:28.560 well defined major factors of PCOS, and that is its 0:24:28.600 --> 0:24:36.239 relationship to insulin resistance. Yeah, so insulin resistance leads to 0:24:36.600 --> 0:24:41.600 glucose intolerance, and that puts people at risk for type 0:24:41.640 --> 0:24:45.400 two diabetes as well as a whole bunch of other 0:24:45.480 --> 0:24:50.680 metabolic complications hyperlipidemia. So having elevated cholesterol levels, that puts 0:24:50.680 --> 0:24:53.439 you at risk for cardiovascular disease, It puts you at 0:24:53.520 --> 0:24:57.960 risk for hypertension, and so much more. And PCOS also 0:24:58.000 --> 0:25:01.320 gets quite a lot of attention as it relates to obesity, 0:25:01.560 --> 0:25:06.240 which I always put in quotes because obesity is it's 0:25:06.359 --> 0:25:09.520 considered a disease in medicine that is defined entirely based 0:25:09.560 --> 0:25:14.880 on BMI, and BMI is not an indicator of health. Right, 0:25:15.520 --> 0:25:20.240 Elevated BMI is associated with PCOS, but whether this is 0:25:20.440 --> 0:25:24.120 cause or consequence is very much still up for debate. 0:25:23.960 --> 0:25:26.359 Which I feel like is a lot of some of 0:25:26.400 --> 0:25:33.200 the symptoms associated or that are prevalent with PCOS. So consequence, yeah. 0:25:32.920 --> 0:25:35.520 Yeah, but all of these and here's what's really important 0:25:35.520 --> 0:25:38.280 about that is that all these other symptoms, and there 0:25:38.320 --> 0:25:41.280 are a lot so like increased risk of insulin resistance, 0:25:41.520 --> 0:25:45.480 risk for type two diabetes, risk for hyperlipidemia. Even people 0:25:45.480 --> 0:25:48.639 who have PCOS are also at an increased risk for 0:25:48.680 --> 0:25:49.920 obstructive sleep apnea. 0:25:50.800 --> 0:25:51.320 We don't know the. 0:25:51.320 --> 0:25:56.800 Mechanism there, but all of those risks increase regardless of BMI. 0:25:57.440 --> 0:26:03.080 They exist regardless of BMI. We know that, or we think, 0:26:03.280 --> 0:26:05.040 at least from the data that we have so far, 0:26:05.080 --> 0:26:07.560 which is mostly in mouse models, that PCOS might be 0:26:07.600 --> 0:26:11.320 related to changes in adipose tissue, like the way that 0:26:11.320 --> 0:26:15.679 your adipose tissue responds to insulin or things like that, 0:26:15.880 --> 0:26:18.639 and have how it like uptakes glucose and things like that. 0:26:19.680 --> 0:26:24.960 But all of the other complications and metabolic complications in 0:26:25.080 --> 0:26:31.000 PCOS are prevalent regardless of BMI, and in like BMI 0:26:31.160 --> 0:26:36.439 matched case control studies, they are elevated in PCOS regardless 0:26:36.480 --> 0:26:41.880 of BMI, just like in people without pcos in some cases, 0:26:41.920 --> 0:26:44.720 and elevated BMI can also put you at higher risk 0:26:44.760 --> 0:26:47.119 for some of these other metabolic complications. So again, what 0:26:47.240 --> 0:26:48.720 is the cause and what is the consequence? 0:26:48.760 --> 0:26:49.239 We don't know. 0:26:50.080 --> 0:26:52.960 What we do know, and what is prevalent enough that 0:26:53.040 --> 0:26:55.800 it has made it into the twenty twenty three guidelines. 0:26:55.960 --> 0:26:59.480 Is the very real problem of fat shaming that happens 0:26:59.520 --> 0:27:03.800 in PCO and weight stigma, like enough so that the 0:27:04.000 --> 0:27:07.679 awareness of this fat shaming and stigma is in the 0:27:07.680 --> 0:27:10.000 PCOS guidelines of Like you need to be aware of 0:27:10.040 --> 0:27:12.480 this if you're a clinician and not do it. Yeah, 0:27:15.080 --> 0:27:21.160 but like you said, we do not know exactly how 0:27:21.560 --> 0:27:25.880 this metabolic dysfunction happens at the beginning, Like what are 0:27:26.200 --> 0:27:28.800 the core causes of it? 0:27:29.320 --> 0:27:35.640 And how does how do other hormones play into this? Oh, 0:27:35.640 --> 0:27:39.680 my gosh, Aaron, what's what's what's the timeline? The sequence? 0:27:40.480 --> 0:27:42.399 The cascade is a by. 0:27:42.320 --> 0:27:44.639 Step If I could tell you a step by step cascade, 0:27:44.680 --> 0:27:46.359 I would have a lot more clarity as to what 0:27:46.400 --> 0:27:48.520 the heck is going on. But I can give you 0:27:48.600 --> 0:27:53.359 some more detail, Okay, to kind of understand a lot 0:27:53.440 --> 0:27:57.240 of what's going on in PCOS. We can first understand 0:27:57.320 --> 0:28:01.480 what's called our HPO axis. This is our hypothalamic pituitary 0:28:01.560 --> 0:28:04.879 ovarian axis or gonadal access because you have one if 0:28:04.880 --> 0:28:10.160 you have testies too, so in your hypothalamus you are 0:28:10.160 --> 0:28:13.960 releasing hormones there's a part in your brain you're releasing hormones. 0:28:14.800 --> 0:28:18.040 The one that is important in PCOS is called gnatotropin 0:28:18.119 --> 0:28:21.080 releasing hormone, and it is. 0:28:21.000 --> 0:28:23.040 Being pulsed out. It is normal. 0:28:23.040 --> 0:28:24.560 It is typical in our brains that it's not being 0:28:24.600 --> 0:28:27.400 released all the time, but we pulse it out in phases. 0:28:27.440 --> 0:28:29.440 Your brain is like, yep, give a little bit, Yep, 0:28:29.480 --> 0:28:32.399 give a little bit. Its job is to travel to 0:28:32.480 --> 0:28:36.000 our petuitary and tell our petuitary, which is another part 0:28:36.000 --> 0:28:40.479 of our brain, to secrete other hormones lutinizing hormone LH 0:28:40.960 --> 0:28:44.560 and follical stimulating hormone FSH. We've talked about these in 0:28:44.560 --> 0:28:48.120 our infertility our pregnancy episodes. These two hormones job is 0:28:48.160 --> 0:28:51.200 to travel through our bloodstream, go to our ovaries and 0:28:51.360 --> 0:28:56.760 modulate the production of estrogen and progesterone and make our 0:28:56.840 --> 0:29:03.680 ovaries mature one follicle release it and ovulate. Right, this 0:29:03.760 --> 0:29:08.160 whole system, our HPO axis works on a system of 0:29:08.280 --> 0:29:12.040 both positive and negative feedback loops. Right, So one part 0:29:12.080 --> 0:29:14.000 of our brain tells another part of our brain tells 0:29:14.000 --> 0:29:17.400 our ovaries, and those hormones go back to our brain 0:29:17.440 --> 0:29:19.560 and they're like, hey, we're here, so calm down. 0:29:19.520 --> 0:29:21.040 Right, yeah, yeah, yeah. 0:29:21.080 --> 0:29:26.280 In PCOS, there is a wrench in this system. What 0:29:26.720 --> 0:29:32.720 exactly the first wrench is we don't know. So we 0:29:32.920 --> 0:29:38.760 know that the pulsatility of this gnatotropin releasing hormone GnRH 0:29:39.160 --> 0:29:42.720 in PCOS is increased, so we see more and more 0:29:42.760 --> 0:29:48.320 frequent pulsatility of GnRH from our hypothalamus. What that does 0:29:48.440 --> 0:29:51.160 is it tells our pituitary ooh, keep going, keep going, 0:29:51.200 --> 0:29:53.960 keep going, and actually leads to a disruption in the 0:29:54.280 --> 0:29:56.320 LH versus FSH ratios. 0:29:56.520 --> 0:29:57.280 Oh. 0:29:57.320 --> 0:30:00.560 And so instead of like it being okay, now ovulate, 0:30:00.640 --> 0:30:03.600 it's like, oh maybe maybe maybe maybe it's just like 0:30:03.880 --> 0:30:05.560 less of a strong message. 0:30:05.800 --> 0:30:09.200 Yeah, And the message is like mature, mature, mature, mature, mature, mature, 0:30:09.600 --> 0:30:11.800 A bunch of follicles, bunch of follicals. But no, there's 0:30:11.840 --> 0:30:15.800 no ovulation, there's no release, there's no release signal. Right, 0:30:15.880 --> 0:30:17.719 And that because that LAH is then going to our 0:30:17.760 --> 0:30:21.360 ovaries and it's being like make make make androgens, make androgens, 0:30:21.400 --> 0:30:25.320 make adrogens, then there's also something else going on because 0:30:25.360 --> 0:30:30.160 that hyper agigen secretion should negative feedback onto our hypothalamus 0:30:30.200 --> 0:30:34.200 and be like hey stop, but that negative feedback is impaired. 0:30:35.240 --> 0:30:38.000 We don't exactly know why. Hmmm. 0:30:39.360 --> 0:30:42.920 Then okay, here's where it gets even more complicated erin Okay, okay, 0:30:43.320 --> 0:30:45.520 where does insulin resistance play into this? 0:30:45.720 --> 0:30:47.040 That's what I'm trying to figure out. 0:30:47.360 --> 0:30:53.160 We know, yeah, that insulin resistance tissue level. Insulin resistance 0:30:53.800 --> 0:30:58.600 leads to an increase in insulin production, right, because if 0:30:58.640 --> 0:31:03.080 your body is trying to red glucose, insulin is in 0:31:03.160 --> 0:31:07.640 charge of that. And if your tissues aren't responding to insulin, 0:31:07.720 --> 0:31:09.960 insulin is binding through the receptors it's supposed to, but 0:31:10.000 --> 0:31:13.880 it's not doing its job, so you can't collect that glucose. 0:31:14.680 --> 0:31:16.920 Then your body's going to make more insulin because it's like, hey, 0:31:16.960 --> 0:31:19.280 there's too much glucose floating around. We need more insulin, 0:31:19.320 --> 0:31:24.280 more insulin, more insulin. That hyper insulinemia feeds back onto 0:31:24.320 --> 0:31:27.840 the ovaries and tells them, by a reason I don't understand, 0:31:27.880 --> 0:31:29.520 to make more androgens. 0:31:31.360 --> 0:31:36.080 Okay, I mean, okay, but no, I don't understand exactly. 0:31:36.320 --> 0:31:38.160 No, we don't know why. 0:31:38.840 --> 0:31:41.840 So in short, we know that all of these feedback 0:31:41.840 --> 0:31:44.480 loops are sort of not working the way that they 0:31:44.480 --> 0:31:45.600 would directly. 0:31:45.520 --> 0:31:46.160 In some way. 0:31:46.360 --> 0:31:48.120 Yeah, there's more. 0:31:48.040 --> 0:31:49.640 And more evidence because we used to think like, oh, 0:31:49.640 --> 0:31:51.959 it's just the ovaries, and there's some evidence in like 0:31:52.040 --> 0:31:54.680 mice and rats that like disruption at the level of 0:31:54.720 --> 0:31:58.280 the ovary, just like a tendency to excess androgen secretion 0:31:58.400 --> 0:32:04.240 to begin with, can produce things like polycystic ovarian morphology. Okay, 0:32:04.400 --> 0:32:06.600 but it again doesn't account for the lack of this 0:32:06.720 --> 0:32:10.800 negative feedback loop. It doesn't necessarily account for this insulin 0:32:10.880 --> 0:32:13.680 resistance piece of it. So there's more evidence that these 0:32:13.720 --> 0:32:17.160 other groups of hormones that act more in our brains 0:32:17.840 --> 0:32:22.040 called kiss peptins and other like other types of hormones 0:32:22.040 --> 0:32:25.520 as well are likely involved. So I guess the point 0:32:25.520 --> 0:32:27.280 of all of this is to say, a number one 0:32:27.280 --> 0:32:28.680 it's complicated. 0:32:28.360 --> 0:32:30.320 Yeah, and b number one. 0:32:31.160 --> 0:32:33.680 While we know a lot number two or be number 0:32:33.680 --> 0:32:40.000 one whatever, A number one, it's complicated, be number two. 0:32:42.560 --> 0:32:46.880 We know a lot about the features of these disruptions 0:32:47.760 --> 0:32:53.080 increase GnRH pulsatility, increased androgens, insulin resistance leading to more 0:32:53.080 --> 0:32:56.760 increased androgens. We also see like a decrease insects hormone 0:32:56.800 --> 0:32:59.560 binding globulin because of these androgens. So like there's all 0:32:59.600 --> 0:33:02.120 these feed back loops that are very well documented and 0:33:02.200 --> 0:33:05.040 drawn in all these papers, But we do not know 0:33:05.640 --> 0:33:11.880 what the first underlying issue really is, right, which means 0:33:11.880 --> 0:33:14.880 that all of our treatments that we have are addressing 0:33:15.040 --> 0:33:19.239 individual parts of the issue but not coming close to 0:33:19.320 --> 0:33:24.720 like curing anything or really getting to like one drug 0:33:24.960 --> 0:33:29.000 or one mechanism fixing this cascade. So do we think 0:33:29.040 --> 0:33:32.800 that it is one mechanism? That is an excellent question. 0:33:33.160 --> 0:33:38.640 Arin no idea, Okay, especially because when you think of 0:33:39.040 --> 0:33:41.520 all of these different phenotypes, right, I said that there 0:33:41.520 --> 0:33:44.720 are four different phenotypes. They also are associated with like 0:33:44.800 --> 0:33:49.600 differential risk in things like insulin resistance. Okay, So types 0:33:49.640 --> 0:33:54.680 A and B that like classic PCOS picture, something like 0:33:54.760 --> 0:33:57.880 eighty percent of people with this phenotype will have evidence 0:33:57.920 --> 0:34:00.400 of insulin resistance and therefore might be at high risk 0:34:00.480 --> 0:34:04.640 of things like diabetes. Phenotypes C we see still a 0:34:04.680 --> 0:34:08.160 significantly increased insulin resistance, but like sixty percent compared to 0:34:08.280 --> 0:34:11.719 eighty percent. And in phenotype D, which is the one 0:34:11.880 --> 0:34:15.840 where people have no clinical hyperandrogenism, about forty percent of 0:34:15.840 --> 0:34:18.920 them we see insulin resistance. But in all of these 0:34:19.400 --> 0:34:22.839 the incidence of type two diabetes and is like four 0:34:22.880 --> 0:34:25.919 times higher in people with PCOS compared to people without 0:34:25.960 --> 0:34:30.840 PCOS regardless of BMI. Huh, though that incidence does increase 0:34:30.880 --> 0:34:31.880 with increasing BMI. 0:34:32.880 --> 0:34:33.360 Okay. 0:34:33.480 --> 0:34:41.480 And so basically, the the outcome of this like domino 0:34:41.960 --> 0:34:45.720 like the path that the dominoes take. It might be different, 0:34:46.200 --> 0:34:48.560 just but we don't know why it might be different. 0:34:48.560 --> 0:34:51.560 But that's what results in these different phenotypes. But the 0:34:51.680 --> 0:34:55.240 end result for the most part is similar in terms 0:34:55.280 --> 0:34:57.000 of health consequences. 0:34:57.360 --> 0:35:00.400 I mean it is similar. It is not exact actually 0:35:00.400 --> 0:35:04.040 the same. It is similar, and then it's also like 0:35:04.440 --> 0:35:08.239 not exactly the same in terms of even those initial dominoes, right, 0:35:08.239 --> 0:35:11.000 because in some people we see this hyperandrogenism and in 0:35:11.120 --> 0:35:14.440 some we don't, but we still call it PCOS. Is 0:35:14.440 --> 0:35:17.040 that really the same disease or not? Is? 0:35:17.360 --> 0:35:18.080 Yeah? Is it? 0:35:18.440 --> 0:35:22.040 We don't know right now, We really don't know. We 0:35:22.080 --> 0:35:24.640 don't because we also don't know like what actually causes 0:35:24.680 --> 0:35:29.400 pcos R. Right. It's very strongly genetic. There is a 0:35:29.440 --> 0:35:34.359 big heritability component. It's like seventy percent heritable. Yeah, And 0:35:34.520 --> 0:35:38.759 that's not necessarily all strictly genetic. There's like at least 0:35:38.760 --> 0:35:41.719 twenty different gene losi in different populations. There's not one 0:35:41.719 --> 0:35:45.480 single gene, but there's also evidence of like epigenetic changes 0:35:46.160 --> 0:35:48.120 that we don't really know what is the trigger for 0:35:48.160 --> 0:35:51.000 these changes. But there's likely some epigenetic things that are 0:35:51.040 --> 0:35:56.319 involved in the like increased risk of PCOS, and then 0:35:56.360 --> 0:35:58.600 there's likely other environmental factors at play that we don't 0:35:58.640 --> 0:36:02.200 really understand. Right, what are all of these other triggers? 0:36:01.680 --> 0:36:04.120 I'm going to say it here because I didn't put 0:36:04.160 --> 0:36:07.680 any of this in my notes, but I didn't want 0:36:07.719 --> 0:36:09.799 to get into the evolutionary There are like a lot 0:36:09.840 --> 0:36:13.520 of different papers I read about the evolutionary origins of 0:36:13.680 --> 0:36:19.799 PCOS as proposed by certain researchers, and it is And 0:36:19.880 --> 0:36:22.719 I was like, ultimately, we don't understand what PCOS is, 0:36:22.880 --> 0:36:26.040 and so how can we really talk about what, like, 0:36:26.200 --> 0:36:28.920 how can we test these hypotheses if we don't know 0:36:28.960 --> 0:36:34.360 what it's caused by? And yeah, so that I didn't 0:36:34.760 --> 0:36:35.880 I don't have anything about that. 0:36:36.080 --> 0:36:37.440 I mean, yeah, because we don't. 0:36:38.080 --> 0:36:39.719 I feel like we don't even have a good We 0:36:39.800 --> 0:36:42.880 have a clinical definition, right, we can diagnostical definition, But 0:36:42.960 --> 0:36:46.279 are all are all of these phenotypes? Are all pcos 0:36:46.280 --> 0:36:46.640 the same? 0:36:46.800 --> 0:36:47.239 I don't know. 0:36:47.440 --> 0:36:50.200 We don't know, we don't know in terms of what 0:36:50.239 --> 0:36:53.040 we do about it and how we treat it. It 0:36:53.120 --> 0:36:56.480 really depends on what we're worried about, what the symptoms 0:36:56.520 --> 0:36:59.000 are that a patient or a person is worried about. 0:36:59.719 --> 0:37:02.960 Because because a lot of these symptoms of pcos are 0:37:03.000 --> 0:37:08.160 related to these androgenic hormones and related to this HPO axis, 0:37:08.560 --> 0:37:11.080 a lot of times we rely on birth control as 0:37:11.120 --> 0:37:14.680 one of the first line treatments for pcos, especially combination 0:37:14.760 --> 0:37:18.359 birth control like estrogen containing birth control, because what that 0:37:18.480 --> 0:37:20.920 does is it helps kind of override a lot of 0:37:20.920 --> 0:37:23.560 this HPO axis. It's going to negate any of these 0:37:23.560 --> 0:37:27.560 ovulatory dysfunctions, it's going to decrease your risk of undermetrial cancer. 0:37:28.440 --> 0:37:34.440 And the estrogen effect especially can help to alleviate a 0:37:34.440 --> 0:37:37.520 lot of the symptoms of excess androgens if those symptoms 0:37:37.520 --> 0:37:41.680 are unwanted, like acne and hersitism, because the estrogen what 0:37:41.719 --> 0:37:45.319 it does is it helps to address this decrease in 0:37:45.400 --> 0:37:49.200 sex hormone binding globulin, which then helps to decrease the 0:37:49.239 --> 0:37:53.879 amount of free testosterone that's circulating. Sometimes, though we might 0:37:54.000 --> 0:37:58.399 use anti androgen specific medications like sperona, lactone or other 0:37:58.440 --> 0:38:01.680 medicines if we're targeting some of those hyper andthrogen symptoms 0:38:01.719 --> 0:38:05.000 as a concern, but none of those are going to 0:38:05.040 --> 0:38:07.880 address the metabolic effects. Right, birth control is not going 0:38:07.960 --> 0:38:11.520 to change insulin resistance if that's present. By the way, 0:38:11.800 --> 0:38:16.120 we don't have a test for insulin resistance. There's no test. 0:38:16.280 --> 0:38:17.800 We don't have a test. We don't have a way 0:38:17.960 --> 0:38:21.400 to test for insulin resistance. Huh. 0:38:21.600 --> 0:38:25.520 We can test for risk of diabetes. But diabetes is 0:38:25.560 --> 0:38:29.520 not just insulin resistance. It's and it's we see our 0:38:29.520 --> 0:38:32.200 diabetes episodes. There's other ways that you can get diabetes 0:38:32.239 --> 0:38:36.239 besides just insulin resistance. But insulin resistance can lead to 0:38:36.480 --> 0:38:41.600 diabetes if you then have impaired glucose tolerance. But insulin 0:38:41.640 --> 0:38:46.240 resistance is like a first step if that's the pathway, 0:38:46.680 --> 0:38:50.200 and we can only see it if it's come to 0:38:50.239 --> 0:38:52.239 the point of, Okay, you have an increase in your 0:38:52.239 --> 0:38:53.840 A one C or you have an increase in your 0:38:53.880 --> 0:38:59.120 fasting glucose. But that's not directly a marker for insulin 0:38:59.160 --> 0:39:01.600 resistance itself, and we don't have a test for that. 0:39:01.600 --> 0:39:06.200 That's easy to do. I just I know that we did. 0:39:06.400 --> 0:39:09.759 Nope, we don't which explains why it's not part of 0:39:09.760 --> 0:39:12.239 the clinical picture exactly because you can't test for it. 0:39:12.280 --> 0:39:14.319 Can't test for it, right, you cannot test for it. 0:39:15.680 --> 0:39:20.080 So but if there is evidence, especially of like glucose intolerance, right, 0:39:20.200 --> 0:39:24.080 like increased ae C or something like that, then you 0:39:24.120 --> 0:39:26.919 can address that with met Foreman is usually the first line, 0:39:26.920 --> 0:39:28.719 and that's a drug that we use for diabetes. It 0:39:28.760 --> 0:39:33.520 helps to increase insulin sensitivity in our tissues. It sometimes 0:39:33.520 --> 0:39:35.920 can also cause weight loss, which may or may not 0:39:35.960 --> 0:39:40.320 be desired, depending on the situation. What's very very interesting 0:39:40.400 --> 0:39:43.640 about met Foreman is that it also has data that 0:39:43.680 --> 0:39:47.719 it helps to regulate ovulation and what exactly is the 0:39:47.760 --> 0:39:50.359 mechanism there, Like does that give us any insight. 0:39:50.040 --> 0:39:51.880 Into what is going on here? 0:39:52.000 --> 0:39:53.680 I don't know that it does, but I just still 0:39:53.719 --> 0:39:55.240 think it's so interesting. 0:39:55.080 --> 0:39:57.080 Right is there? Does that is that? 0:39:57.120 --> 0:39:59.240 Does that help shine a light on the link between 0:39:59.560 --> 0:40:01.160 I think process. 0:40:00.880 --> 0:40:03.000 It helps chin to light on there because when you 0:40:03.040 --> 0:40:05.800 look at these grap we should post one of these 0:40:05.960 --> 0:40:09.719 like graphs of what these feedback loops look like and 0:40:09.719 --> 0:40:14.319 how they're disrupted in pcos. There is a strong link 0:40:14.360 --> 0:40:18.680 between insulin resistance and hyperinsulinemia and and grogen production in 0:40:18.680 --> 0:40:21.480 the ovaries. So we know that that's like an inward arrow. 0:40:21.800 --> 0:40:22.560 There's just no. 0:40:22.719 --> 0:40:25.600 Backward arrow that that goes. Like, then why does the 0:40:25.600 --> 0:40:30.200 insulin resistance come up in the first place? That gods yees, yeah, yeah, 0:40:30.320 --> 0:40:33.920 Like is insulin resistance actually the primary mechanism? I don't know, 0:40:33.960 --> 0:40:37.560 But then why do we see Anyways, it's much but 0:40:38.280 --> 0:40:40.440 for people who maybe want to get pregnant on our 0:40:40.440 --> 0:40:44.600 struggle with infertility, sometimes met Forman can then be used 0:40:44.880 --> 0:40:48.880 to help alleviate the anovulation. It is not first line 0:40:49.080 --> 0:40:53.239 if the goal is pregnancy, though usually first line what 0:40:53.280 --> 0:40:56.120 we use as a medicine called letrozol or another similar 0:40:56.160 --> 0:41:00.520 medicine that triggers ovulation that's more directly triggering ovulate. But 0:41:00.760 --> 0:41:04.040 met Foreman can and it has good data that it 0:41:04.120 --> 0:41:09.480 can normalize ovulation to a regular degree, which can help 0:41:09.520 --> 0:41:13.040 with infertility if that's a goal. And then there's also 0:41:13.600 --> 0:41:17.520 an interest, of course in using newer medicines like glp 0:41:17.680 --> 0:41:22.200 ones which are the ozembics of the world, or other 0:41:22.320 --> 0:41:25.840 combination medicines. But we'll get there later in this episode. 0:41:25.960 --> 0:41:30.640 Arin quick question, give it to me menopause. 0:41:31.200 --> 0:41:37.600 Ah, yes, yeah, what's the question? 0:41:37.960 --> 0:41:41.080 Well, the question is, like I guess, the question is 0:41:41.120 --> 0:41:44.880 a very vague, unformed question. But just like for people 0:41:44.920 --> 0:41:49.160 who have PCOS, is their menopause experience any different? 0:41:50.200 --> 0:41:51.520 This is such a great question. 0:41:51.640 --> 0:41:55.759 No idea, Okay, no, no one has examined it. 0:41:56.000 --> 0:41:58.799 All of these papers are like, hey, yeah, so a 0:41:58.840 --> 0:42:00.960 lot of what we know about PCOS we think of 0:42:01.040 --> 0:42:04.799 as a reproductive disorder, and so its primary effects are 0:42:04.840 --> 0:42:07.399 in the reproductive years. So we don't have a lot 0:42:07.400 --> 0:42:12.080 of data on postmenopausal PCOS. Is the insulin resistance still 0:42:12.120 --> 0:42:15.240 a thing? Are you at higher risk for cardiovascular disease 0:42:15.280 --> 0:42:18.600 and type two diabetes postmenopausal compared to someone who has 0:42:18.719 --> 0:42:21.520 Like does your PCOS still exist postmenopause? 0:42:21.800 --> 0:42:23.520 Right, That's what I was trying to That's what I 0:42:23.560 --> 0:42:26.560 was trying to ask, and the great question, I guess. 0:42:26.640 --> 0:42:30.759 The other question then is Okay, So, and this maybe 0:42:30.840 --> 0:42:32.840 kind of gets into what I'm going to talk about 0:42:32.880 --> 0:42:37.440 a little bit, But like, you get a diagnosis of PCOS, 0:42:38.000 --> 0:42:42.560 you are not interested in becoming pregnant. You maybe are 0:42:42.600 --> 0:42:48.280 not interested in addressing any of the other symptoms of PCOS. 0:42:49.640 --> 0:42:52.440 Is there anything in your medical care. That is, like, 0:42:52.520 --> 0:42:55.719 we should have increased screening for cardiovascular disease. We had 0:42:55.719 --> 0:42:56.640 to have this in that. 0:42:57.480 --> 0:43:04.160 Is that something that physicians do do? Does anyone do it? 0:43:04.200 --> 0:43:05.560 Is the question I can't answer. 0:43:05.960 --> 0:43:08.520 That is the guidelines though that those are the guidelines, 0:43:08.640 --> 0:43:11.680 especially from the twenty twenty three update. You should be 0:43:11.719 --> 0:43:16.000 screened for potentially for sleep apnea, which not everyone is 0:43:16.080 --> 0:43:17.759 necessarily needs to be screened for sleep apnea, but if 0:43:17.760 --> 0:43:19.680 you have PCOS, you probably should at least be screened 0:43:19.680 --> 0:43:23.160 with like some of the questionnaires. You should be screened 0:43:23.239 --> 0:43:25.759 for diabetes, so checking in A and C. You should 0:43:25.800 --> 0:43:29.440 be screened for hyperlipidemia, even if you don't want to 0:43:29.480 --> 0:43:34.080 address any of the symptoms of hyperandrogenism. And it does 0:43:34.120 --> 0:43:36.440 not matter to you whether like you don't want to 0:43:36.440 --> 0:43:38.359 get pregnant, and so does it matter to you if 0:43:38.360 --> 0:43:40.239 you're not ovulating on a regular schedule. You do need 0:43:40.239 --> 0:43:42.840 to think about endometrial protection. You have to do something 0:43:42.880 --> 0:43:45.120 to reduce that risk of endometrial cancer. So that is 0:43:45.120 --> 0:43:48.680 something that you have to think about. And yeah, those 0:43:48.719 --> 0:43:50.040 are I mean, those are the main things. There's there's 0:43:50.040 --> 0:43:51.759 probably more than that. I'm forgetting off the top of 0:43:51.760 --> 0:43:56.960 my head. Also, depression and anxiety are higher in people 0:43:56.960 --> 0:44:00.960 with PCOS. Why we don't know is that just because 0:44:01.000 --> 0:44:04.440 of how people are treated with PCOS by the medical system, 0:44:05.000 --> 0:44:07.200 how long it can take to get a diagnosis, how 0:44:07.320 --> 0:44:09.760 much they're like ignored by the medical system. 0:44:09.960 --> 0:44:10.440 We don't know. 0:44:10.880 --> 0:44:12.880 Is it just because it does it actually have anything 0:44:12.880 --> 0:44:15.920 to do with PCOS and the like pathology there, or 0:44:15.960 --> 0:44:16.480 is it all. 0:44:16.360 --> 0:44:17.600 Just our medical system? We don't know. 0:44:17.840 --> 0:44:20.080 Yeah, but it's an important thing to keep in mind 0:44:20.320 --> 0:44:27.439 as well as Yes, society exactly, Aaron, that was only 0:44:27.760 --> 0:44:29.359 twice as long as I intepreated? 0:44:30.600 --> 0:44:33.719 So tell me how did we get to hear? What 0:44:33.760 --> 0:44:34.160 do we know? 0:44:35.920 --> 0:44:40.600 You know, those are some great questions. Let's let's get 0:44:40.640 --> 0:44:58.719 into it, Okay. For all that we still don't know 0:44:59.120 --> 0:45:04.799 about the biology of PCOS, this condition can teach us 0:45:05.239 --> 0:45:10.520 so much when it comes to the power of societal expectations, 0:45:11.120 --> 0:45:15.880 the inadequacy of a name, our failure to provide care 0:45:16.040 --> 0:45:20.080 to all who need it, and how silence, stigma, and 0:45:20.200 --> 0:45:22.760 shame can profoundly. 0:45:22.120 --> 0:45:26.279 Deepen the impact of a medical condition. At least it 0:45:26.320 --> 0:45:29.520 can teach us those things if we are willing to listen. 0:45:30.120 --> 0:45:31.480 Yeah, can we learn those things? 0:45:31.520 --> 0:45:36.360 Can we learn those things? Prevalence estimates of pcos vary. 0:45:36.640 --> 0:45:39.680 The most common numbers I've seen are six to twenty 0:45:39.680 --> 0:45:42.759 percent of people assigned female at birth. Others say, you know, 0:45:42.800 --> 0:45:49.480 one in ten, a huge, huge prevalence, and yet PCOS 0:45:49.520 --> 0:45:54.279 receives less funding for research compared to other similarly prevalent conditions. 0:45:54.960 --> 0:45:58.680 There is less awareness, both in the medical community as 0:45:58.719 --> 0:46:02.080 well as within the general public, and we still lag 0:46:02.160 --> 0:46:08.080 behind in terms of treatment options and medical knowledge about pcos. Clearly, 0:46:08.239 --> 0:46:12.880 not enough of us are listening. Hopefully that will change 0:46:13.120 --> 0:46:16.879 thanks to the incredible advocacy work by some groups and individuals, 0:46:17.000 --> 0:46:19.759 and thanks to the Internet, which I never thought i'd say, 0:46:19.880 --> 0:46:23.640 but truly thanks to the Internet where people with PCOS 0:46:23.680 --> 0:46:27.040 can find the support and community that is so often 0:46:27.160 --> 0:46:31.000 lacking in their everyday lives or in interactions with their 0:46:31.040 --> 0:46:34.600 healthcare provider. Before I go any further, I want to 0:46:34.640 --> 0:46:37.760 shout out one advocate in particular, and that is doctor 0:46:37.840 --> 0:46:42.280 Stacey L. Williams, a social health psychologist at East Tennessee 0:46:42.440 --> 0:46:45.960 State University and author of an incredible book that I 0:46:46.000 --> 0:46:49.880 read for this episode titled The Psychology of PCOS. Building 0:46:49.920 --> 0:46:56.239 the science and breaking the silence as someone who does 0:46:56.280 --> 0:46:58.680 not have PCOS but thought they knew a thing or 0:46:58.719 --> 0:47:00.840 two about it, which it turned out to be true 0:47:00.960 --> 0:47:04.640 in the literal sense. I found this book to be 0:47:04.760 --> 0:47:09.480 incredibly eye opening and perspective shifting truly, and almost everything 0:47:09.480 --> 0:47:11.200 that I'm going to talk about when it comes to 0:47:11.239 --> 0:47:13.880 PCOS today and some of the issues that we see 0:47:14.200 --> 0:47:17.200 comes from this wonderful book. But before we get into 0:47:17.640 --> 0:47:21.200 today in the today's landscape, let's go back in time 0:47:21.320 --> 0:47:24.080 to get a sense of the lengthy history of this condition. 0:47:25.040 --> 0:47:28.680 So PCOS is likely an ancient disease in humans, and 0:47:28.920 --> 0:47:31.880 it's probably not limited to our species. One of the 0:47:32.000 --> 0:47:35.960 challenges with understanding the root causes of PCOS is not 0:47:36.040 --> 0:47:39.319 having a naturally occurring animal model. But I did come 0:47:39.360 --> 0:47:43.480 across a paper that described Reese's monkeys that had naturally 0:47:43.520 --> 0:47:46.840 occurring high levels of testosterone and seem to exhibit some 0:47:46.880 --> 0:47:50.640 of the clinical picture of PCOS. It's still like, it's. 0:47:51.120 --> 0:47:53.920 Not clear, you know. Yeah. 0:47:54.280 --> 0:47:57.479 The first likely descriptions of the condition in humans come 0:47:57.560 --> 0:48:02.400 from ancient Greece in hippocrates Diseases of Women text written 0:48:02.560 --> 0:48:03.960 in the fourth century BCE. 0:48:04.480 --> 0:48:06.879 Oh gosh, can't wait for this quote. 0:48:07.320 --> 0:48:10.600 But those women whose menstruation is less than three days 0:48:10.840 --> 0:48:14.239 or is meager are robust, with a healthy complexion and 0:48:14.280 --> 0:48:18.480 a masculine appearance. Yet they are not concerned about bearing children, 0:48:18.800 --> 0:48:20.160 nor do they become pregnant. 0:48:20.600 --> 0:48:22.360 End quote. Okay, yep. 0:48:23.239 --> 0:48:27.680 Other ancient texts mention hersatism or hersaitism in combination with 0:48:27.800 --> 0:48:31.680 changes in mensis as a condition, and another Greek physician, 0:48:31.960 --> 0:48:36.280 Soreness of Ephesus, wrote around the second century CE quote 0:48:36.600 --> 0:48:40.000 sometimes it is also natural not to menstruate at all. 0:48:40.400 --> 0:48:43.080 It is natural too in persons whose bodies are of 0:48:43.120 --> 0:48:46.319 a masculine type. We observe that the majority of those 0:48:46.440 --> 0:48:50.640 not menstruating are rather robust, like mannish and sterile women. 0:48:51.400 --> 0:48:52.960 Quote. 0:48:53.320 --> 0:48:58.799 I know language is not great, ary, yeah, but what 0:48:58.840 --> 0:49:02.600 these descriptions show is that pcos was likely an ancient 0:49:02.600 --> 0:49:05.920 disorder and common enough that it was mentioned in several 0:49:06.000 --> 0:49:10.480 old medical texts, and that it has always been described 0:49:10.480 --> 0:49:16.000 as violating expectations of femininity. The next description that historians 0:49:16.040 --> 0:49:18.840 point out comes from seventeen twenty one, when an Italian 0:49:18.880 --> 0:49:24.080 physician Vallisneri described a married, quote unquote infertile woman who 0:49:24.160 --> 0:49:27.520 died young at twenty one years and upon autopsy was 0:49:27.560 --> 0:49:31.319 found to have shiny ovaries with a white surface, and 0:49:31.360 --> 0:49:34.600 the size of ovaries as pigeon eggs or ovaries the 0:49:34.640 --> 0:49:35.560 size of pigeon eggs. 0:49:35.719 --> 0:49:39.600 Okay, I have no idea, like how big a pigeon 0:49:39.640 --> 0:49:42.200 egg is. I'm not sure either. I should have imagined 0:49:42.239 --> 0:49:46.880 they're small, though, like pigeons aren't very big birds. Yeah, Okay, I. 0:49:46.880 --> 0:49:50.640 Don't know all right. Additional mentions of what was likely 0:49:50.680 --> 0:49:54.000 pcos popped up throughout the eighteenth and nineteenth centuries, including 0:49:54.040 --> 0:49:57.279 from Rokotanski, the famous pathologist I mentioned before on the 0:49:57.320 --> 0:50:02.080 podcast who did like tens of thousands of autopsies, and 0:50:02.280 --> 0:50:05.239 this period, especially in like the late nineteenth century early 0:50:05.280 --> 0:50:09.080 twentieth century, was crucial time for building a foundation of 0:50:09.120 --> 0:50:12.480 knowledge for understanding the role of different hormones in our 0:50:12.480 --> 0:50:16.120 physiology and what could happen when things do not go 0:50:16.200 --> 0:50:20.919 as expected. This was also when the testosterone equals male 0:50:21.880 --> 0:50:25.600 estrogen equals female false dichotomy was established. 0:50:25.800 --> 0:50:27.960 Oh love that? Yeah? 0:50:28.080 --> 0:50:29.320 Still on learning that. 0:50:29.239 --> 0:50:30.879 I think? Yeah. 0:50:30.920 --> 0:50:33.120 And so while that piece of the puzzle, like the 0:50:33.160 --> 0:50:36.040 hormone piece of the puzzle, wouldn't get slotted into pcos 0:50:36.160 --> 0:50:39.839 until the nineteen sixties, when researchers demonstrated the ovaries role 0:50:39.920 --> 0:50:44.200 in producing androgens. A complete clinical picture of the condition 0:50:44.440 --> 0:50:47.600 was formed by nineteen thirty five. Wow less complete. 0:50:47.680 --> 0:50:47.919 Yeah. 0:50:48.640 --> 0:50:52.719 That year, two physicians Irving Freilerstein and Michael Leo Leventhal 0:50:52.760 --> 0:50:57.319 published a paper titled AIM and Area associated with bilateral 0:50:57.360 --> 0:50:58.560 polycystic Ovaries. 0:50:58.760 --> 0:50:59.640 Okay, there you. 0:50:59.600 --> 0:51:02.480 Go, and in it they described the case reports that 0:51:02.520 --> 0:51:06.319 they had collected over the previous few years while investigating 0:51:06.360 --> 0:51:11.200 factors underlying difficulty getting pregnant. They followed these patients for 0:51:11.280 --> 0:51:14.399 long periods of time and truly got to know them, 0:51:14.440 --> 0:51:17.440 got to know their histories, got to know just everything 0:51:17.480 --> 0:51:19.080 about them. It was sort of this like, you know what, 0:51:19.160 --> 0:51:22.080 let's just cast a wide net and see what comes out. 0:51:22.719 --> 0:51:25.520 And by doing this, which is not a very common 0:51:25.560 --> 0:51:30.160 thing done today, they were able to draw out patterns 0:51:30.200 --> 0:51:33.480 that otherwise might have been missed. A subset of their 0:51:33.520 --> 0:51:37.320 patients had started menstruating years before, but their periods since 0:51:37.520 --> 0:51:41.719 had been unpredictable or just lacking entirely. They tended to 0:51:41.760 --> 0:51:45.920 have more hair growth than average and enlarged cystic ovaries, 0:51:45.960 --> 0:51:49.640 often larger than the uterus even at least a few, 0:51:50.400 --> 0:51:53.000 and they performed surgeries on a few of their patients 0:51:53.040 --> 0:51:55.719 to remove the cysts and part of the ovaries, both 0:51:55.719 --> 0:51:58.920 for diagnostic as well as therapeutic purposes, and a couple 0:51:58.920 --> 0:52:03.319 of people actually delivered children after the surgery. So what 0:52:03.400 --> 0:52:06.799 was different about Stein and Levenhal's clinical picture, like, why 0:52:06.920 --> 0:52:09.680 is this the one that put pcos on the medical map? 0:52:09.760 --> 0:52:10.320 So to speak? 0:52:11.520 --> 0:52:15.200 They were the first to describe the triad of polycystic 0:52:15.200 --> 0:52:21.720 ovarian morphology, hersitism, and infrequent irregular periods. And of course 0:52:21.800 --> 0:52:26.640 this is not a perfect clinical picture, which over the 0:52:26.680 --> 0:52:31.160 decades has evolved to account for more diverse symptoms and 0:52:31.480 --> 0:52:35.399 still maybe as one could describe it as incomplete lacking yes, 0:52:36.239 --> 0:52:39.640 and their focus on ovarian cysts, ultimately leading to the 0:52:39.719 --> 0:52:43.640 name polycystic ovary syndrome was misleading since cysts are not 0:52:43.800 --> 0:52:45.120 always present. 0:52:44.960 --> 0:52:49.680 Yeah, or like yeah, it's not quite accurate. Yeah, you 0:52:49.719 --> 0:52:52.440 could say, I mean, if you assist just a fluid 0:52:52.480 --> 0:52:55.080 filled thing, then sure, sure we'll call it. Sure, Yeah, 0:52:55.640 --> 0:52:58.120 that be presnent. Yeah, doesn't have to be present exactly. 0:52:59.640 --> 0:53:02.520 But what they did was provide a starting point and 0:53:02.640 --> 0:53:06.040 drive interest in this condition and in the decades since, 0:53:06.160 --> 0:53:08.880 researchers have added detail and depth to what we know 0:53:08.960 --> 0:53:14.479 about PCOS, from diagnosis to possible treatments, but not nearly enough. 0:53:15.760 --> 0:53:18.319 To quote doctor Stacy Williams, who's the author of the 0:53:18.320 --> 0:53:23.239 Psychology of PCOS, quote, it is unfathomable that in the 0:53:23.280 --> 0:53:27.319 twenty first century we are still grappling with diagnosis and 0:53:27.400 --> 0:53:32.120 treatment for PCOS. After more than eighty five years since 0:53:32.200 --> 0:53:37.440 PCOS was formally identified, doctors still lack knowledge of the syndrome. 0:53:38.120 --> 0:53:41.959 Combine that reality with a continued lack of cultural sensitivity 0:53:42.000 --> 0:53:45.440 of providers towards their patients, and we have a recipe 0:53:45.480 --> 0:53:51.480 for continued delays in diagnosis, biased interactions, and increased risk 0:53:51.680 --> 0:53:53.040 of worse health outcomes. 0:53:53.560 --> 0:53:54.360 End quote. 0:53:54.560 --> 0:54:02.200 Yeah, the resulting cost of this is huge on the 0:54:02.239 --> 0:54:06.120 economic side, eight billion dollars annually in the US alone, 0:54:06.280 --> 0:54:09.960 that was estimated in twenty twenty two. That's a split PCOS, 0:54:10.719 --> 0:54:14.080 and that's split about equally between reproductive issues and metabolic 0:54:14.200 --> 0:54:19.239 vascular issues, and is likely an underestimate. Aaron, you took 0:54:19.320 --> 0:54:22.680 us through some of the physical costs associated with PCOS, 0:54:22.719 --> 0:54:27.400 some of which can be substantial, but the psychological costs 0:54:27.440 --> 0:54:33.080 of this condition can be immeasurable and mostly go unacknowledged, 0:54:33.400 --> 0:54:39.000 at least in the medical literature. PCOS, like many chronic conditions, 0:54:39.040 --> 0:54:45.840 reveals a divide between how society expects you to act, look, 0:54:46.040 --> 0:54:49.920 and feel and how you actually act, look and feel. 0:54:50.920 --> 0:54:54.200 The price for not meeting those expectations can be steep, 0:54:54.560 --> 0:54:59.360 whether it results from medical gaslighting, bullying, or internalized stigma. 0:55:00.160 --> 0:55:02.880 People with PCOS are at a higher risk of depression 0:55:02.880 --> 0:55:06.359 and anxiety. Like you said, and it's difficult to disentangle 0:55:06.520 --> 0:55:10.120 whether these mental health impacts are a direct or indirect 0:55:10.160 --> 0:55:13.520 consequence of PCOS. Is it hormone dysregulation, is it the 0:55:13.560 --> 0:55:16.600 medications someone has prescribed? Is it the stigma you face 0:55:16.640 --> 0:55:19.240 with PCOS? Is it not just one thing but many. 0:55:20.239 --> 0:55:22.759 We don't have a good answer, but if we want 0:55:22.800 --> 0:55:26.000 to find one, what we need is more information, not 0:55:26.360 --> 0:55:30.839 just about the biological underpinnings of pcos, but especially the 0:55:30.880 --> 0:55:35.200 lived experiences. What is it like to live with a 0:55:35.280 --> 0:55:40.319 condition whose symptoms mark you visibly or invisibly as not 0:55:40.480 --> 0:55:45.560 conforming to societal norms or medical expectations. How does our 0:55:45.600 --> 0:55:50.319 society or our medical establishment treat someone with PCOS? And 0:55:50.360 --> 0:55:53.600 how is that wrapped up in ingrained notions of gender 0:55:53.640 --> 0:55:59.240 and sexuality. Let's get into it, okay, and I'm roughly 0:55:59.280 --> 0:56:03.480 breaking it down between outside of clinic and inside clinic. 0:56:03.680 --> 0:56:04.040 Okay. 0:56:04.840 --> 0:56:08.400 As you described, Aaron PCOS is associated with a broad 0:56:08.600 --> 0:56:11.280 array of signs and symptoms, some of which are visible, 0:56:11.560 --> 0:56:14.160 like you know what is called male pattern body hair 0:56:14.600 --> 0:56:20.359 or baldness, weight gain, others which aren't visible, such as 0:56:20.400 --> 0:56:25.080 irregular periods, difficulty getting pregnant, but many of which challenge 0:56:25.160 --> 0:56:29.720 gender norms. Our society has hammered into us that women 0:56:29.920 --> 0:56:32.719 should not be hairy, that in fact, any body hair 0:56:32.840 --> 0:56:35.879 or facial hair is shameful and disgusting, and we should 0:56:35.920 --> 0:56:37.359 take steps to conceal. 0:56:37.040 --> 0:56:38.959 It and avoid it. La away. 0:56:39.320 --> 0:56:42.480 I mean, bearded ladies were a staple of circuses for 0:56:42.520 --> 0:56:47.560 goodness sake. Our society equates fatness with a moral failing, 0:56:48.040 --> 0:56:51.120 believing that it demonstrates a lack of self control, and 0:56:51.200 --> 0:56:56.400 women especially should be delicate, slender angels. Our society tells 0:56:56.480 --> 0:56:59.000 us we become women when we get our first period, 0:56:59.360 --> 0:57:02.360 and that are flee bleeding is a powerful reminder of 0:57:02.400 --> 0:57:08.319 our womanhood. Oh God, sorry, nauseous. Our society assumes that 0:57:08.440 --> 0:57:12.600 every woman will want to give birth. Our society expects 0:57:12.640 --> 0:57:15.600 that every person assigned female at birth should look a 0:57:15.600 --> 0:57:19.040 certain way, act a certain way, and want certain things, 0:57:20.280 --> 0:57:26.120 and PCOS can throw a wrench into society's expectations sometimes 0:57:26.200 --> 0:57:29.919 because we are raised in the society and these expectations 0:57:29.960 --> 0:57:34.320 are deeply ingrained in us. This can lead to intense 0:57:34.360 --> 0:57:38.000 feelings of stigma that come from within if you don't 0:57:38.000 --> 0:57:43.520 menstrate regularly, and menstruation, though itself is stigmatized, is associated 0:57:43.560 --> 0:57:46.440 with womanhood. Does that mean that you are less of 0:57:46.440 --> 0:57:50.080 a woman? Of course not, but that is a difficult 0:57:50.080 --> 0:57:54.640 thing to unlearn. The author of the Psychology of PCOS 0:57:54.680 --> 0:57:57.720 interviewed fifty people with the condition for the book and 0:57:57.920 --> 0:58:02.120 included snippets of the interviews, which which we're so insightful, Like, 0:58:02.200 --> 0:58:04.880 I loved that approach so much. I think it's so important, 0:58:04.920 --> 0:58:07.280 and I want to share a few throughout the rest 0:58:07.280 --> 0:58:11.880 of this So Joe late twenties gender queer non binary 0:58:12.040 --> 0:58:15.080 described being bullied for having male pattern facial hair when 0:58:15.080 --> 0:58:18.000 they were younger and said that they quote spent a 0:58:18.040 --> 0:58:20.240 lot of time trying to get rid of my body hair, 0:58:20.400 --> 0:58:23.040 to the extent that nobody would even be able to 0:58:23.120 --> 0:58:26.400 know I even had it. So I feel that it's 0:58:26.400 --> 0:58:29.240 a cultural mandate for people who are trying to pass 0:58:29.280 --> 0:58:32.560 as women that you can't have even stubble in places 0:58:32.560 --> 0:58:35.000 that you're not supposed to have hair, which is pretty 0:58:35.080 --> 0:58:37.520 much everywhere except your head. It's a lot of time 0:58:37.600 --> 0:58:40.080 and a lot of paranoia to try and maintain that 0:58:40.160 --> 0:58:43.200 appearance if that's not what your body is actually doing. 0:58:43.720 --> 0:58:46.000 And that was a big source of feeling invalidated as 0:58:46.000 --> 0:58:50.000 a woman for a long time. End quote And like, Okay, 0:58:50.120 --> 0:58:52.200 I don't have PCOS as far as I know, but 0:58:52.320 --> 0:58:55.840 I do have a lot of body hair, thanks genetics, 0:58:56.080 --> 0:59:00.480 And it has been and continues to be a source 0:59:00.480 --> 0:59:04.560 of shame and like embarrassment and anxiety in my life. 0:59:04.600 --> 0:59:07.760 And it was just like it. 0:59:07.320 --> 0:59:11.160 Still to this day. Oh anyway, yes, no, it's very real. 0:59:11.400 --> 0:59:16.360 It's very real. And then there's another first hand account 0:59:16.440 --> 0:59:19.120 or another like snippet I want to share from Kim 0:59:19.360 --> 0:59:22.880 mid thirties cis gender, who said, quote before I was 0:59:22.880 --> 0:59:26.120 diagnosed with PCOS, I really just felt like my body 0:59:26.200 --> 0:59:28.160 was broken, and I think I had a lot of 0:59:28.200 --> 0:59:31.480 shame around not understanding why I was having trouble with 0:59:31.560 --> 0:59:34.440 periods and what this pain was that other people in 0:59:34.480 --> 0:59:37.840 my life, who menstraight don't have. So what was going 0:59:37.880 --> 0:59:40.360 on for me? Why was I weird? And I think 0:59:40.440 --> 0:59:43.520 that shame made me feel isolated because I couldn't talk 0:59:43.560 --> 0:59:45.920 about it or I didn't know I could talk about it. 0:59:46.400 --> 0:59:47.000 End quote. 0:59:48.480 --> 0:59:52.400 Stigma can also arise from other people. One person interviewed 0:59:52.400 --> 0:59:55.400 in the book describes getting facial hair shavers for Christmas 0:59:55.480 --> 1:00:01.320 from their mom. Oh yeah, I mean I bullied all 1:00:01.360 --> 1:00:03.760 throughout middle school and high school for body hair. 1:00:05.520 --> 1:00:08.760 Yeah. Why, Oh my gosh, why body hair? 1:00:09.120 --> 1:00:12.320 Like I mean that we could do a whole episode 1:00:12.320 --> 1:00:14.720 on that, but I think we should, Maybe we should. 1:00:14.760 --> 1:00:17.240 I think part of it too, is like Razor companies 1:00:17.240 --> 1:00:18.960 were like, oh, we're missing half the population. 1:00:19.280 --> 1:00:21.480 Yeah, yeah, you're disgusting. You're disgusting. 1:00:21.520 --> 1:00:24.560 Your hair is disgusting, it's unhealthy, it's unhygienic. 1:00:25.200 --> 1:00:26.680 Yeah, it makes me so upset. 1:00:28.080 --> 1:00:31.240 And then Meg early twenties cis gender, talks about a 1:00:31.280 --> 1:00:34.760 college field trip for her geography major involving canoeing. 1:00:35.000 --> 1:00:35.440 Quote. 1:00:35.800 --> 1:00:38.840 The professor was concerned about my ability to canoe because 1:00:38.920 --> 1:00:42.120 I'm overweight, Therefore I might not have enough stamina even 1:00:42.160 --> 1:00:45.160 though I've been kayaking all my life and I'm very 1:00:45.160 --> 1:00:49.920 good at canoeing and kayaking. Quote yeah, I mean that's 1:00:51.040 --> 1:00:57.280 Another person interviewed described how her parents don't really quote 1:00:57.360 --> 1:01:01.840 unquote believe in PCOS and that the weight is completely 1:01:01.920 --> 1:01:03.080 a matter of self control. 1:01:04.960 --> 1:01:06.760 The amount of fat shaming. 1:01:06.760 --> 1:01:16.440 It's it's ridiculous, yea, it's overwhelming. Yeah, yeah, yeah, yeah, 1:01:16.520 --> 1:01:20.720 there is. There is nothing inherently shameful about any part 1:01:20.840 --> 1:01:25.760 of PCOS. But because we are exposed to societal expectations 1:01:25.960 --> 1:01:29.720 from the minute we are born, and multiple symptoms of 1:01:29.800 --> 1:01:34.320 PCOS do not align with those expectations, stigma remains a 1:01:34.440 --> 1:01:39.320 huge issue, whether that comes from within or from without. Yeah, 1:01:39.360 --> 1:01:42.800 but not everyone experiences PCOS in the same way. So, 1:01:42.840 --> 1:01:46.000 for instance, some cisgender women may feel self conscious about 1:01:46.000 --> 1:01:49.680 their facial hair. Others may be done performing femininity by 1:01:49.720 --> 1:01:52.440 removing that hair, and they're like, no, I'm growing it 1:01:52.480 --> 1:01:54.560 out right, I don't care, it doesn't bother me. And 1:01:54.720 --> 1:01:58.760 other people that don't identify as women may welcome that 1:01:58.840 --> 1:02:01.280 facial hair, feeling that it more closely aligns with their 1:02:01.320 --> 1:02:06.200 gender identity. Along those lines, infrequent or unpredictable periods might 1:02:06.280 --> 1:02:09.400 be a painful reminder to cisgender women who are trying 1:02:09.440 --> 1:02:12.800 to become pregnant, or a source of anxiety for those 1:02:12.880 --> 1:02:16.320 who do not want to be pregnant, while absent periods 1:02:16.400 --> 1:02:18.840 might be the desired outcome for people who find them 1:02:18.840 --> 1:02:22.960 distressing since they do not align with their gender, and 1:02:23.040 --> 1:02:26.280 then there's everything in between. People can feel a million 1:02:26.280 --> 1:02:30.800 different ways about these different symptoms. Kendall late twenties non 1:02:30.800 --> 1:02:35.040 binary describes the mixed feelings that can arise quote, but 1:02:35.120 --> 1:02:38.680 the gender dysphoria. I feel like PCOS actually helps a 1:02:38.720 --> 1:02:41.240 little bit, but it also kind of makes it worse 1:02:41.280 --> 1:02:43.920 because I'm having all these problems that revolve around my 1:02:44.040 --> 1:02:46.200 female anatomy. So it's kind of like a push and 1:02:46.240 --> 1:02:50.160 pull of two differing emotions. And before I felt as 1:02:50.200 --> 1:02:53.080 though I was ready to identify as transgender, it definitely 1:02:53.120 --> 1:02:56.000 made me feel terrible about my body, very much like 1:02:56.040 --> 1:02:59.520 I was unlikable, unattractive to other people. But now I 1:02:59.520 --> 1:03:02.040 feel the oposit I feel like it makes me more 1:03:02.080 --> 1:03:06.560 attractive because I'm transgender now and I present masculinely, but 1:03:06.600 --> 1:03:08.840 at the same time, the health aspects and if I 1:03:08.880 --> 1:03:11.320 don't watch myself, I could gain weight. Then I will 1:03:11.320 --> 1:03:17.720 feel even worse about myself end quote. Yeah. There hasn't 1:03:17.760 --> 1:03:21.400 been very much research on gender identity and PCOS, but 1:03:21.560 --> 1:03:24.400 one study looking at the experience of transgender men with 1:03:24.480 --> 1:03:28.800 PCOS found less gender dysphoria and less negative body image 1:03:28.840 --> 1:03:32.560 in those with PCOS compared to those without interesting there 1:03:32.600 --> 1:03:34.880 is no hard and fast rule for how someone will 1:03:34.920 --> 1:03:38.920 experience PCOS. Maybe there's shame or stigma. Maybe there's confidence 1:03:38.960 --> 1:03:44.240 and power, Maybe there's discomfort or sadness. Maybe there's empathy 1:03:44.280 --> 1:03:47.760 and understanding, and maybe there's everything all at once or 1:03:47.800 --> 1:03:51.560 at different stages of your life. Each experience is unique 1:03:51.560 --> 1:03:55.320 and influenced by a person's inner and outer world. Do 1:03:55.360 --> 1:03:58.920 they have someone or a community of someone's that supports, 1:03:59.040 --> 1:04:03.280 understands and listen to them. Part of what perpetuates stigma 1:04:03.360 --> 1:04:06.640 in PCOS is a lack of awareness surrounding this condition. 1:04:07.200 --> 1:04:09.640 People don't know what it is, and since it affects 1:04:09.720 --> 1:04:12.680 those assigned female at birth, there's a tendency to assume 1:04:12.720 --> 1:04:16.240 that it's a gynecological disorder. And while we don't talk 1:04:16.280 --> 1:04:20.920 about anything down there, down there no limits, that's not 1:04:21.360 --> 1:04:26.800 the light company. Yeah, and this unwillingness to engage with 1:04:26.880 --> 1:04:30.400 PCOS because it's seen as a quote unquote women's disease, 1:04:30.760 --> 1:04:34.400 shrouds it in silence, leading to less understanding and less 1:04:34.440 --> 1:04:37.000 interest in both the general public as well as the 1:04:37.040 --> 1:04:42.320 medical community. Just as society has its expectations of what 1:04:42.360 --> 1:04:45.400 a woman should be, medicine has their own notion of 1:04:45.440 --> 1:04:48.919 what PCOS looks like and how it should be managed. Yeah, 1:04:48.960 --> 1:04:52.960 they do, and often this leads to a much narrower 1:04:53.080 --> 1:04:56.320 view of this condition that excludes people who might not 1:04:56.480 --> 1:04:59.960 fit the you know, quote unquote typical clinical picture. 1:04:59.760 --> 1:05:03.760 R which is phenotype A and B or classic PCOS yep, yep. 1:05:04.120 --> 1:05:07.720 And this results in delays and diagnosis and inappropriate treatment. 1:05:08.640 --> 1:05:12.720 Because of its impact on fertility, PCOS is often seen 1:05:12.920 --> 1:05:17.320 primarily as a condition of heterosexual women who are struggling 1:05:17.360 --> 1:05:20.640 to become pregnant, and treatment is prescribed accordingly. 1:05:20.840 --> 1:05:21.080 Yep. 1:05:22.080 --> 1:05:26.640 This erases the experience of so many people who do 1:05:26.680 --> 1:05:30.680 not fit that description. M hm, oh, you've got irregular periods. 1:05:30.800 --> 1:05:33.120 Let's get you on some birth control so you'll bleed monthly, 1:05:33.600 --> 1:05:36.520 which doesn't take into consideration that someone might not want 1:05:36.520 --> 1:05:37.720 to have periods at all. 1:05:38.200 --> 1:05:42.480 Yeah, maybe sorry, Just like this is my personal opinion, like, 1:05:42.720 --> 1:05:44.240 why would we want to have periods? 1:05:44.280 --> 1:05:45.040 Why? Why? 1:05:45.480 --> 1:05:45.600 Right? 1:05:45.880 --> 1:05:50.200 Some people do? People do? People definitely don't. Uh huh. Absolutely, 1:05:50.680 --> 1:05:53.720 people feel different ways about this. There's no one way. 1:05:53.840 --> 1:05:58.560 Yeah, or maybe your doctor says it's you know that 1:05:58.600 --> 1:06:00.960 facial hair, it's from your hormone imbalance. 1:06:01.200 --> 1:06:03.640 You're a good candidate for electrolysis. Let's set up an 1:06:03.640 --> 1:06:07.520 appointment for you. Again, pointing out ways that you don't 1:06:07.560 --> 1:06:12.320 conform to gender expectations and pressuring you into performing femininity 1:06:12.400 --> 1:06:15.360 and making you feel othered and rejected, whether or not 1:06:15.400 --> 1:06:19.200 it's well intentioned. And then there's you really need to 1:06:19.200 --> 1:06:21.600 try harder to lose weight. It's not healthy. Are you 1:06:21.680 --> 1:06:24.480 exercising at all? You should eat less processed foods. 1:06:24.680 --> 1:06:25.920 You're doing it to yourself. 1:06:26.120 --> 1:06:28.880 You're doing it to yourself. Assuming that someone's weight is 1:06:28.920 --> 1:06:32.320 solely due to poor diet or poor health behaviors not 1:06:32.360 --> 1:06:36.680 related to PCOS, and that's someone's weight is entirely responsible 1:06:36.680 --> 1:06:39.240 for all their symptoms. Oh, you have pain, you should 1:06:39.240 --> 1:06:40.000 try to lose some weight. 1:06:40.800 --> 1:06:45.000 Also, assuming that their weight is the problem at all. Yes, yeah, 1:06:45.040 --> 1:06:48.800 but assuming that their weight, that their BMI is a problem, 1:06:48.920 --> 1:06:53.680 because obesity is a quote unquote disease like oh, it drives. 1:06:53.400 --> 1:06:58.200 Me, and this weight bias in medicine can lead to 1:06:58.400 --> 1:07:03.440 disordered eating, or maybe the doctor will say something like, okay, 1:07:03.600 --> 1:07:05.880 you're sure you don't want to become pregnant, Well, then 1:07:05.920 --> 1:07:08.520 there's not really anything you need to worry about. 1:07:09.160 --> 1:07:12.320 Oh gosh, that one gives me palpitations. 1:07:11.920 --> 1:07:16.280 One hundred percent. And this is you know, as you described, 1:07:16.760 --> 1:07:23.240 PCOS is associated with other health outcomes not related to fertility, right, diabetes, 1:07:23.280 --> 1:07:26.520 cardiovascular disease, high cholesterol, high blood pressure, fatty liver disease, 1:07:26.520 --> 1:07:28.120 and a mutual cancer metabolic syndrome. 1:07:28.120 --> 1:07:32.480 I mean there's like, yeah, sleep apnia, sleep apnia. 1:07:32.600 --> 1:07:33.520 Yeah. 1:07:32.960 --> 1:07:36.720 The author of the psychology of PCOS, who has the 1:07:36.760 --> 1:07:40.400 condition herself, said that in the thirty years since her diagnosis, 1:07:40.600 --> 1:07:44.520 no doctor has ever told her about these other health consequences. 1:07:45.400 --> 1:07:47.840 And I get, you know, n of one anecdote, but 1:07:48.000 --> 1:07:49.880 still that is not a unique experience. 1:07:49.960 --> 1:07:52.040 Well, and I just have to say this is where 1:07:52.080 --> 1:07:55.720 like I honestly was, so I'm a primary care provider, Yeah, 1:07:55.800 --> 1:07:58.400 I care for people with PCOS all the time. I 1:07:58.560 --> 1:08:02.960 was so embarrassed by how little I knew about the 1:08:03.040 --> 1:08:07.240 extent of the metabolic complications and how important they are 1:08:07.440 --> 1:08:10.240 first of all, regardless of BMI. Second of all, like 1:08:11.080 --> 1:08:14.040 to at least screen for despite how flawed our screening 1:08:14.080 --> 1:08:19.160 tools might be, and in everyone like it. Just it 1:08:19.240 --> 1:08:21.720 is not as well known as it should be, despite 1:08:21.760 --> 1:08:25.360 efforts to standardize these guidelines and get this information out there, 1:08:25.360 --> 1:08:27.120 and despite the fact that it is much better today 1:08:27.120 --> 1:08:29.120 than it was like prior to twenty eighteen. 1:08:29.520 --> 1:08:33.080 Yeah, I mean, that's it's very true. And I have 1:08:33.280 --> 1:08:36.600 a study that was reported on It was back in 1:08:36.640 --> 1:08:39.640 two thousand and seven, so prior to twenty eighteen, but 1:08:39.680 --> 1:08:43.000 it was testing US medical residence knowledge of pcos who 1:08:43.040 --> 1:08:43.719 I bet it was bad. 1:08:43.880 --> 1:08:44.040 Oh. 1:08:44.040 --> 1:08:47.840 They found that they scored on average fifty percent and 1:08:47.880 --> 1:08:51.080 that only a subset scored higher than seventy percent, like 1:08:51.280 --> 1:08:53.920 who were specializing in women's health. I think, Okay, yeah, 1:08:54.000 --> 1:08:59.120 huh huh. That is abysmal for a condition that affects 1:08:59.360 --> 1:09:05.000 one intent ten people conservatively assigned female at birth. It's inexcusable. 1:09:05.240 --> 1:09:09.240 And that's also an underestimate, right, Like one estimate I 1:09:09.280 --> 1:09:13.920 saw suggested that seventy percent of cases go undiagnosed. Wow 1:09:14.080 --> 1:09:19.320 wa yeah yeah, if you don't fit the classical clinical 1:09:19.360 --> 1:09:22.280 picture phoenotype A and B. Your doctor might dismiss you. 1:09:22.600 --> 1:09:25.080 They'll point out your weight and say, ah, but you're 1:09:25.080 --> 1:09:28.840 not obese. I don't think it's PCOS. You're thin or 1:09:29.040 --> 1:09:31.519 while you're older, maybe your periods are just slowing down 1:09:31.800 --> 1:09:35.000 even if they've been quote unquote slow your whole life. 1:09:35.520 --> 1:09:39.240 Delays and diagnosis for PCOS are exacerbated by race, by 1:09:39.280 --> 1:09:43.280 socioeconomic status, and by gender identity. The term women's health, 1:09:43.800 --> 1:09:47.840 along with all the other gendered language surrounding PCOS, illustrates this. 1:09:48.560 --> 1:09:51.479 But of course this doesn't apply to all healthcare providers, 1:09:51.520 --> 1:09:55.520 and some people have really great experiences with their individual providers, 1:09:56.200 --> 1:09:59.639 But even for them, even for those providers and overall, 1:09:59.720 --> 1:10:04.240 lack of knowledge about PCOS is limiting. What might the 1:10:04.280 --> 1:10:07.840 trans non binary experience be like for someone with PCOS? 1:10:08.120 --> 1:10:11.320 What do we know about hormone replacement therapy and PCOS? 1:10:11.960 --> 1:10:15.320 Is a healthcare provider equipped to answer those questions or 1:10:15.600 --> 1:10:20.320 willing to look for the answers? Do the answers even exist? 1:10:21.200 --> 1:10:23.040 There needs to be a shift in the way that 1:10:23.080 --> 1:10:28.080 we diagnose, treat, study, and talk about PCOS. We need 1:10:28.120 --> 1:10:31.160 to incorporate mental health care do a better job educating 1:10:31.200 --> 1:10:36.360 healthcare providers, raise awareness with the general public, improve treatment options, 1:10:36.560 --> 1:10:40.360 conduct more research into every aspect of this, and have 1:10:40.680 --> 1:10:47.160 more compassion and self compassion. Unfortunately, these changes won't happen overnight, 1:10:47.479 --> 1:10:51.400 but progress is being made by advocacy groups, by online 1:10:51.439 --> 1:10:54.760 communities where people can learn and share, and by some 1:10:54.840 --> 1:10:59.080 researchers who are trying to better understand this condition. And so, 1:10:59.120 --> 1:11:01.759 speaking of which, I'll turn it over to you, Aaron, 1:11:01.800 --> 1:11:03.920 to tell us where we stand today when it comes 1:11:03.960 --> 1:11:04.760 to PCOS. 1:11:05.360 --> 1:11:08.760 I can't wait. I have a huge surprise for you erin. 1:11:08.880 --> 1:11:11.519 Oh, okay, I'm going to take this whole thing in 1:11:11.600 --> 1:11:14.040 these last ten minutes and turn it on its head 1:11:14.280 --> 1:11:16.120 and then drop the mic and walk away. 1:11:17.120 --> 1:11:47.080 Ready, okay, yes, please, you said already. 1:11:47.320 --> 1:11:51.880 Most papers cite an estimated prevalence anywhere between five or 1:11:51.920 --> 1:11:55.760 six and twenty percent. Most of the newer papers, like 1:11:55.760 --> 1:11:57.920 the newest twenty twenty three guidelines said maybe ten to 1:11:58.000 --> 1:12:02.240 thirteen percent. Okay, but know the prevalence is thought to 1:12:02.320 --> 1:12:07.200 be relatively homogeneous across the globe, with maybe slightly higher 1:12:07.240 --> 1:12:11.720 prevalence in people of Southeast Asian descent and Eastern Mediterranean descent. 1:12:12.920 --> 1:12:14.080 Underlying that we don't know. 1:12:15.080 --> 1:12:19.200 And there's maybe some data that it's increasing in the 1:12:19.400 --> 1:12:22.519 recent decades, but it's very unclear to me whether this 1:12:22.720 --> 1:12:25.840 is related to any true increases in incidents or just 1:12:25.920 --> 1:12:31.400 increasing awareness and diagnosis or things like that. So when 1:12:31.400 --> 1:12:34.320 it comes to current research, you laid it out for 1:12:34.400 --> 1:12:37.639 us really nicely. Arin, there's a lot to be desired 1:12:38.680 --> 1:12:40.599 for me. I kind of just was like, what do 1:12:40.680 --> 1:12:45.040 I want to know about pcls. We know how much 1:12:45.080 --> 1:12:48.120 insulin resistance is a major factor, but we don't have 1:12:48.160 --> 1:12:51.280 any essays that can really measure insulin resistance, so love, 1:12:52.040 --> 1:12:54.240 I'd love more research on that, and there's certainly people 1:12:54.439 --> 1:12:56.920 doing that, and there are ways to measure it, it's 1:12:56.960 --> 1:12:59.519 just that they're not easy to do Clinically, They're like 1:13:00.320 --> 1:13:04.160 time intensive, labor intensive, expensive, so they can't be used. 1:13:04.600 --> 1:13:06.479 So then people are trying to come up with like, Okay, 1:13:06.479 --> 1:13:09.080 what is something that we can use that like measures 1:13:09.120 --> 1:13:13.080 up to these gold standard versions. There's also a lot 1:13:13.080 --> 1:13:15.519 of work that needs to be done that is being 1:13:15.560 --> 1:13:20.200 done on like understanding some of this kind of higher 1:13:20.280 --> 1:13:24.200 level what is this underlying cause, what is linking insulin 1:13:24.240 --> 1:13:28.559 resistance and this hyperandrogenism. Are these kiss peptins and other 1:13:28.920 --> 1:13:33.080 like peptides and receptors in our brain, in our hypothalamus 1:13:33.120 --> 1:13:36.000 Are those involved? Do we have a master regulator switch 1:13:36.040 --> 1:13:38.680 that we can find that we could target. We don't know, 1:13:39.320 --> 1:13:42.080 but a lot of people are working on potentially looking 1:13:42.160 --> 1:13:48.920 at other targets for medications. I mentioned glps. These are 1:13:49.000 --> 1:13:54.080 all the rage right now. GLP one receptor agonists. We 1:13:54.120 --> 1:13:57.559 need to do an episode on these they I know 1:13:58.200 --> 1:14:01.320 they What would they would be target is in part 1:14:01.360 --> 1:14:04.320 this insulin resistance because what they helped do is kind 1:14:04.320 --> 1:14:08.080 of regulate insulin release from our pancreas. And so there 1:14:08.120 --> 1:14:10.519 was a study that came out recently that looked at 1:14:10.800 --> 1:14:16.759 GLP ones alone plus really interesting combinations of glps plus 1:14:16.800 --> 1:14:22.559 other medicines including estrogen for pcos and they found that 1:14:22.600 --> 1:14:24.519 in some at least in this study which was on 1:14:24.680 --> 1:14:27.000 mice and rats, I actually don't remember if it was 1:14:27.040 --> 1:14:30.519 mice or rats, but they found a better treatment like 1:14:30.560 --> 1:14:33.360 alleviation of all of the various things that they look 1:14:33.400 --> 1:14:37.080 at in mice and rats with pcos then compared to 1:14:37.120 --> 1:14:42.080 met foreman, which is very interesting. The GLP plus estrogen combination. 1:14:42.160 --> 1:14:48.680 Yeah, the effects are so broad, so broad, it's really fascinating, 1:14:48.880 --> 1:14:52.000 and it goes like way beyond. It's like, you know, 1:14:52.520 --> 1:14:57.880 weight loss from GLP ones versus weight loss from not 1:14:58.040 --> 1:15:01.679 golp ones, and it's like there are extra effects. Yeah, 1:15:01.720 --> 1:15:03.480 Like it's just like what's happening. 1:15:03.240 --> 1:15:06.439 Well, And like the cardio the cardiologists are on the 1:15:06.720 --> 1:15:10.280 cardiovasca effects are so good, the Kid's protection, the and. 1:15:10.280 --> 1:15:14.280 Care episode on jlp ones and cardiovascular disease and heart 1:15:14.280 --> 1:15:16.600 failure especially, so if you are interested. 1:15:16.360 --> 1:15:19.959 Check out it's it's pretty major. They're also still very expensive, 1:15:20.040 --> 1:15:21.800 and any new drugs that have come out were going 1:15:21.840 --> 1:15:26.680 to be even more expensive, so that's another thing too. No, 1:15:27.760 --> 1:15:29.599 but here's where I want to take this whole table 1:15:29.600 --> 1:15:33.920 and flip it over. Ready for this, we have talked 1:15:33.960 --> 1:15:41.720 so far exclusively about PCOS polycystic ovarian morphology as a 1:15:41.800 --> 1:15:45.880 disease of people assigned female at birth, as in people 1:15:46.000 --> 1:15:52.160 with ovaries. However, polycystic ovarian morphology is not necessary to 1:15:52.280 --> 1:15:57.280 the definition right and in fact, the presence of ovaries 1:15:57.520 --> 1:16:03.440 themselves may not be in the metabolic phenotype of PCOS. 1:16:03.439 --> 1:16:06.679 That's a quote from one of the papers. Because we 1:16:06.800 --> 1:16:13.720 see very similar metabolic abnormalities and very similar hormonal disruptions 1:16:13.760 --> 1:16:17.599 in terms of free testosterone DGS, sex hormone binding globulin. 1:16:17.680 --> 1:16:22.600 Looking at all of these hormones in both people assigned 1:16:22.680 --> 1:16:27.200 female at birth with ovaries and in people with testicles. 1:16:28.160 --> 1:16:32.680 All right, so, huh, what's happening? What's happening? Aaron, I 1:16:32.760 --> 1:16:38.080 dug deep into this. I'm glad because there is a 1:16:38.200 --> 1:16:42.720 male equivalent that likely exists. However, it does not have 1:16:42.920 --> 1:16:46.200 a clinical definition, It does not have any clinical criteria. 1:16:46.600 --> 1:16:49.759 There are plenty of papers on it. Let's get into it. Yeah, 1:16:50.000 --> 1:16:53.880 we see in family members like male family members of 1:16:53.920 --> 1:16:58.080 people with PCOS, either siblings of or children of people 1:16:58.080 --> 1:17:03.960 with PCOS, in incidence in things like early onset androgenic 1:17:04.000 --> 1:17:07.639 alopecia so male pattern hair loss before age thirty five. 1:17:08.720 --> 1:17:13.200 We also see increases in metabolic syndromes including insulin resistance, 1:17:13.240 --> 1:17:18.000 type two diabetes, dyslipidymia, hypertension, cardiovascular disease, And in studies 1:17:18.000 --> 1:17:20.320 that have actually looked at this, we see a similar 1:17:20.360 --> 1:17:24.760 androgenic hormone profile. We can see increases in things like dhgas. 1:17:24.960 --> 1:17:28.559 We can see increases in antimulearian hormone males also make 1:17:28.600 --> 1:17:32.600 it and LH and FSH, and sometimes we see it. 1:17:32.720 --> 1:17:35.479 Sometimes we see a decrease in free testosterone, but then 1:17:36.080 --> 1:17:38.920 an increase in these other types of testosterones and things. 1:17:39.000 --> 1:17:43.320 So anyways, it is hypothesized based on all of this 1:17:44.000 --> 1:17:47.200 that first of all, there is in fact a similar 1:17:47.479 --> 1:17:52.320 metabolic and hormonal profile that is essentially a male equivalent 1:17:52.479 --> 1:17:57.400 a person with testes equivalent to PCOS, and that early 1:17:57.520 --> 1:18:02.320 onset male pattern hair loss is possibly one like physical 1:18:02.640 --> 1:18:07.599 visual marker for this syndrome. Except that about thirty percent 1:18:07.920 --> 1:18:12.520 of people assigned MAIL at birth have early onset androgenic alopecia. 1:18:12.840 --> 1:18:15.439 So does that mean that it's just not as specific 1:18:15.479 --> 1:18:17.719 as a marker. Does it mean that the incidence is higher? 1:18:17.880 --> 1:18:19.800 What does that mean we don't have multiple. 1:18:19.439 --> 1:18:22.120 Causes of it that exactly are not related to this syndrome. 1:18:22.200 --> 1:18:24.639 Yeah, And when we look at like the actual gen 1:18:24.680 --> 1:18:27.080 lo side that we know are associated with PCOS, we 1:18:27.120 --> 1:18:29.559 see those gene lo sie in these males that have 1:18:29.640 --> 1:18:33.720 these other symptoms. And yet when I, for example, when 1:18:33.760 --> 1:18:35.680 on up to date, which is where I often go 1:18:35.920 --> 1:18:38.280 as a clinician, but also when I'm like, does this 1:18:38.439 --> 1:18:41.280 and did I just miss this. It is nowhere mentioned 1:18:41.360 --> 1:18:43.360 on the PCOS page when I tried to look up 1:18:43.400 --> 1:18:44.640 like male equivalent. 1:18:44.200 --> 1:18:45.040 PCOS, it does. 1:18:45.640 --> 1:18:48.320 It's not a thing AARON because we don't have any 1:18:48.560 --> 1:18:49.839 test for it. 1:18:50.560 --> 1:18:56.640 Or presumably very many treatments. If somebody wants treat it 1:18:56.640 --> 1:18:57.120 would be. 1:18:57.120 --> 1:19:01.120 The same things in terms of like the metabolic symptoms, right, 1:19:01.120 --> 1:19:03.519 so we'd be talking about we'd be talking about met foreman, 1:19:03.560 --> 1:19:06.599 we'd be talking about and these other things. What would 1:19:06.600 --> 1:19:09.160 we need to do to treat the male pattern hair loss? 1:19:09.160 --> 1:19:11.800 Maybe we do the same kinds of things that we 1:19:11.840 --> 1:19:13.760 would do in females. 1:19:13.920 --> 1:19:18.519 But yeah, we don't have AARON. We don't. We do not. 1:19:19.240 --> 1:19:22.120 This is not recognized as a clinical condition. I want 1:19:22.160 --> 1:19:25.479 to make that very clear. But it is recognized in 1:19:25.520 --> 1:19:29.479 the literature dating back a couple decades, huh, at least 1:19:29.479 --> 1:19:35.600 a decade. And I feel like this highlights so PCOS 1:19:35.600 --> 1:19:38.400 for me, like the biggest takeaways that I have from PCOS, 1:19:38.439 --> 1:19:41.559 aside from just like how much we don't know, is, 1:19:42.040 --> 1:19:45.760 first of all, how much what we think of as 1:19:45.840 --> 1:19:51.960 binaries in medicine are spectrums, right, And where we put 1:19:52.040 --> 1:19:56.439 our cutoff markers, what is abnormally high testosterone for a female, 1:19:56.800 --> 1:20:01.120 what is abnormally low free testosterone for a male? All 1:20:01.200 --> 1:20:04.639 of this is somewhat arbitrary, right, and we've known this 1:20:04.680 --> 1:20:06.920 for a long time, but it becomes so much more 1:20:06.960 --> 1:20:10.640 important when we're looking at a condition like PCOS. 1:20:10.960 --> 1:20:14.840 Right, I find it very interesting, like this is I 1:20:14.840 --> 1:20:18.280 think that, yes, this is very revealing of the way 1:20:18.280 --> 1:20:26.000 that medicine considers bodies and binaries. And I'm just like 1:20:26.080 --> 1:20:31.479 thinking about this, like the male version of PCOS. What 1:20:31.600 --> 1:20:33.960 does that like? That should be able to tell us 1:20:34.200 --> 1:20:36.760 more about the root cause. 1:20:36.600 --> 1:20:40.080 It should, right, it should if we started looking at 1:20:40.200 --> 1:20:43.240 we started looking at why aren't we looking at it? 1:20:43.320 --> 1:20:45.120 I mean, there are people who are right because these 1:20:45.120 --> 1:20:45.880 papers exist. 1:20:45.960 --> 1:20:47.920 I know that you said that this is this is 1:20:48.120 --> 1:20:50.240 two decades old, or people start looking at you. 1:20:50.960 --> 1:20:53.120 It's more than ten years old. So two decades might 1:20:53.160 --> 1:20:54.200 have been an exaggeration. 1:20:54.240 --> 1:20:55.920 I don't remember when the first paper. 1:20:55.720 --> 1:21:00.840 Was because I feel like in this case, then the 1:21:01.400 --> 1:21:04.680 thing that really struck me about PCOS is that we 1:21:04.800 --> 1:21:09.080 are failing to capture people. We are failing to meet 1:21:09.120 --> 1:21:12.639 the needs that they have in many different ways. Sometimes 1:21:12.680 --> 1:21:14.840 that means we're not giving them the treatments that they want. 1:21:15.000 --> 1:21:18.479 We're not diagnosing them. Sometimes it means that we are 1:21:19.240 --> 1:21:22.120 giving them treatments they don't want, right, and that, oh, 1:21:22.200 --> 1:21:26.520 the birth control actually worsens your symptoms of anxiety and depression. 1:21:27.600 --> 1:21:29.880 And also I don't want periods, so I don't need 1:21:29.920 --> 1:21:36.600 to bleed monthly. But we also it's just like it 1:21:36.880 --> 1:21:42.120 shows our narrow view of this and how difficult it 1:21:42.200 --> 1:21:47.559 is to change these to change these perspectives and to 1:21:47.720 --> 1:21:50.960 like broad and actually broaden a clinical picture of something. 1:21:51.600 --> 1:21:58.840 It also, for me, highlights how stigmatized women's health is 1:21:59.160 --> 1:22:05.120 one percent because if you label a disease polycystic ovarian syndrome, 1:22:05.760 --> 1:22:11.040 inherently you assume it only affects people with ovaries, which 1:22:11.080 --> 1:22:13.600 means that we're ignoring it, we're dismissing it, we're not 1:22:13.680 --> 1:22:18.120 funding its research, which means that everyone's health is compromised 1:22:18.479 --> 1:22:21.360 because women's health affects men's health too. 1:22:21.640 --> 1:22:23.320 Women's health is health, it's human. 1:22:23.560 --> 1:22:27.040 It is human health, okay, And whether you have ovaries 1:22:27.080 --> 1:22:29.200 or whether you have testes, we should be looking at this. 1:22:31.479 --> 1:22:32.960 That's like my big rant. 1:22:33.400 --> 1:22:38.240 I feel like I have learned so so much huh 1:22:38.320 --> 1:22:42.120 about everything I know medicine about PCOS, but also about 1:22:42.160 --> 1:22:45.960 medicine and society and perspectives. 1:22:45.320 --> 1:22:49.479 And yeah, I know, and it just yeah, there's so much, 1:22:49.520 --> 1:22:53.639 there's so much still that we don't know. Yeah, especially 1:22:53.680 --> 1:22:57.000 like you were saying about the long term potential for 1:22:57.080 --> 1:23:03.759 complications postmenopausal PCOS PCOS intestines. You can't call it PCs. 1:23:03.800 --> 1:23:06.799 There's a paper that isn't yet published. Actually it's printed 1:23:06.840 --> 1:23:09.880 as a preprint, so presumably it will be published soon, 1:23:09.880 --> 1:23:11.679 but I do have a link to it. That's about 1:23:11.720 --> 1:23:14.120 how we need to rename PCOS because it's such a 1:23:14.120 --> 1:23:18.120 false name, like it's such a misnomer, and so we'll 1:23:18.120 --> 1:23:21.960 see what changes. Maybe it will change soon. What will 1:23:21.960 --> 1:23:22.479 we call it? 1:23:22.520 --> 1:23:23.040 I don't know. 1:23:24.000 --> 1:23:26.679 Someone was like this, I feel like I read something somewhere, 1:23:26.680 --> 1:23:28.160 and I wish I had kept the quote in, But 1:23:28.200 --> 1:23:32.639 it was like, this name is so ingrained in medicine 1:23:32.640 --> 1:23:35.800 that it's going to be as easy to change the 1:23:35.920 --> 1:23:38.280 name and get people to accept it as it is 1:23:38.320 --> 1:23:41.360 to find the ultimate cause which will then force a 1:23:41.479 --> 1:23:44.560 name rechanging or something like that, our name change. 1:23:45.920 --> 1:23:46.880 Yeah, I know. 1:23:47.320 --> 1:23:50.120 Yeah, Well, if you want to read so much more, 1:23:50.479 --> 1:23:52.800 so much, we can tell you so much about it 1:23:52.960 --> 1:23:55.599 or where to find it rather on our website. 1:23:56.520 --> 1:24:00.400 Yep okay I once again the book The secon Cology 1:24:00.439 --> 1:24:03.360 of PCOS by doctor Stacy Williams. Great book, check it out. 1:24:03.439 --> 1:24:05.800 And then for like the overall history kind of part 1:24:05.800 --> 1:24:08.160 of it, there was a paper I have a few, 1:24:08.160 --> 1:24:10.479 but there was a paper by Aziz and Adashi from 1:24:10.479 --> 1:24:13.280 twenty sixteen called Stein eleventhal eighty years on. 1:24:14.680 --> 1:24:17.080 I've got links to both the twenty twenty three and 1:24:17.240 --> 1:24:21.479 the twenty eighteen guidelines on the recommendations like evidence based 1:24:21.479 --> 1:24:25.120 Recommendations for Assessment and management, so those are both. There 1:24:25.920 --> 1:24:29.040 two papers that I loved that were just overviews of PCOS. 1:24:29.120 --> 1:24:32.000 One was from the Lancet Diabetes and Endocrinology from twenty 1:24:32.000 --> 1:24:36.439 twenty two, just titled Polycystical Variant Syndrome. And the other 1:24:36.479 --> 1:24:39.719 one is from BMJ Medicine from twenty twenty three titled 1:24:39.720 --> 1:24:45.360 polycystico very Syndrome, Pathophysiology and Therapeutic Opportunities. And then those 1:24:45.479 --> 1:24:49.000 couple of papers that I loved about the male equivalent 1:24:49.320 --> 1:24:56.360 of PCOS. One was titled Male Equivalent polycystico Variant Syndrome Hormonal, 1:24:56.360 --> 1:25:00.240 Metabolic and Clinical Aspects, and that was by Diguardo all 1:25:00.280 --> 1:25:02.719 from twenty twenty, and there's another one too from twenty eighteen. 1:25:03.680 --> 1:25:06.400 So you can find the list of sources from this 1:25:06.479 --> 1:25:09.800 episode and all of our episodes on our website, this 1:25:09.800 --> 1:25:12.599 podcast wikill you dot com under the episode stap yep. 1:25:12.720 --> 1:25:18.040 You can thank you again to Logan for providing the 1:25:18.040 --> 1:25:21.200 first hand account. We cannot, we don't have the words 1:25:21.200 --> 1:25:22.680 to thank you, but it means so much. Thank you, 1:25:22.720 --> 1:25:23.599 Thank you, it does. 1:25:23.680 --> 1:25:24.679 Thank you so much. 1:25:25.760 --> 1:25:28.439 Thank you to Bloodmobile for providing the music for this 1:25:28.560 --> 1:25:30.440 episode and all of our episodes. 1:25:30.800 --> 1:25:34.400 Thank you to Leanna and Tom and Brent and Pete 1:25:34.479 --> 1:25:38.240 and Mike and Jess and everyone else that's exactly right 1:25:38.320 --> 1:25:39.919 for making all of this possible. 1:25:40.320 --> 1:25:44.320 Yes, thank you, and thank you to you listeners. We 1:25:44.439 --> 1:25:48.200 hope that you also learned something from this or I 1:25:48.200 --> 1:25:51.600 don't know, Yeah, tell us what you think if you 1:25:51.720 --> 1:25:54.840 knew all of this already. Wow, yeah, that's impressive. Teach 1:25:54.920 --> 1:25:58.879 us something please, and thank you as always to our patrons. 1:25:58.960 --> 1:26:02.200 Your support me the absolute world to us. Thank you, 1:26:02.600 --> 1:26:05.920 Thank you well. Until next time, wash your hands 1:26:06.000 --> 1:26:07.040 You filthy animals.