PCOS - Polycystic Ovarian Syndrome. Fertility, Weight and ‘Balancing Hormones.’ Uncut with Dr Izzy Smith
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This episode was recorded on Camaragal land. Hi guys, and welcome back to another episode of Life Uncut. I'm Brittany. And I'm Keisha. And I'm here for a special reason today because...

not only am I feeling in falora, but I also have the condition that we're going to talk about. Absolutely. So we do have a very special guest and friend of the podcast, Dr. Izzy Smith with us. This is not Izzy's first time on the podcast. We had Izzy back in 2021 where we did an episode on PCOS and endometriosis.

We then did an episode on PMDD, and today we're going to be revisiting our episode in a way back in 2021 to talk about PCOS. The reason for that is our very own Keisha does have PCOS, and Keisha, you've been really open about that over the last couple of years, spoken about it a lot on the podcast, and well, I shouldn't say a lot. We've dabbled in it. But this is one of those episodes and those topics that has been requested so much by you guys recently.

And it really made us realize that even though we did touch on it a couple of years ago, there's so much misinformation and misunderstanding about, I think, a lot of women's issues, but endometriosis and PCOS together. A lot of people conflate the two. A lot of people don't understand what they are. If maybe they have one, there's a lot of misdiagnosis. And just to let you know who Izzy is again, if you have forgotten, she's an endocrinologist who has specialist training in women's health.

PCOS, amenorrhea, menopause, thyroid dysfunction, eating disorders. You really do do it all, Izzy. And we're so grateful that you're back today to talk about this very important topic. Thanks, Britt. I feel quite nostalgic thinking about that episode in 2021. In my house? The podcast was a bit different then.

A bit different. That's when we became friends. It was. It was four years ago now. But here we are today. Exciting. Thanks for coming in. My PCOS story, I think, is not all that uncommon. I was trying to think about this this morning and I actually cannot remember when I was diagnosed, but it would have to be about...

I think it was about four years ago now. Yeah, three, three and a half years ago. Yeah, and like I said, not an uncommon story in the sense that I had been to at least three different GPs, many of them multiple times over the space of, I would say, more than eight years with the symptoms that I was experiencing. And I was kind of, I guess I would say that I was going to them with some complaints about a few things that we will get into, some symptoms, I guess, of PCOS.

And it wasn't until I actually went and saw a dermatologist and I went to see a dermatologist because I had adult acne, really bad along my chin line, that type that's really sore, quite hormonal and quite painful. And it was through the process of going on a medication with my dermatologist that I actually got some blood work done. And she was like, this is kind of symptomatic of something. I want you to go and see an endocrinologist.

That is how I ended up finding out that I had PCOS. And what I mean by this story of like a lot of people find out that they have it through ways that are not because they're going to their doctors with PCOS, it's as they're investigating other symptoms or maybe other conditions that they might be trying to rule out that I think that they can go, oh, hang on a second, this all makes sense.

PCOS is often really misunderstood. Can you just give us a brief overview of what the condition is and what's happening in our body on a hormonal level? So PCOS stands for polycystic ovarian syndrome. It's a bit of a silly name because the ovaries don't have cysts. It's actually polyfollicular, so lots of follicles in the ovary.

PFOS, we're renaming today. Yeah, it could be called ovulatory hyperandrogenism dysfunction syndrome. It doesn't really flow off the tongue though. No one's going to know that. We'll give it an acronym. So with polycystic ovarian syndrome, it's a very broad spectrum of different symptoms related to essentially ovulatory dysfunction, so our ovaries.

whether they're making too much male hormones, so what we call hyperandrogenism, and that can cause pimples, increased body hair, thinning of the hair on our head, so the hyperandrogenism aspect. It also can cause ovulatory dysfunction in terms of missed periods, so fertility or buildup of the endometrium, which is a risk factor for endometrial cancer can happen. And we also know it's associated with increased risk

risk of metabolic syndrome. There's insulin resistance, increased risk of developing diabetes or cardiovascular disease down the track. And really it all flows from abnormal communication from the pituitary, so a gland in our brain that controls the ovaries and the ovaries and also our adrenal glands to some point. But it really is a very broad condition and some people might have really severe high levels of androgens, no periods for years.

type 2 diabetes, all of those metabolic syndromes, or people might just have an occasional slightly irregular period. So I do see PCOS in the popular kind of media put into one category, which of course you can't give individual complex medical advice and explanations in media and social media, but really it's such a broad condition and each person's PCOS would be kind of different.

Is that why it's so often misunderstood and misdiagnosed? Because everyone's symptoms vary so much. And I guess in saying that, what are the other variations that we're seeing from person to person? I know you just gave us two. Why is it misdiagnosed? It's interesting with Keisha telling me her story because I'm

I'm obviously biased. I'm an endocrinologist. I'm always thinking about hormones. But if I had a young woman who was having acne, the first thing I would think about would be checking her testosterone levels and thinking about PCOS. PCOS occurs in around one in nine women in reproductive age group. So it's really common. When I explain PCOS to patients, I say these are the four domains I'm worrying about. The high levels of androgens,

So increased body hair, you know, acne. And their sex hormones, is that correct? Yeah, androgens and testosterone. Okay. So we see with the polyfollicular, all of these little follicles develop and rather than one follicle develop into the main one that's then ovulated and that's how fertility happens, we ovulate.

And if that is fertilized, it becomes a pregnancy. If it doesn't, you make progesterone, then those hormone levels drop and you have a menstrual period. If you don't ovulate, you don't have that increase in progesterone and you don't have the trigger to then have a menstrual period. So in PCOS, you've got lots of follicles, hence the name, polycystic, should be polyfollicular, and they make more testosterone compared to estrogen than normal.

So the increased acne, body hair, that's what we call the hyperandrogenism symptoms. And then the irregular periods because you're not ovulating. So people might have, we say a period more than 35 days is abnormally long, a cycle length. So definitely if there's less than eight periods per year, we call it oligomenorrhea or they can have the term amenorrhea, which is no periods. Mm-hmm.

And then that's obviously, if you're not ovulating, you can't conceive a pregnancy. So fertility is an issue. And then because there is this insulin resistance associated with it, there is those metabolic syndromes, the diabetes challenges, you know, people find it hard to lose weight with PCOS.

And the other fourth domain that I always talk about is there is an increased risk of mental health conditions, anxiety and depression. And for my patients with PCOS, I always do some type of validated mental health screen because we know that's really common. It's a bit of chicken or egg. Is it the abnormal hormones that are causing the PCOS or is it the symptoms of PCOS impacting someone's mood and mental health? So in reality, I think it's a bit of both.

Why it's misdiagnosed, it's also because they're nonspecific symptoms of, you know, in saying that, I can't believe it's misdiagnosed. If somebody has irregular periods, that needs to be investigated and not someone just put on the pill. That's a band-aid. It has a useful role, the pill and PCOS, but we need an underlying diagnosis. Well, you're not finding out the source of the issue, are you? You're like, oh, this will fix whatever it is. Exactly. And...

I think part of the issue is our medical system with 15-minute appointments, seeing a different doctor every time. You can't have, and I'm really lucky I have 45 minutes with my patients the first time I meet them. I also see PCOS incorrectly diagnosed. Sometimes a young woman might have irregular periods because she's developing an eating disorder and she has one pimple and someone goes, oh, you've got PCOS. And then she's told to lose weight and just exacerbates the eating disorder more or it's

Also because it's really common to have those polycystic findings on ovary in young women. So the diagnostic criteria actually changed 2023 that we don't look at the ovary criteria for diagnosis in women who are less than around 10 years after their first period. And again, I often see women have an ultrasound at 18. They're told they have PCOS-19.

when they really didn't. And I'm often educating women later in life, no, you never had this condition. You had a normal variant of polyfollicular ovaries, which is common in about 30% of people, especially young women. That's really interesting because I remember getting that pelvic ultrasound and I remember looking at the screen and going –

What are those bubbles? Follicles. What is going on there? And it turns out that, yes, they did also have, I thought it was PCO, so the polycystic ovaries. Maybe it was polyfollicular ovaries. It is still called polycystic ovaries. It's just I'm being a nerdy doctor who's pernickety about terms.

But yes, let's not confuse people. It's definitely PCOS. But I do think it's important. And the thing that I thought was quite interesting at the time, as you who told me this is, is that having cystic ovaries does not mean that you have polycystic ovarian syndrome and vice versa. And I think this also kind of comes into how it is quite a hard condition to diagnose because

I had elevated levels of androgens, but your hormone levels can change throughout the day even. Like not even from day to day or week to week or month to month. It can be within the same day based off of a lot of different things. And I do worry that there's this increase in at-home hormone testing or seeing a non-medical practitioner who has, in inverted commas, done blood work analysis training. And there is so much emphasis on a blood test result. And...

Really, a blood test is one data point in time. It does not tell you the whole picture. And that's where the clinical experience is incredibly important. And I do think doctors get a bit of a bad rap at times, understandably, but we cannot expect GPs who are generalists, who can relocate a shoulder,

do a newborn baby check, look after someone in pregnancy, cut out a skin cancer to be experts in, for example, polycystic ovarian syndrome. But what we need is better education to know when to maybe refer to a specialist if required. But yes, large cysts are not PCOS at all. Large cysts are a large cyst and they're painful, whereas polycystic ovarian syndrome doesn't have large cysts and is in a painful condition. We see that confused in the media all the time. So does PCOS...

cause fertility issues? And if so, why? If you've still got your period, sorry. I mean the actual cysts themselves. So if you are ovulating each month, you have a chance to conceive a pregnancy. What I see with women with PCOS is they might have a 45-day length cycle. So that means rather than 12 chances per year to conceive a pregnancy, they've only got eight chances per year to conceive a pregnancy.

Now with PCOS, I'll just quickly briefly explain the diagnosis. We say people need to have two of three things and that is the irregular periods, high levels of androgens and the polycystic ovary findings on ultrasound. Now we also include a high level of AMH, the egg reserve test, anti-malarian hormone. So we need two of those three.

Then we also further categorize it to lean PCOS or overweight PCOS. It's a bit of a silly definition because if someone has a BMI of 24.9, they're counted as lean PCOS, but if their BMI is 25.1, they're overweight PCOS. In reality, it's more if there's that obvious insulin resistance type 2 diabetes. So if someone is having irregular cycle length,

their fertility can be impacted. And also if they have some of those associations, so insulin resistance, mild type 2 diabetes,

carrying excess weight, obesity, that can also impact fertility as well. So fertility is an issue with PCOS in saying that lots of people with PCOS have no fertility problems. They might more have the high androgens whereas their menstrual cycle is fine. Can we talk about insulin resistance? And I think it actually kind of couples with this whole fertility conversation. I think a lot of the PCOS things, it all kind of goes hand in hand.

Is insulin-resistant PCOS a separate condition to other PCOS or how does that work and what is insulin resistance? So insulin is a hormone our pancreas makes to help glucose get inside our cells. It's also important for fat storage and energy balance metabolism. Insulin resistance is when your body doesn't respond to insulin properly and you need to make higher levels of insulin to achieve the job that insulin does.

Most people with PCOS have some degree of insulin resistance and they're probably also sensitive to insulin resistance. So

We've done studies where we give people high levels of insulin through a drip, high levels of glucose, high levels of insulin, and we see the pituitary, so the gland that controls the ovaries, the balance of the LH and the FSH, which we're getting pretty sciencey here, but that is part of the underlying cause of PCOS is high LH to FSH ratio. We see the high levels of insulin cause that. So it's...

probably that people who have insulin resistance and their pituitary is very sensitive to that insulin resistance are the ones at risk of developing PCOS because lots of people have insulin resistance and don't have PCOS. And most people do have a degree of insulin resistance. The figures are quoted about 75, 80%. But

some people it might be so mild that it's not picked up in standard testing. The data we have is based on these really fancy studies called like a, you know, insulin hyperglycemic clamp test where we get someone in the lab, we give them, you know, a glucose and insulin infusion and we can pick up even mild insulin resistance. That's not appropriate for the everyday person. They're not going to go and sit in a research lab for six hours. But we do see people who are, you know, lean are

are more likely to have insulin resistance if they have PCOS compared to someone who

who doesn't have PCOS. So, you know, the insulin resistance is a part genetic and lifestyle factor. And most people with PCOS have some degree of insulin resistance. And that was why most people respond so beautifully to a medication like metformin or, you know, the supplements, mino, inositol and exercise. I remember with my diagnosis, I got lots of bloods done over the course of a couple of different months. And I also had to do a glucose tolerance test.

And so I think a lot of women who are pregnant will be familiar with this because it's a gestation. Make sure it's chilled. Yeah. It's similar to like a gestational diabetes. It's exactly the same. Yeah. So basically you go into the doctor's office, you get your blood taken, you drink the most disgustingly sweet drink I have ever had in my life. I actually had to lay down multiple times because I thought I was going to vomit. It was disgusting. Imagine doing that in pregnant or

me. Oh, my heart goes out. People vomit sometimes and the poor things have to go and do it again. Yeah. And so I had blood taken an hour later and then another hour later. So two hours post drinking this syrup. And I remember being a little bit confused by this because I was told that I like puffed

the test by the standard of type 2 diabetes. So I knew that I didn't have type 2 diabetes, but from what I remember, and this was years and years ago, my endocrinologist did say, like, you're showing quite severe signs of insulin resistance and this is why we need to go down a bit of a medication path. Can you explain how a medication that impacts insulin impacts or I guess alleviates a lot of the symptoms of PCOS? So Keisha, it's a great example that when

We need to have a lot of experience when we look at test results because something can be just within normal range. That's very different if the levels are right at the lower end of the reference range. And your endocrinologist probably also looked at something called sex hormone binding globulin, which is lowered in insulin resistance. They probably looked at your triglycerides, your liver function tests, all of these things together and found

made her think, I know her because I work at her practice. Yes. And also I remember taking the sheet to you and being like, Izzy, I got my results. I got a patient copy. Do you want to have a look at them? And so they would have put all of those things together and said, you probably have some degree of insulin resistance.

And so we give a medication. Usually it's metformin is the first line. We know it has a lot of evidence for lowering androgens and improving menstrual cycle. And it improves our cells' ability to respond to insulin. It also decreases how much glucose our liver makes.

and therefore we are decreasing how much insulin we're making and that is improving the pituitary from, you know, the messages from the brain to the ovary, that LH to FSH ratio, also benefiting the ovaries themselves are sensitive to the high levels of insulin. So lowering the insulin levels improves that dysfunction that is causing the increased androgens and the irregular menstrual cycle. Also can help with weight loss as well for patients with PCOS as well.

Can you completely cure PCOS once you have it or do you just get it to a manageable, maintainable level? It's a great question. So someone will always have a disposition to having PCOS. For example, Keisha, you probably have a degree of genetic insulin resistance with a genetic predisposition to PCOS. We know it runs in families.

However, again, it's individualized, but someone can have lifestyle changes. Maybe they lose a little bit of weight or they're on metformin and there is no evidence of their PCOS.

Could they develop PCOS again in the future? Definitely. But you can manage it and have all of the symptoms managed, but you still have that predisposition. Iz, I'd love to talk about weight. And I just want for everyone listening to be aware of the fact that this is a pretty complex conversation to have because we live in a society that is fat phobic. We have had so much diet culture messaging. I even remember when I was diagnosed with lean PCOS, I remember saying to my doctor,

Firstly, I don't feel lean. I feel like I can look at food, I could sniff it and put on weight from it. That's kind of the relationship that I had with food to the point where I never felt as though I had disordered eating from a psychological standpoint. I actually felt it was though I needed to have that much control so that I didn't put on anything.

excess amounts of weight because my weight would fluctuate by 10 to 15 kilos like a yo-yo. It's hard to have these conversations while also acknowledging that talking about weight is a tricky thing to do. I just want people to be aware that I know that this could be coupled with

disordered eating like conversation and I don't want for it to be but it is such a hard thing for people with PCOS to manage and I actually would go as far to say that every single woman I've ever spoken to who has PCOS is kind of like how do you manage your weight is how do we navigate these conversations with weight management with PCOS and why is it so important for us to be aware about weight management?

Keisha, you've summed it up really well that it is complex. And I often signpost with my patients because often, firstly, also the other association with PCOS, apart from increased risk of mental health disorders, depression and anxiety, is an increased risk of disordered eating.

And I'm sure in part that stems from going to doctors and them saying, you've just got to lose some weight, eat less, move more. And the negative associations they've had with the healthcare system or within their family. So often my patients are already really stressed about talking to me about weight. And I signpost that at the start and say, this is bad.

complicated and it can be a motive. If you don't want to talk about it today, we don't have to if you do. And I

I explain that in PCOS, we have a lot of research that says, you know, I always say to my patients, I don't care what size someone is, what you look like in a bikini, I'm trying to decrease your risk of cardiovascular disease. I'm trying to decrease your risk of fertility problems. I'm trying to make sure you don't get diabetes. And that's my goals. And trying to do that in a really health focus. With my patients, I never focus on restriction. I go, what do we want to add to your life? Let's add more, you know, veggies, fruits, vegetables.

water, exercise, and that's this more positive mindset because restriction is a punishment. This is exactly what I say to my patients. If we restrict and you have this restriction mindset, you feel like you're being punished for being who you are and we're simple creatures. We don't like punishment. We're not going to do it. This needs to be an empowering, positive thing. And I discussed that some weight loss can help with managing the symptoms of PCOS and

However, even if it doesn't result in weight loss, increasing exercise, a Mediterranean diet that supports that underlying insulin resistance can still benefit PCOS. In terms of why people with PCOS do struggle with weight gain or finding it harder to lose weight, it's a contentious issue. It's contentious of...

You know, is it the PCOS itself that makes it difficult to lose weight or people who are prone to gaining weight are more likely to develop PCOS? I do see, usually for someone who doesn't have PCOS, we have them on metformin, they don't lose weight. When you put some people on metformin, I've had patients who say, I have not changed anything.

I went on metformin and I found it easy to lose weight for the first time. I was the second. Yeah. And so that does show that that insulin resistance and that higher levels of insulin is likely a factor of why people struggle to lose weight. And our bodies aren't these simple closed systems, the energy in, energy out. Yes, to some degree that is true, but all of the factors that impact how much energy is coming in and how much energy is coming out is really complicated. We all know the person who –

you know, lives off takeaway food and is skinny as a rake. And we believe them, but we never kind of believe the person that struggles with their weight who says, I'm eating really healthily. Oh, I'm so glad you touched on that is because honestly, and I'm really also glad that you touched on the psychological aspect of it because there is a point where you're sitting in front of, it could be a GP, it could be a partner, it could be a parent, right?

And I just remember being like, no, but I am. I am exercising. I am eating well. Like I feel like I'm being gaslit by my own body. It was so confusing and there's so much shame built into having PCOS as well. Like you think about the symptoms of cystic acne or adult acne, excess hair growth around your face. You were waxing your moustache for quite a while there. I'm lucky.

unfair. Like people with dark hair, I can only bloody imagine how much you have to deal with this. The side effects of PCOS suck and it really can make you play mental mind games. Adding infertility for people and worrying about their future health. So just quickly going back to the weight thing though, it is interesting. I was at a conference in Boston last year and

And they did have studies showing people with PCOS, if they did do the same weight loss intervention as someone without PCOS, they did still lose similar amounts of weight. That's interesting. So we are gaslighting you, Keisha. Maybe. I mean, my next question on that study would be like, okay, what about long term? You know, what happens after they go off of this, you know, controlled experiment eating plan? What happens next? Because like I said, my weight fluctuated so much like a yo-yo. I was able to lose it.

But I was also able to gain it so insanely quickly. And I just felt like everything was inflamed all the time. I felt as though I was running along the beach next to people, but I was dragging a tire. You know, everything just seemed to be that little bit more hard. That's definitely what I hear from my patients.

and I think there needs to be a lot more research in this area. We do know that losing about 5% of body weight improves insulin sensitivity and that's the therapeutic goal I work with with some of my patients, especially if they've got the irregular menstrual cycles and they've got clear insulin resistance. In saying that, I have...

like Olympic athletes who have PCOS. They're exercising 20 hours a week. If they exercise more, it's not going to improve their PCOS. For some people, this is clearly a strongly genetic issue that needs some medication. And we haven't really touched on the underlying causes, but we know things like our in utero exposure to androgens, potentially some endocrine disrupting chemicals. How do you have in utero exposure to androgens? So,

what your mother's levels of androgens were when you were in utero. And now there's this humongous area of research related to endocrine disrupting chemicals. So like I said, I've got Olympic athletes with PCOS. We know a lot of sports people, team sports. I look through the Matildas player. I'm like, oh, I wonder who her endocrinologist is. You know, a lot of women with team sports, it's about 25% of elite team sport players have PCOS. Wow.

We're genetically wired to be team players. I think maybe the slight high levels of androgens in some role could be beneficial for athletic performance, you know, another area of research. But I guess what I'm trying to say is it's not as simple as just eat less and move more. Some people are Olympic athletes and they still have PCOS. There is a role for medications because a lot of people as well might carry some extra weight and they never develop PCOS. Having said that, what are some of the other external sources like cortisol and stress?

What role does cortisol and stress play in PCOS symptoms? That is a great question. And there is so much on social media demonizing cortisol, despite it being a life-saving hormone. So cortisol is made by our adrenal glands, and it's important for blood pressure and our blood glucose levels. And that's important for our stress response. So if we didn't have cortisol, we would die. Now, what I see on social media, and it really upsets me because it's just so wildly wrong,

is that people with PCOS should not be doing high-intensity exercise because high-intensity exercise increases cortisol and cortisol causes insulin resistance.

Based on that mechanism, and that's a mechanism, there isn't actual study outcomes showing this. Based on that mechanism, anyone who did regular exercise would have insulin resistance and develop type 2 diabetes. Anyone with type 2 diabetes shouldn't do exercise. So it's a lot on social media. We see people talking about a mechanism without actual studies based on people to prove that's

Correct. A lot of fear mongering. Yeah. But you hear that and you go, oh, that's true. It does cause insulin resistance. You know, it kind of can make sense. But if you look at the outcome, you know, especially the, who's the guy, Huberman, loves looking at mechanisms of animal data and then making sure

claims, does this massive jump, one, that that animal data is consistent in humans, which is a big, massive claim, and then also claiming that that mechanism results in an outcome. So there's a lot on social media based on mechanisms. You really want to look at outcomes in people, and we have lots of studies showing exercise improves PCOS. In terms of cortisol, how much does it increase PCOS and its role in PCOS? Hard to know because we really don't have good data. You would have to do

Because cortisol is a hormone that goes up and down, literally second to second, minute to minute. To get good data on this, we would need to be doing 24-hour urine cortisol collections on people all the time. Like every hour. All the time. Yes, exactly. And then seeing how it translates to their PCOS, which we're never really going to do. I will wee for you for 24 hours if you need to. Okay, she will. Okay, but we need you to keep up.

Bridget's a volunteer, isn't she? But you'd have to do it continuously. Right, okay. But I do see that stress.

does impact reproductive health, both turning off periods and PCOS stress. We can't recover if we're constantly stressed. And if we're not recovering, our levels of inflammation stay high. And yes, definitely, I do think psychological stress would have an impact on people's PCOS and their functional hypothalamic amenorrhea. But it's not the cortisol that's the problem. It's the behaviors that are driving the chronic stress. It's

It's frustrating, isn't it? Because, and we've spoken about this in other aspects when we talk about infertility, people trying to fall pregnant. The impact that stress has on the body is huge, but no one in the history of ever stopped stressing when a doctor says you need to stop stressing. So it's one of those things that you understand what stress does to your body and you understand the negative impacts, but it's very hard to tell yourself. And then it's hard as well because we don't have clear evidence.

test to do to go, okay, your stress levels are 7 out of 10. Let's bring them down to 5 out of 10 because I can see X, Y, Z parameter. Sometimes I joke that I'm a fatigueologist. When a patient sees a GP and they've done all the tests and they're just still really tired all the time, they refer to an endocrinologist for, in inverted commas,

hormonal imbalance hormonal imbalance is not a diagnosis yeah you know it's a blanket statement it's a blanket statement but I will see people for their fatigue and I'll do all the tests I'll make sure do they have celiac disease I check them for sleep apnea I'll check for insulin resistance all these thyroid of course things that can cause fatigue but often then I have a good chat with them I go okay so your dad died a year ago then you were made redundant in your job six months ago oh and

you've been doing your MBA on top of this. And you've had a miscarriage and you've got, yeah, all these things. And they really want a abnormal test result. And I go, this is real. You know, you have a condition and that's called chronic stress, unrelenting stress, and that has really negatively impacted your health. Do I have a clear test that I can go, like I said, you're an eight out of 10 stress, let's bring it down to a six? No, I don't. But

I am a doctor and I've had those stressful periods and I know how much it impacts your body and I don't need a test result because I'm so in tune, I would say, with my health to know, okay, this is bad. I need to make some changes. So subjective. Yeah, but it's hard because we want to label. As I always say to my patients, I'm

My job isn't to tell you there's nothing wrong with you at stress. My job is to exclude absolutely everything that could be a medical condition and help you with managing the stress. Let's look through things very objectively. So we shouldn't ever put someone's symptoms or condition just down to stress. We need to exclude everything else. But I

I guess what I'm trying to say is chronic stress really does impact our health. We don't have clear ways of measuring it, but it is real even if it isn't an abnormal test result and doesn't mean you don't deserve to try and work on some, you know, intentional lifestyle changes to make things a bit less stressful. But again, you can't just, you know, okay, cool, I'm stressed. Let me just take this stress supplement and now I don't have all these challenges in my life.

Speaking of supplementation, I would love to get your take on the amount of social media content that is, you know, to target hormonal imbalances. I'll put that in quotation marks for everybody.

And I guess all of these not so much evidence-based content or supplements and things that you can purchase, how do you feel about them and how do we spot the difference? First thing, the reason why we're saying inverted commas hormone imbalance is because we have literally hundreds of hormones and we either usually have a deficiency or an excess of hormone. So there isn't really such a diagnosis.

of a hormone imbalance. Yes, maybe we could say PCOS is slightly higher androgens than estrogen. However, you have excess androgens. That's the diagnosis. All three of us here, me much less than Britt, have some degree of social media platforms.

And we can just acknowledge, we get messages from companies going, hey, do you want to promote this supplement? We'll pay you this much to do a post. So just as an FYI, anytime you see an influencer who's recommending a supplement, it's probably just because she's had a DM asking her to promote that supplement.

I occasionally do paid ads, but it sounds wanky and I sound like the influencer I'm bagging out, but it would only ever be something I really believe in. And as a doctor, I can't recommend any TGA-approved supplement anyway. So for me, it'd be more something daggy, like these are my favorite runners and I don't know, Running Shop gave me a bit of a discount. You know, the whole new world of advertising, influencers have a lot of trust with their audience.

And that builds on that trust. So of course the audience will go, they look great. Their skin's wonderful. You know, maybe I should have that supplement. It's not actually treating something. You need to have a diagnosis and know what you're trying to treat. There are definitely supplements that are beneficial, but a generic supplement for a hormonal condition just doesn't really make sense. Maybe some of them have insulin sensitizing agents. They've got some cinnamon or, you know, some other glycogen.

However, I have had patients who have taken general hormone supplements and ended up in my clinic room profoundly low thyroid hormones because they've taken a supplement with whopping doses of iodine. Or I've seen people with the other really high levels of thyroid hormones because of supplements. What is that like? I'm just thinking now. I've had heaps of people asking me to advertise supplements.

And I've advertised supplements before in the past, but there have always been things that I've already taken. Having said that, I might have been taking supplements like you just said that I thought were doing good for me and adding to my general health that they're not. There are definitely supplements that are like multivitamins and stuff for women because we're always told women should be taking multivitamins and stuff. I take multivitamins. Is that not a thing? For my –

Thoughts with supplements. I say to patients, if you're low in something, a multivitamin is not going to be enough to bring it up. And if you're not low in it, you probably don't need it. So a multivitamin is lots of different things and a little bit of them. They probably don't hurt. We keep doing studies of meta-analysis. Do multivitamins help? They're probably not going to do any harm. Yeah, right. So if it's going to placebo you. Yeah.

It's probably not going to do any harm. There are definitely supplements I recommend, you know, vitamin D, magnesium, sometimes zinc. I take magnesium. Yes. It's really good for almost any women's health issue. You know, PMS, painful periods, perimenopause, magnesium is great. So I do often prescribe supplements.

but I'm prescribing a specific supplement for a specific condition. It's a bit like going, oh, you've got a medical condition. I'm just going to throw a handful of tablets at you and hope it works. One of them will take. But it's also on the patient side, and I've been this person. That's why I can say it. I was in a vulnerable place where I was just looking for help. I just wanted answers, and I wanted something that was going to make the inflammation and the side effects that I was experiencing from PCOS go away. I just wanted them to reduce, and so I was like –

I'll try anything. Something that I know a lot of people, they really like, a lot of people with PCOS, I mean, is the Inositol. Am I saying that right? Literally four years ago when I ran on this podcast, I think I pronounced it wrong and I'm still pronouncing it wrong. My-O-Inositol is an insulin sensitizing supplement and it does have

Some evidence for PCOS, I would usually use metformin because it's funny how we don't mind taking a supplement. We don't want to take a pharmaceutical. When a pharmaceutical is highly regulated, we know what's in it. Whereas a supplement, depending on where it's made, it can be lots of other stuff. But yes, that is a supplement. It does have some evidence for PCOS.

mainly through improving insulin resistance. So for anyone listening, I take Metformin at the moment to improve my insulin sensitivity. What are some other medicinal options for people, whether it be to alleviate a side effect of PCOS or to actually try and treat the underlying cause? Wonderful question.

I'm going to briefly touch on lifestyle because there is heaps on social media. It's not complicated. It's a Mediterranean diet, moderate carbohydrate. Low carbohydrate diets haven't been shown to be really more effective than a Mediterranean style diet. Then it's exercise in line with the National Physical Activity Guidelines, 30 minutes of moderate to vigorous physical activity most days, two strength sessionings. So

Not rocket science, just literally pretty much the recommendations for the general population. Eat well and move your body. Yeah, exactly. And I really do, the Mediterranean diet does have quite a lot of evidence. So I'd really recommend that. And it's delicious. Exactly. Olive oil, lots of veggies, not too much red meat, some lean proteins and good quality carbohydrates, low GI carbohydrates. So that's the lifestyle.

then the exercise, high intensity exercise increases a protein called sex hormone binding globulin, which is like this protein that is a sponge and will sponge up testosterone, which is great. The high levels of exercise can also decrease LH and improve that LH to FSH ratio. So for most of my PCOS patients, that's why I want to

cry and bang my head against a wall when they've said they've been too scared to do high intensity exercise because they're all worse than their PCOS. You're like, please do it. Well, I also think that there's a, because we can sometimes have excess testosterone, I always felt as though I would put on muscle quickly. And because I was already kind of trying to alleviate weight gain, I was like, I don't want to look big and muscly as well. Ask any, you know, gym junkie guy who is

eats chicken and broccoli and brown rice 10 times a day and works out four hours a day, you're not going to get bulky. And the levels of testosterone, they're not that much higher. You might have had a testosterone of 2.2 and normally it's about 1.5. So the absolute levels aren't that high in terms of pharmaceutical and medication. So it's all about what we're trying to achieve. So if I have a

young woman who hasn't had a period in two years and she's got a buildup of the lining of her endometrium. So that's the lining of the uterus, which means she's at risk of endometrial cancer. She doesn't want to have a pregnancy anytime soon. I'm going to say, I think we should pop you on the pill because we just need to look after this endometrium right now. And that's my priority. If so, you know, to get cancer because PCOS can be a risk factor for endometrial cancer.

If someone is in their early 30s and maybe wanting to conceive a pregnancy sometime, of course I'm not going to put them on the pill because we're trying to improve their ovulatory function. I'm going to have them on metformin. I'm going to be doing all of the lifestyle things. And that's really the evidence for improving menstrual cycles.

If their high levels of androgens are more of the problem, we might talk about spironolactone, which is an anti-androgen medication. So it blocks the testosterone receptor. And then after maybe they've had their children, we might think about going back on the pill. Yes, the pill is not going to fix the

underlying PCOS. However, it will help manage the symptoms. And that's why the pill understandably gets a bad rap because the 18-year-old girl with PCOS gets put on the pill and is told, don't worry about your PCOS until you want to conceive a pregnancy. She comes off it at 34 and her periods don't come back. She's got acne and she goes, holy crap, I've got this terrible PCOS that I haven't worked on, I haven't managed.

And I didn't know about. And at 34, you know, we know fertility starts to decline at 35. Maybe she would have tried to conceive pregnancies earlier on if she knew she only had eight chances per year of trying to conceive compared to most people have 12 chances per year. Anyway, what I'm also saying now shows how individualized it is. It's all about the individual in front of you and what their management priorities are.

are. So there's never going to be blanket advice for everyone. What about pretty controversial one at the moment, weight loss medications? So GLP-1s, semaglutide, ozempic, Wegovi, Monjaro, I think is another one. We've also done a whole episode on these with Johan Hari that I will link in the show notes for anyone about those weight loss drugs.

Are they an adequate or a good choice for a medication for someone with PCOS? Firstly, that episode you did was wonderful. Oh, thank you. I appreciate that. I think it explained the nuance of these medications so well because we live in a society that likes to be really divisive and in reality things are much more complicated. I do commonly prescribe these medications, GLP-1 agonists. They have evidence for decreasing PCOS.

heart attacks, strokes, heart failure. Does that mean they're right for everyone? Of course not, but they do have a really beneficial role for some people and they are very effective for weight loss and improving insulin sensitivity. So acting on the liver to decrease the glucose production from the liver, decreasing fat in the liver that's causing insulin resistance. So they do have definitely a role. You can't conceive a pregnancy on these medications. We don't have safety data. So I will

We'll have, for example, if I had a young patient who was not wanting to conceive a pregnancy for a while, maybe she was 28 or 30, and I know she has quite a few years before her fertility really declines, and she had PCOS.

and other complications from her weight, maybe mild type 2 diabetes, high blood pressure, I might say to her, how about we try and focus on a little bit of weight loss to improve those things, improve your fertility and decrease your risk of early miscarriage and stillbirth. We do know obesity, especially at those quite high levels, are associated with increased pregnancy complications. And it's...

I'm going to say again, it's really complicated and challenging discussing weight because, you know, I never talk about weight on my social media because it's such a nuanced thing and I will have talked to the individual in front of me and I'll have these balanced conversations. But I will sometimes, as I said, with that imaginary patient, I might try and use a GLP-1 to help some weight come down to improve fertility and improve fertility outcomes. We would stop it before they were trying to conceive. Interesting.

Speaking about fertility, just so that people at home listening right now really understand it, because the one thing you hear the most is people say, oh, I've got PCOS. I'm not going to be able to fall pregnant. I've got PCOS. It's going to be really hard for me to fall pregnant. Even if they have their periods and a regular cycle, they still are convinced from the fear-mongering and everyone that's just spreading this misinformation. What would you say is the best approach for somebody that is in that situation that wants to conceive naturally?

So my recommendations to my patients is if you have a regular menstrual cycle and you are less than 40, and definitely if you're less than 38,

you are fertile until proven otherwise. And it's such an irony because there's a market trying to get women to test their fertility, which really we do not have accurate tests for. We can test male fertility very easily, but hey, there's no fear-mongering businesses focusing on men's fear. Really, they just do a semen analysis and you can test their fertility much more accurately than a female's. So I would say to my patients, and I say this all the time, if you have a regular menstrual cycle, you are ovulating.

you don't have a fertility condition that you're aware of such a severe endometriosis. And even if you do, you know, you are fertile until proven otherwise.

The best test of fertility is trying to conceive. And it's hard because most things in life we have control over. We can try and make some order from the chaos. But fertility is much more challenging and you've kind of just got to wait until you try. You know, make sure you are ovulating. You don't have any fertility disorders. But the best test is actually waiting until you conceive. The biggest impact that

though of fertility is age, unfortunately. Most people up until they're 40 can conceive a pregnancy. It just might take them longer because more of the eggs have DNA damage. So at 35, about 50% of our eggs have DNA damage. So it means each month it's about a 50-50 chance of if it's a, in inverted commas, good egg. So yes, fertility, regular menstrual cycle. And if you are worried about your fertility, I would say talk to your doctor if there's anything you can do or any concerns.

Last one from me. I've seen a lot of social media fodder about endocrine disruptors to the point where I've actually been a little bit concerned about things like perfumes and I've tried to limit my use of perfumes knowing that we were going to speak to you and I could find out whether it was actually something I needed to be worried about. And like incenses and things like burning in your home. Endocrine disrupting chemicals, EDCs for short, is a terminology we use for

Things in our environment, either natural or synthetic, that impact how our hormones work. So it could impact the actual hormone or it could block the receptor or activate the receptor. So just a smell in the home can do that? It's actually the things that have the main evidence is pesticides. So, you know, if you're a farmer or exposed to lots of pesticides, the next one is plastics.

So increasing research into kind of microplastics and forever plastics. There's a great podcast actually on a science versus if anyone wants on endocrine disrupting chemicals and plastics. And the other one is kind of cosmetic products. Most of the cosmetic products that do have proven endocrine disrupting chemicals, especially in Australia, are not really available anymore. So there has been a lot of change. Europe has really led the way in this.

but they are chemicals, very, very small, that can impact how our hormones work. So it's hard because we don't have good evidence in terms of what we call a randomized control trial. We can't say to a group of people, okay, you wear pesticides and eat out of microwave plastic containers for 10 years and this group don't.

That would be a randomized control trial. All we can do is what we call observational data where we have a group of people and ask them about, okay, do you hate your food in this or look at their levels of microplastics. And that's where we find associations, but we can't find good causation.

In saying that, we do have increasing data that some of these endocrine disrupting chemicals will impact fertility probably through our reproductive hormones or our thyroid hormones. But it's mainly the people that have the very high level of exposure. We live in our world. We can't live in a bubble and not have some exposure. Can't avoid it in this day and age, can you? But the recommendations I say...

is try and avoid plastics. Like heating up food. Here I am with my plastic water bottle, but don't microwave food in plastics. Try and store things if you can in glass containers. If you've got a plastic water bottle, if the water's been sitting there for hours, it's been in your car for 24 hours and it's sat in the sun, I wouldn't drink out of that water. God, I've done that so many times. And obviously pesticides are

My family are farmers, so this is relevant but maybe less relevant to many other people. But, you know, if you own gardening and you're using pesticides, very clear safety. And then, you know, checking your makeup products. But, again, most makeup products in Australia now, the manufacturing has changed. Is that the same for perfume? I don't know why I've seen so much specifically on fragrance in terms of endocrine disruptor social media content. I think probably because it's women who use makeup, so that would be getting a lot more attention. Right.

I can't give specifics on makeup and perfumes as much because there's so many different types of products. There's a few great people on social media. Can I mention some? Yeah. There's someone called The Eco World that does great posts on this. And the Endocrine Society website, that's getting pretty sciencey.

Seems like a good place to go. Yeah, that's the US Endocrine Society. I'm going to a conference there soon. Have some great resources as do Hormones Australia website. But yes, the main things would be, you know, really plastics and pesticides are where most of the research is at. Okay. Well, Izzy, I think you're just the most wonderful person. You are someone who has helped me so much in my PCOS journey. I really appreciate just being able to turn to you and

ask you a lot of questions. And I hope today's episode for anyone listening has either been really validating in the sense that you might have PCOS and you just wanted to learn a little bit more about it. Maybe we've kind of dispelled some of the myths about PCOS, of which I just think there are so, so, so many. Well, it goes back to, again, like we say it all the time, but just to be media literate, just to know where to look and where you're getting your information from. There are going to be people sprouting information

that look like really reliable sources and the way they say things so confidently. But as long as you're going back to these genuinely reliable sources that Izzy just mentioned. I like media literacy. That is such a good term. It is. It's like just being in control of what you're consuming. Yeah. I always say to people, do they have qualifications and are they working in the field? Someone who did a medical degree 20 years ago and has never worked as a doctor or even in women's health, that's actually not a good source. Yeah.

Totally. They need to be recognised by their peers working in the area involved in research. CP, Continued Professional Development. That's a good source. But no, thanks so much, Keisha. That lovely comment made me blush before. But I guess just to summarise, I would say PCOS thesis is common, one in

nine, one in eight women of reproductive age. If any of those symptoms sound familiar, get them checked out by your GP. Find a GP with an interest in women's health. You know, the guy that wanted to do orthopedic surgery and now...

does mainly skin cancer removals. He's not the person to go to about your PCOS and that's not blaming him. We just can't be experts in everything. So see a GP with an interest, maybe see an endocrinologist and, you know, hopefully they can help with some of those symptoms or getting answers. And for anyone wanting to learn more from Izzy, her Instagram, her brand new website will also be linked in our show notes. Thank you. You're the best. Thanks, Keisha and Britt. It was really fun.