The Root Causes And Treatment For PCOS with Dr. Heather Huddleston

Coming up on this episode of the Doctor's Pharmacy.

I think a lot of patients with PCOS sort of end up getting bounced around to different doctors, never really getting great explanations about what's going on with them and what are sort of some appropriate treatment pathways for them.

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Episode of the Doctor's Pharmacy. Welcome to the Doctor's Pharmacy. I'm Dr. Mark Hyman. That's Pharmacy with an F, a place for conversations that matter. If you struggle with hormones, if you've had something called PCOS or knowing someone with it or know anybody with infertility or acne or irregular periods, this podcast might be quite interesting for you because we're going to discuss polycystic ovarian syndrome, a really common problem that affects so many women, maybe five to 10% of women in America and around the world. And we're talking to an expert in PCOS, Dr. Heather Huddleston. She's a professor of OBGYN and reproductive sciences. She's a specialist in reproductive endocrinology and fertility and cares for people with a whole bunch of reproductive and fertility issues. She's really interested in PCOS, polycystic ovarian syndrome, and other things like recurrent pregnancy loss, uterine disorders. She is the founder of the UCSF Multidisciplinary PCOS Clinic and Research Center. That clinic provides care with an integrated group of doctors and providers with expertise in reproductive endocrinology, dermatology, nutrition, I love that, and psychology. She also does a lot of research, oversees programs on how we can understand exercise, depression, cognition, sleep, metabolic health, and how all that affects PCOS. She's taught all over the place. She's published major journals and she's a graduate of Harvard Medical School. She's done her OB-GYN and fellowship in reproductive endocrinology at Brigham Women's Hospital in Boston and she's worked at UCSF since finishing her training in 2005 and I actually did a UCSF residency at Santa Rosa in Family Practice. So we have that in common.

So welcome, Heather.

Thank you so much for having me.

All right. So I did a little bit of a clip on PCOS on my podcast, and it caused a lot of discussion and a lot of controversy, and everybody's got opinions. And like many things in medicine and in life, it's not black and white. There's many layers to this conversation, which we couldn't really address in that short clip. And I discussed something that is a huge factor in women's health, which is insulin resistance. and weight gain, which often interfere with hormonal function. And yet, you know, that's only one piece of the puzzle. It's not all about diet. And we're going to talk about PCOS in general. We're going to talk about what factors cause it, how to treat it, and how obviously also nutrition plays a role. But I'm really, really excited to talk to you about it. And let's just get started by talking about how common this is. You know, about five to 10% of women who are of childbearing age have this. And it's a really important cause of infertility. At Walter Willett at Harvard, he wrote a book called the Fertility Diet, which was a lot about this. It's also the most common hormonal disorder in premenopausal women, yet often the cause of it and treating this is not well understood by most doctors. So, you know, tell us a little bit how PCS has sort of been the sort of neglected stepchild of medicine, OBGYN, and how we can kind of correct that.

Yeah, I think it's a great question. I mean, I think it's a somewhat complicated disorder in the sense that it brings in a lot of different systems and a lot of different kind of ramifications that cross a bunch of disciplines. And I think the way medicine sort of is practiced in the United States these days is it's very siloed and there are sort of certain doctors that take care of one little specialty and P2S has kind of fallen through the cracks in many ways of all of those specialties in my view. I mean, so P2S really brings in a hormonal component, it brings in a gynecologic and reproductive component, it brings in a metabolic component, and all of those things really weave together not only in the path of physiology, but also in the outcomes. And there's not really one specialty that really adequately covers those. OB-GYNs maybe know some of the reproductive piece, but they're not as always up to speed on that metabolic. Endocrinologists might know a little bit more about the metabolic piece, but they are a little nervous about what's going on with the reproductive side. So as a result, I think a lot of patients with PCOS sort of end up getting bounced around to different doctors, never really getting great explanations about what's going on with them and what are sort of some appropriate treatment pathways for them.

It's so true. And I think often doctors aren't great at diagnosing it, and and maybe you can take us through what are the key symptoms that you would look for in a patient who came to see you with PCOS?

Yeah. So first of all, just to echo what you said, there's been some studies, international studies that have shown that the common average number of physicians or providers that people with PCOS see before getting a diagnosis is something like on average of four.

So.

People are definitely wandering around trying to get a you know, someone to really help them. But there is an international kind of consensus at this point around the way that we diagnose PCOS and this has sort of been developed and sort of hammered out over the past 20 years. And it looks for three things and you really just need two of those things. So the first is irregular cycles or what we mean like long cycles going every 40 days or fewer than eight periods a year. The second component is hyperandrogenism, so either clinical hyperandrogenism, meaning hirsutism and acne, or biopsies.

Hair growth. Hair growth on your face.

Yeah. Or a blood test is showing elevated androgens. And then the third component is features of polycystic ovaries on an ultrasound. And so those are the three components, and you just need two. And so if I have someone coming to me looking to see if they, if the things that are going on with them sort of fit within the box of PCOS, those are the three components that I'm going to look at.

Typically, when I was in medical school, I remember learning that this is typically overweight women, and that's not always the case. I actually have had many patients who are thin who have PCOS and struggle with acne and hair loss and irregular cycles. So, can you kind of take us down the road of what is it besides the weight that can cause this? What are the causes? Obviously, part of it can be insulin resistance and diet and sugar and starch, but it's not the only thing. So, what are the causes of PCOS?

Well, I think it's a little bit of a million dollar question. There's a lot of research trying to answer that question. It's also a very heterogeneous disorder, so I don't know if there's one thing that causes it for everybody. But I think we do know that a major underlying factor is the hyperandrogenism that is, you know, that there's elevated androgens starting at puberty, and that that may then sort of underlie a lot of the phEnomena that comes across with women. So one of the things we know is that there's an increase in visceral adiposity or sort of- Dr.

Belly fat.

Dr. Belly fat that happens that we know is more common in general with men, but this is what happens when you have elevated androgens in a woman, especially starting at puberty, they lay down fat in that area. And that in women causes a lot of inflammation that then can really be a setup for insulin resistance. So there may be sort of a pathway where you see hyperandrogenism Androgenism then in many people also leading to the insulin resistance. Then you start to get into a little bit of a vicious cycle because the insulin resistance in and of itself causes some weight gain, but it also can drive androgen production from the ovaries. So starting at puberty, a lot of these people get into a little bit of a vicious cycle. It's very hard, if not impossible, to get out of.

What starts the high levels of androgens.

Or the male hormones, testosterone, and others? So it's a debated issue. I think that there's One component may be that there's just an, if you look at some of the enzymes in the ovary and in the adrenal gland, there's just sort of an overactivity of those enzymes in the ovary and in the adrenal gland. So there's some thought that it's just an intrinsic overproduction of androgens. There's also, at least in some patients, we think just from the get-go they have an increased LH secretion from their pituitary. This is a hormone that drives androgen production. from the ovary. And so they may be set up by that even sort of in utero to have increased LH secretion. So we don't really know, but we know that at puberty immediately these girls will often start to have much higher endocrine levels than their peers. And then that sort of lays the groundwork for a sequence of events to happen.

Yeah, you know, one of the things it's sort of read a lot about is the role of endocrine disruptors. in our health. And endocrine disruptors are environmental chemicals. Years ago, I read a book called Our Stolen Future by Theo Colborn. It was kind of like the silent spring of its time, where she mapped out the ways in which environmental chemicals affect all kinds of reproductive functions. And whether it's determining sex or determining risk of cancers or infertility in animals and human models, how do you think environmental toxins play a role in the uptick of what seems like this increasing phenomena of endocrine disorders in women.

I think it's hard to know how much they are causative in terms of PCOS. I think it's possible. I certainly think it's definitely possible that they may exacerbate certain elements of it by interfering with hormonal function. But PCOS has been around for a long time, as far as we can tell. It seems to be present at a pretty standard or set prevalence across many different countries and so and parts of the world, which somewhat argues against it being truly environmental. Now, I do think that certain environmental disrupt endocrine disruptors or just societal patterns, especially diet, can definitely exacerbate the way PCOS gets manifest. So if you look at PCOS patients in Europe, especially 10 or 20 years ago or in China, they tended to be much more lean than patients in the United States and have much less sort of inflammation and insulin resistance. And so there's certainly if you have a PCOS phenotype and you put it in an environment where there is calorie excess or limited physical activity, you are going to see potentially, at least in some patients, an exacerbation of the symptoms. but I don't know that you, I don't know that in my view and from what I understand about this, this syndrome, I don't think it's necessarily caused by our lifestyle.

And, and, and the nutritional part, what, what role does that play? Because, you know, I've had many patients with infertility who, when we address the starch and sugar in their diet and treat the insulin resistance, they get better. And, I mean, I had a very close relative who had obesity and pretty severe PCOS and hirsutism and acne. And we radically changed her diet and she was able to get pregnant and have a baby. So can you talk about the nutritional aspects of PCOS and how that plays a role and where it doesn't play a role?

Yeah, I mean, I think for sure there's evidence that in some people with PCOS, especially if there's evidence of insulin resistance or if there's evidence of glucose intolerance, that they clearly have entered a a phase where they're not processing glucose well, that if you act to correct that through diet and through exercise and you reduce the degree of insulin resistance, you reduce the degree of adiposity, that in some of those patients they will ovulate more regularly, they will have more successful, more healthy pregnancies. So that is certainly something that I think I always talk to my patients about when I see them. If think that there's a window for that. There are patients, however, especially when you look at some of the lean PCOS patients or patients from the point of adolescence have never had regular cycles. I think it's a lot to say, oh, just change your diet and you're going to start ovulating. I don't think that's always the case. So I think every patient's a little different and you need to really look at it. What I usually look at though is I want to say, how are we going to get you as healthy as possible for pregnancy? and maybe that will help you get pregnant. Maybe it won't, but I wanna get you as healthy as you can for pregnancy and get your insulin resistance as.

Much as possible under control.

Yeah.

How about the microbiome? Because this is sort of the era of the microbiome. And before, nobody ever thought that the gut played a role in hormones or endocrine health or infertility, but now it's clear that it's sort of got its finger in everywhere. And we've seen studies, for example, on breast cancer, women who take antibiotics have high risk of breast cancer. We know that the microbiome plays a big role in hormone metabolism. so can you talk about what you're learning about that and how that plays a role and how you approach that?

Well, I think that there's definitely some really interesting research going on around microbiome and PCOS, and there's this idea that there may be a more sort of inflammatory microbiome that leads to more inflammation in the body. And we know that many patients with PCOS just have high rates of inflammation that is detectable. And you look at sort of blood markers or just even of the insulin resistance. So this isn't in many ways an inflammatory disorder. And so there is research going into like how much of that might be driven by the microbiome. And, you know, that's a little outside my scope and maybe more your scope exactly how that may be the case. But I think it's definitely a really interesting area for us to try to understand more, you know, how much that may be sort of setting people up to have PCOS sort of evolve at adolescence and really to exacerbate the metabolic phenotype.

Yeah, well, we said something super interesting about the inflammation because inflammation independent of its source seems to be a trigger for all kinds of things, obviously chronic disease in many ways, but for these hormonal disorders. So can you talk and maybe unpack a little bit more about the link between inflammation and endocrine disorders and in particular PCOS?

Well, I think for sure we know the inflammation may have some direct effect on ovarian dysfunction. So there are some studies showing that if you treat inflammation, you can improve sort of ovulation to some degree in the ovary. So there may be a direct effect of inflammation on the ovary. There's also a path where inflammation does drive up insulin resistance, and that's through sort of TNF-alpha and other cytokines that are thought to interfere with insulin action. and we know that insulin resistance really drives androgen production from the ovary, at least in patients with PCOS. So there's definitely a metabolic sort of driver of the hyperandrogenism and hormonal dysfunction and anovulatory sort of status that we do see. And then we also know that the inflammation in and of itself has really important downstream consequences, not only in terms of cardiovascular disease, but There's more and more of a thought around depression and cognition that may be impacted by inflammation. So I do think it's really an important piece of this disorder that we want to try to get a handle on and try to treat.

It's so important and it's so many causes of inflammation. It can be environmental toxins. It can be the microbiome. It can be inflammatory foods. I mean, there's so many factors that we know that are driving inflammation in our society that are just getting worse and worse. And so it might be not one thing, it may be so many different things.

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Week'S episode of the Doctor's Pharmacy. Can you talk about the difference between the patients you see with PCOS who would be the typical ones we learn about in medical school? They're overweight, they have acne, hair loss on their head, facial hair. irregular periods and fertility versus the ones who are thin and exercise and don't seem to have any weight issues. Is there a different subtype? Are these the same kind of condition? How are they different?

I think that they're probably subtypes. I think that this is a, ketosis is I think a very heterogeneous disorder. It's really just a syndrome, right? It's a collection of things that kind of go together and sort of have somewhat of a shared pathophysiology. But it's not like, you know, if you think about something like hypothyroidism, which is very much, you know, it's like your thyroid gland isn't functioning, you're going to have this, you fix this, it, you know, translates. PCOS is messier. And so, yeah, so the patient, there is a lean phenotype, we call it lean PCOS, and it's often quite different than the obese PCOS. Some of the things that may be similar is the lack of ovulation, the need for help with fertility care. So that may be a constant. The other thing that may be a constant is trouble with elevated androgens, so hair growth on the face, acne, that can still manifest in lean PCOS. But lean PCOS patients are lucky in that they're often not quite as much struggling with some of the metabolic features. Although in studies where they measure insulin resistance very closely and very carefully in research settings in even lean PCOS, they are more insulin resistant than lean non-PCOS. So there is still an insulin resistance piece there, but it's sort of either genetically not as sort of exacerbated or maybe that that person has just a very healthy lifestyle and they're able to keep a lot of it at bay.

And what, you know, what are the, what are the consequences for people if they have P2S? What should they be aware of? What should they know about in terms of their own health and long-term risks?

I mean, it's, I think, a very multifaceted disorder. There's generally sort of five or six things that I go through with patients with PCOS. So the first is menstrual cycle control. So it's important for people to have somewhat regular menstrual cycles or to have at least some sort of progesterone in their system to prevent overgrowth of the lining. There's the management of their skin or cutaneous findings with PCOS. So how can they manage their hair growth? There's fertility concerns, there's metabolic concerns, especially things like future diabetes, future cardiovascular disease. And then there's a lot of mental health disorders that we see in PCOS. So there's a high rate of depression.

Yeah. And do you think it's a cause or a consequence of it?

I mean, it's something I've been really interested in researching. One of the things we've shown in some of our work has been a very strong correlation between insulin resistance actually and depression. And even when you control for body weight and even when you control for androgens, even when you control for hirsutism. So, you know, I do think at least in some of these patients that insulin resistance in and of itself, maybe contributing to depression. That's something we see in the diabetes literature as well.

That's a frightening idea because when you look at the metabolic health of America, I think the new data came out from Tufts that 93.2% of Americans are metabolically unhealthy, meaning they have some degree of insulin resistance. And we also see this sort of epidemic of mental health disorders and depression. And I don't think people realize that sugar and starch and processed foods is driving not only weight issues but also.

Mental health Yeah, I think it's, to me, one of the more profound connections and profound concerns. And I think it's unfortunate because in some ways that depression can often make it harder to address the diet and the exercise. You know, if you're feeling depressed, you're not in the most ideal state to sort of make those important lifestyle changes. So I think it's important that we take into consideration what's happening in terms of a mental health milieu for patients with PCOS and take that into account when we kind of talk to them about treatment because that's an important component, I think, that needs to be addressed if we want them to make those important lifestyle changes.

Yeah, for sure. So when you see someone with this problem, what's your general therapeutic approach? How do you treat these patients? What are the ways that we sort of can help them have a regular cycle to their acne, their hair growth, their hair loss? And, you know, I think you mentioned something really important, which is that you want them to have progesterone, which is sort of the antidote to this over build up of estrogens that happens in these patients. And they don't ovulate every cycle, so they don't make progesterone, which is what you do when you ovulate. So can you talk about what are the kind of therapeutic approaches and how do we potentially use progesterone or other therapies like that?

I mean, so I think in terms of therapeutic approaches with PCOS, it's always hard because I think it to some degree depends on what is their like, what are they trying to achieve? You know, are they trying to get pregnant at this moment or not? But in terms of the menstrual, let's say it's someone who's like 22 and she's coming to me because she's only having three periods a year. And when she does, that's very heavy bleeding. I want to address that because we know that when people go many, many, many cycles without ovulating, it means they don't get progesterone. And that means that estrogen is going to cause over time buildup of the uterine lining, which can lead to very heavy menstrual cycles, but it also is a risk factor for endometrial cancer over time. So it is important that patients with PCOS get some sort of progesterone exposure. And that can be in the form of oral contraceptives, it can be in the form of bioidentical progesterone being taken cyclically, It can be in the form of an IUD that releases progesterone. I mean, so there's a lot of ways to do it. But if I have a patient who's having three cycles a year or something like that, that's an important conversation that I'm going to have is like, look, we need to figure out some way for you to have progesterone because it's not healthy for your uterus to not have that progesterone over time.

So that's helpful. And what else do you do to help with their, so besides bioidentical progesterone, what other kind of therapies support these patients?

In terms of their other symptoms or.

Yeah, how do you deal with hair loss or how do you deal with the acne or how do you deal with the irregular cycles? What hormonal therapies are used besides that?

Yeah, so I think the irregular cycles would be addressed through some sort of progesterone, but the hair loss or hair growth or acne, those skin findings are most or best address, quite honestly, by being on something like a birth control pill because the, and you're going to suppress the sort of stimulation of the ovary that's driving up the androgens. And you're also going to increase sex hormone binding globulin, which is a protein from the liver that really soaks up that extra androgen. So that's honestly the best way to get benefit in terms of this, especially hirsutism and acne. And then sometimes we'll even use medications that will block androgen action like spironolactone. Now, I do have patients who don't want to go on those medications and feel like that's not fixing the underlying problem and it's just patching it or they don't want to be on the pill for a variety of reasons. So that tool is not always the ideal tool for our patients, but it is certainly one that I would discuss.

And what role do you see as diet? Is it a strong lever for changing these patients? reproductive health and their cycles and their symptoms. I mean, if you basically put people on a low starch sugar sort of diet that treats the insulin resistance, do you see big changes in their clinical picture?

I think in some for sure. And I think, you know, there haven't been great studies on this. There's been a few. I do think that if patients are able to maintain a very low carb diet, sort of a ketogenic diet.

They.

Will be able to really manage their insulin resistance. And that really takes away one of the sort of drivers or triggers or things that's really exacerbating their sort of phenotype or their symptoms. So if you are able to get the patient to sort of embrace that approach, I do think that you will see that often patients will see benefits. I think it's something that has to be monitored. I don't think all patients will suddenly start having regular cycles and their hair growth isn't going to suddenly go away. But some patients may have more cycles. Some patients may be able to conceive that way on their own without fertility treatment, but others will not. So I think it's something that I try to discuss as an option, but I think I shy away from saying like, here's a way to fix this because I think in all honesty it doesn't fix it for some patients and that's really frustrating if they feel like they're sort of somehow failing.

Well, it sort of speaks to how little we know, right? Because in some patients it works and in some patients it doesn't and you don't really know which one's which, right?

And it's really about personalizing care. Yeah. So, I think it's a challenge and I do think it's one, I mean, PCOS is definitely a disorder that just takes a lot of personalization because it's such a diverse heterogeneous disorder. The concerns and the goals are often very diverse. So I think no patient and no treatment plan, quite honestly, is exactly the same.

And, you know, years ago I read an article in the New England Journal of Medicine about D-chiro-inositol and PCOS, which is a derivative of B vitamin. It seemed very promising. It kind of seemed to fall off the radar. What is the role of that and/or other supplements in the treatment of PCOS?

I mean, I think it's still on the radar in the sense that people are using it, people are trying to study it. I think that there's been sort of mixed results in the studies that are out there. I think we're somewhat hampered by the fact that people are taking it in different sort of formulations and different ratios and different dosages, which makes it a little hard to sort of figure out whether it's working. I will say anecdotally, I do have patients who seem to become more regular in their cycling when they're taking it, and they find it easier to take than other medications that might do that, like metformin. So I think that there's potential there. And I think, I do, I think there is a pretty good study being run right now that hopefully will give us some answers. So I, I definitely think it's on the radar. Yeah.

And what about other supplements? Do you ever prescribe other things to help with nutrition or with insulin resistance or any of the symptoms? Like for example saw palmetto is something often used. It's a five alpha reductase inhibitor, which is like what you use for inhibiting androgen production for the prostate and for men, for example, like Proscar.

Yeah.

Finasteride.

I have had patients taking that. I'm curious to you know, hear how much you see as a benefit. Like, do you see patients really come back and say it worked or. Yeah, it really depends on the individual. Right.

So someone's like, oh, yeah, they notice your acne better or. It's like spironolactone, a similar, similar effect to that. But it's an herbal formula. I mean, it's used for men's prostate, so it's a little weird to give it to women. But I said, well, don't worry about the name of the product that says prostate on it, but you didn't wear it. What about the mechanism action of the herb or. you know, and I wonder about, you know, Omega-3s or vitamin D or.

Yeah. So, I mean, I feel like vitamin D is really important. I definitely, we check vitamin D on all of our patients coming in. We definitely find many, many of our patients are deficient. So I, I do try to get patients to sort of really replete their levels of vitamin D. Beyond that, though, I would just say we really just take a pretty common sense. approach to the diet and trying to work with where that patient is at that time. So some people's diet is terrible and there's a lot of room for improvement. Some people are already doing a lot of the right things and you're just tweaking it. I find one of the big things that's missing is exercise and some of our studies have shown such significant benefits for patients who are able to sort of keep that as part of their life. You know, we've looked at sort of our patients who exercise and our patients who don't, and it's dramatic, I think, how much sort of metabolic benefit patients can get if they can be active on a daily basis.

Yeah, that's such a key thing. So tell us about the mechanism of action. You know, you've done a lot of.

Research on this, but how does this work? You know, I think there's the main mechanism of action, and, you know, it's probably deeper than this, but we know that just by increasing muscle mass, you're going to sort of improve insulin signaling, you're going to improve glucose uptake. And so there just seems to be a direct correlation with insulin resistance and exercise that I think is profound. Some of my patients will come back after exercising and they'll say, I didn't really lose that much weight, and they'll be very frustrated about that. But if you look at their numbers, you'll see that they've, you know, their insulin levels have dropped, their glucose levels have dropped. And so sometimes for me, it's about really showing them, like, you are healthier, you probably gained some muscle, and that's why it's not a different number on scale. I think that's one thing. But I also think getting back to the depression piece, like there's a, you know, really often significant improvement in sort of self-acceptance and in mood that happens with exercise that then, I think, can translate into sort of more energy for all sorts of lifestyle improvements. And then that ultimately translates to insulin resistance improvements.

Yeah, for sure. So you've done a lot of research. What are you most excited about that you're working in terms of the research on this and endocrinology in general and PCOS and fertility?

I mean, I think for me, you know, my biggest interest has been around the mood. I've been interested in looking at cognition and how it's impacted in PCOS. And then another area that I've been really interested in doing more work in, and we have a small pilot study starting is on sleep. Because I think sleep, is often very disrupted in people with PCOS. We know there's a high rate of sleep apnea, but even beyond that, other sleep disorders. And I also think sleep is like a really key thing that can help with insulin resistance. So I guess I'm really interested in a lot of these things around the edges of PCOS that we can sort of fix to sort of improve quality of life. I don't know that I feel like I'm going to necessarily cure PCOS or make it not ever be thing, but I think we can do a lot to improve the experience of having it.

So would you say if you fix insulin resistance that PCOS gets resolved or are there other factors that keep it going forward? In other words, if you've got someone's insulin perfect and you've got their blood sugar normal and you've got their lipid profile normal through diet, lifestyle, whatever, would that kind of eliminate PCOS or is there still factors that are driving PCOS beyond and some resistance?

I think there's still factors driving it, at least in most, you know, to the extent that it's truly a disorder of elevated androgens, you're not gonna completely like take that away by fixing the insulin resistance. You are going to minimize a lot of the symptoms. You're gonna potentially make it a very manageable disorder by managing the insulin resistance. you're gonna make it so it's not such a burden. But I don't know that you sort of can wave a wand and it's no longer there. I think that sort of intrinsic physiology that person was born with is still there. You're just sort of helping them manage it better.

Do you think it's partly genetic?

I mean, this is like a huge kind of controversy as well in the field. So, like, there was a lot of research that went on trying to look at, you know, these GWAS studies looking at all of these genes. People had a lot of excitement about finding the PCOS genes, and ultimately they did not find very much. I mean, they found some genes that maybe explained like 10%. So, you know, there's some thought now that it may have to do with sort of a, you know, basically like epigenetic phenomenon where maybe the maternal androgen maybe driving or causing sort of changes in the fetus in utero that then set the fetus up to sort of have a PCOS phenotype. And we know that that's sort of true in animal models that you can induce PCOS by maternal androgen. So to what extent that explains it in humans, we don't know. Maybe there's this microbiome theory, you know. So I don't know that we know. I think that there's a lot of there's probably multiple pieces, probably multiple genes and multiple environmental factors that maybe set it up initially. And then, you know, once it's in place, it kind of self-perpetuates.

Yeah, and it's such a common problem, like we talked about earlier. It's like five to 10% of women at some level. And, I mean, that's a big chunk of the population. So you're probably very busy, my guess. you also created a platform, which is kind of exciting, which is, or an advisor to platform, which is an all-in-one virtual care platform for people with PCOS called Alara Health. How does that work and what does it provide and how do people get supported through this process? Because, you know, a lot of the stuff that has to be done is behavior change, lifestyle change, and it's not just taking a pill.

Yeah, exactly. A lot of times it's having a partner that you work with over time that can really sort to kind of take you step by step through the improvements you need to make. But yeah, so Alara is, you know, it's, I think it's very much similar to what we do in our multidisciplinary clinic, but it's taking it, you know, to a virtual platform and making it available to people sort of all over the country. And so, as we talked about, I think PCOS sort of falls through the cracks and there's not a lot of providers who really, you know, own this disorder. so I was really excited when I heard about Alara as just something that could sort of bring, I think, an evidence-based approach to PCOS that incorporates things like nutrition and mental health support and can do it sort of virtually and can do it over time in a way that really sort of partners with women and so, and just improves access. You know, I think that there's a lot of people with PCOS, PCOS out there that Don't feel like they're getting the care they need.

So oh millions, clearly millions of people have this, right?

So exactly. And, you know, I mean, there's a few clinics in a few cities and there's, you know, there's always going to be a few practitioners who really own it and understand it and want to talk about it, but many practitioners don't. And so this is a way, I think, to give access to more people to sort of feel like they have a home for their PCOS, feel like someone who understands PCOS can sort of walk them through the ways to improve their quality of life or achieve the goals that they want to achieve.

So if you were sort of, you know, this is really great because I think it offers a forum for people to get connected to other people who have this issue. It offers guidance on how to do the things you need to do to kind of reset your system and, and move yourself down the path of health. From the perspective of, you know, an expert in this field, when you see a patient, You know, what sort of tell us, kind of take us through maybe a case before we close of what you see, maybe a few cases of how they presented, what were the different kind of findings and what were the approaches that you used and how did you sort of move them down the path to health?

Okay. I mean, I think I've always found that partnering with patients and being able to sort of see them somewhat frequently has been a really big sort of helpful way to kind of help them make the improvements they want to make. I think an example might be, let's say, say, a 22 year old that I originally saw who was came in, didn't know why she wasn't having periods, didn't know why she had excess of hair growth and acne. And we did a workup, we identified PCOS, we did a lot of education around PCOS. At that time, it made sense for this patient to go on birth control pills to sort of manage a lot of the symptoms. And so she went on birth control pills for a few years, but then several years later came back, didn't want to be on birth control pills anymore, had gone off, had gained some weight, was thinking about starting a family soon. So at that point, you know, I ran some metabolic tests and found that she was insulin resistant and wanted her to work on that before starting, you know, to try to conceive. And so at that point we had her sort of work with a nutritionist or I worked with her and had her start exercising, that would be sort of the program I would want that patient on at that time to sort of optimize her health before getting ready to conceive. And then, you know, ideally those things have been improved and then it would be time to sort of think about the different ways to help someone get pregnant. And, but as you said, some patients through the use of sort of diet, exercise or other ways to improve insulin resistance may start ovulating on their own. And in those cases, they are very much capable of conceiving. PCOS is not a fertility diagnosis, it's just a disorder of ovulation. So many of those patients may be able to conceive on their own. But if not, if they're not ovulating regularly enough despite doing all those right things, then there are other ways that we can help people get pregnant by boosting ovulation through medication.

For sure. Amazing. One of the things you said you just want to touch on because it's not really common is measuring insulin. Now, I never learned to do it in medical school. I almost never see insulin measured on any lab panels that patients come to with from other physicians. And something you measure, I've been measuring it for almost 30 years. And I'm curious about how do you diagnose insulin resistance? Because if you look at the data on our metabolic health, I mean 90% of Americans are metabolic unhealthy. and that to some degree is a degree of insulin resistance. And yet it's the most common disorder in the world right now, and yet most doctors don't know how to diagnose it. So how do you approach diagnosing someone with insulin resistance?

Yeah, I mean, we take a deep dive, I think, into people's metabolic health in ways that a lot of doctors maybe don't. We measure, I like to measure fasting insulin and fasting glucose, and the simplest way to diagnose insulin resistance there would be to calculate a home IR, which is a, you plug two numbers in basically to a formula and you can get a home IR and if it's over 2.1, there's some degree of insulin resistance. Even simpler though is just looking at the fasting insulin. I think you're in the double digits, you already know you're probably a little insulin resistant and many of our patients with PCOS are much higher than that. We also do a glucose tolerance test. which is another test I think a lot of doctors don't do, but I think it's also really helpful. A lot of patients with PCOS, their fasting glucose is going to be relatively normal, but if you give them that 75 grams of sugar, two hours later their sugar is still really high. So that's another way of sort of, I mean, it's not quite specifically insulin resistance, but essentially it is because you're basically showing this patient is not able to dispose of glucose.

Do you measure insulin too on that test?

To be honest, I do. I mean, I think that's, it's almost more of like research, kind of like, I don't know that we have like really validated measures or what's a firm cutoff there. But I will say in many of our patients with PCOS, we see very, very high two-hour numbers, sometimes like 300. And to me, I like to see that because it really tells me kind of what I'm working with and how sort of friends that the grieve in some resistances.

Yeah, that's such an important observation. I had a patient once who was typical apple shape, very Central obesity, very overweight. And I was shocked because her hemoglobin A1C, which your average blood sugar was normal, her basting blood sugar was perfect in the 90s. And I said, well, let's just do a glucose tolerance test. And we measured insulin and we measured glucose, and it was shocking. Her blood sugar never budged. I mean, it went from, like, maybe 90 to 110, it was perfect at one and two hours. But her insulin, you know, was high fasting, like probably 20 or 30, but it went up to like two or 300. And I was like, holy crap. You know, this person clearly, when you look at her, was insulin resistant, but her blood sugar and insulin and he was normal, which is what most doctors will check. So you'll miss so much if you don't look at the insulin also. So I think that's a real take home for people is ask your doctor to check your insulin at least fasting. And you said it double digits. Now, if you look at the reference range on insulin in most labs, it's like 15 or something or even more. That's not optimal. That's probably like less than five is good. And, you know, five to ten is maybe okay. Over ten, no way. So I think it's just, we just have to kind of get better at diagnosing this as a, as a medical profession because we're really bad at it, and it's such a key. driver of not just infertility and hormonal disorders, but obviously diabetes and heart disease and cancer and dementia. So it's just really across the board, one of our biggest problems.

Yeah, I mean, I think we know that just even those high levels of insulin, hyperinsulinemia, I mean, clearly is driving some of the problems in PCOS, but there's, you know, thoughts of how much that might drive cancer growth and things like that. And if you see that patients underneath the surface, it's almost like you're seeing how things are playing out. you see that their insulin are sky high two hours after glucose, which is, you know, happening to that person every single day when they have glucose. You know, you're getting almost like this sort of underneath the hood look at what's going on in their physiology and you can see where that's going to go. It's going to not go well. And so that's, to me, that's often like a really great way to like look at those numbers with a patient and explain that to them and often it can really motivating for patients when they see that to make the changes that they want to make. Yeah, that's great.

I mean, and there's so much new technology, the continuous glucose monitors that are emerging. I met somebody who's developing this company, which is like a band-aid that measures your blood sugar. It's sort of a new tech thing. I don't even know how it works. Some transdermal way to measure. So I think people are going to be getting more and more able to understand their health in real time. And I think the work you're doing is so important. so I really appreciate what you're doing. And I think it's very hopeful because from listening to it, it's really clear that you can make a lot of progress with both the condition and the symptoms, both in improving fertility, regular cycles, improving acne, hair loss, and things that really are distressing for women. So I think it's a very hopeful conversation. It's great that you're looking at all the intersectionality of inflammation and the microbiome and environmental toxins. and diet and all these things that often are kind of stepchildren of medicine, but actually play a big role in all these disorders, whether we like it or not. So thank you so much for what you do and I look forward to keeping track of your work. You can find more about Dr. Heather Huddleston by checking out a Lara Health or UCSF.org/providers/providersdoc@heatherhuddleston. And if you like this podcast and you know someone who would benefit from it. Please share it on social media, subscribe wherever your podcast, leave a comment, have you helped your own condition of infertility or PCOS and maybe we can learn something from you and we'll see you next week on the Doctor's Pharmacy. Hey everybody, it's Dr. Hyman. Thanks for tuning into the Doctor's Pharmacy. I hope you're loving this podcast. It's one of my favorite things to do and introducing you all the that I know and I love and that I've learned so much from. And I wanna tell you about something else I'm doing, which is called Mark's Picks. It's my weekly newsletter. And in it, I share my favorite stuff, from foods to supplements to gadgets to tools to enhance your health. It's all the cool stuff that I use and that my team uses to optimize and enhance our health. And I'd love you to sign up for the weekly newsletter. I'll only send it to you once a week on Fridays. Nothing else, I promise. And all you have to do is go to drhyman.com/pix to sign up. That's drhyman.com/pix, P-I-C-K-S, and sign up for the newsletter and I'll share with you my favorite stuff that I use to enhance my health and get healthier and better and live younger longer.

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