25: Managing PCOS: A Holistic Approach to Hormonal Health

Today I am interviewing really one of my dear friends, Dr. Cassie Smith, and she is an endocrinologist at Modern Endocrine. Her and her team are dedicated to providing comprehensive and personalized endocrinology care for conditions such as insulin resistance, weight management, thyroid disorders and hormonal imbalances. Her Practice follows a 10 step system to repair cellular damage, restore gut health, enhance metabolism, balance hormones, and promote overall wellness through a holist, holistic and preventative approach. I couldn't be more excited about this conversation. We are digging into all things pcos, which I found, even as a clinician, to be super valuable, insightful, and of course we'll also dig into the role of GLPs in managing PCOs and even dispelling a few myths from endocrinologists. So I hope you enjoy. Welcome to Modern Thyroid and Wellness, the podcast that explores the intricate dance between health, wellness and thyroid, unraveling the threads that weave our vitality together. I'm your host, McCall McPherson, and I'm so thrilled to guide you on this journey to optimal wellness. Well, thank you so much. Uh, I'll call you Cassie, but it's really Dr. Cassie Smith. You are. She is a wonderful friend of mine, a very, very big source for inspiration and collaboration. So thank you so much for being here today and taking the time to share your knowledge with us.

Yeah, thank you for having me. I know we've been trying to make it happen, so I'm glad we made it happen.

I know we're, we're too busy ladies, for sure. So today we're talking about something we haven't spoken before about on the podcast. We are digging into things PCOs and I figured we could launch this conversation with the basics, like what are some key symptoms of pcos and how does it impact our metabolic health?

I think those are great ways to start or places to start. So I think one thing to point out too is a lot of people, PCOS is kind of a buzzword right now. A lot of people are, are looking at it. And that's because 1 in 10 people in the United States, actually McCall, have PCOS. 1 in 10 women. And that's an estimate. I would say that what I see in clinic, it's probably closer to like 1 in 5 now because I don't know, after Covid, like everyone's adrenals are just kind of shot. And there's, there's different kinds of PCOS too. And so I think that's where a lot of clinicians get messed up. They teach us in med school so here's what they teach you in med school. PCOS is a hormonal imbalance. It's also a metabolic issue, and I know we're going to talk about that, but it's the hormonal imbalance where you have to have two out of three symptoms. This is what they teach providers. You have to have irregular or absent menstrual cycles, which a lot of people don't even know if they have because they've been on birth control for so long. But if you've ever had irregular or absent menstrual cycles, that's one thing it's called. So they're not having normal ovulation. They teach you that you need to have cysts on your ovaries. And not everyone's had an ultrasound on their ovaries. Right. But there's certain criteria of how many cysts and how big they have to be. And the third criteria is something called hyper androgenism, which means either by lab work, they have elevated testosterone levels. I take that also to mean elevated insulin issues, because this is a metabolic issue, although not all, not everyone agrees with that. But elevated androgen levels, meaning high testosterone, or they have signs of hirsutism, like act. So a lot of just hormonal acne, hair growth, things like that. So these are the three symptoms of PCOS that we're all taught in school, right? And the Rotterdam criteria is you have to have two out of three of those symptoms, and if you meet that, you have pcos. And so a lot of providers are looking for people to put people in those boxes, just like with thyroid issues. The problem becomes that we actually know now that PCOS is not only a hormonal issue, but it's a metabolic issue. And so people with PCOS have a lot of metabolic issues, like fatty liver disease, like insulin resistance, like type 2 OB, type 2 diabetes, and obesity. And so, and we actually, if you have pcos, you have higher rates of having endometrial cancer and things like that. So it's not only a hormonal issue, but it's a metabolic issue. And I think a lot of this metabolic stuff is stemming from other things. And so in school they teach you, like, PCOS is this hormonal issue that women will come in and they'll have irregular menstrual cycles. And these are the things you're looking for, when in reality there's about six types of pcos. And one of them is an adrenal type, pcos, one of them is a hypothyroid type pcos. One of them is an insulin resistant type, pcos. And so I think that a lot of people are missing this, providers and patients, because they're looking for this one textbook diagnosis of PCOS when we now know that there are many. There's lots of causes, there's inflammatory causes, there's thyroid causes, there's adrenal causes. Does that make sense?

No, it does. I mean, that is super, super insightful. I want to unravel some of that too, as this conversation goes on, because it is similar to thyroid in the way that you describe it being. Patients almost need to be driving this conversation. Like they can't rely on their clinician to just for them to show up and get a clear answer on day one. And I have heard that from my own patients that I've even shared with you. Like, I am no PCOS expert, which is why I'm so excited to bring you on today. But it, it, it's so empowering for us to have these conversations that then they can harness for the betterment of their own health and drive that conversation and their ability to find relief. Tell me a little bit about why insulin resistance, if it's in that subtype in particular, why is it so common in pcos?

Yeah, so really I would say I don't ever see a patient with PCOS that doesn't have a form of insulin resistance. Insulin resistance is kind of that metabolic part that you get with pcos. It's because when you have pcos, you have typically those higher androgen levels, right? And so when you have higher androgen in women, that means testosterone, so your testosterone levels are higher. When you have higher levels of testosterone, it's kind of like the chicken and the egg, what came first. But when you have elevated insulin levels, whether that be from genetics, lack of sleep, poor diet, stress, a bad gut, whatever, when your insulin levels are high, that high insulin is going to drive your ovaries to make more androgen, more testosterone. And when you make more testosterone with pcos, this makes your PCOS worse. Right? Because the high androgen symptoms are, or the high androgen levels are causing a lot of the symptoms they're having. And so then you'll get higher insulin. And so it's, it's just like this big wheel, this nasty wheel that we get on. But people with pcos, their hormonal imbalance, also when your androgen levels are higher and your estrogen levels, a lot of these women have really high estrogen levels. I know you talk about estrogen dominance and Their progesterone is low. This imbalance of hormones also messes with their gut. Right. And so we have a huge issue with gut health in a lot of these people where they're not getting adequate amounts of progesterone or maybe they have too much testosterone, it's causing an imbalance of bad bacteria in their gut. They have lower good bacteria and then they develop things called leaky gut or small bacteria, small intestinal bacterial overgrowth. And what that means is your gut is now inflamed. Kind of like your thyroid gets inflamed when you have Hashimoto's. Our gut is inflamed. And then when our gut becomes inflamed, that kind of causes systemic inflammation throughout our body. Not only affects our thyroid and our adrenal and our hormones, but it's going to increase inflammation. And then that elevated inflammation is going to drive insulin levels higher. So it's just like this big repetitive circle in these people. And so a lot of them are going to have very high insulin levels. Not always. I have some PCOS people who are not insulin resistant, dominant. I actually saw a girl today, this was pretty fascinating. Very thin girl, having issues with infertility, which is one of the big symptoms you get with pcos. And so she came to see me. She works night shift, she's a nurse, so she works night shift three to four nights a week. And then she flips back to days to take care of her children and be with her family. And her adrenal gland is completely shot. It is a mess. Her thyroid is also a mess. And so she actually has an adrenal thyroid combination causing her pcos. But her insulin was actually fairly normal because she's trying to exercise and eat well and things like that. So it's just pretty interesting what you can see with pcos. But she, she definitely has PCOS because she has, she's not having menstrual cycle, she's having fertility issues. And, and she had all the classic signs like her testosterone level was high, her LH was higher than her fsh. So she's got a lot of blood work that goes with it. And she had some cysts on her ovaries, but very thin. And so it's just, it's a very interesting thing how all of our hormones work together, right? Our adrenal, our thyroid, our gut, our ovaries, they all work together to kind of cause this issue with insulin, but it's all inflammatory based.

Interesting. And then in someone like your patient today, this is fascinating for Me, would you first approach and try to address her pcos, or would you try to address her thyroid slash adrenals? Like, if there's six different types, and I want to circle back to, like, touch on all the six types. But do you start with, like, a root cause, with the type and the driving factor of that, or where do you even, like, where do you begin in her?

It's hard, but what I try to do is lay out for them all the things that are driving it. Right. And then, yes, we. We try to go to their root cause. And. And so in her. Her infertility is actually a result of her progesterone being so low. So her progesterone is undetectable and has been because her cortisol is so out of whack, Right? So your cortisol and your progesterone are very, very tightly intertwined. But also her thyroid, her TSH was 10 because she's not taking her medicine because she forgets, right? She's like, well, I'm on nights, I'm on days. I don't remember to take it. And so on her. We just laid it out. I was like, listen, sister number one, you've got to stop flipping back and forth. Like, we've got to get you on a schedule. You have to take your thyroid medicine, because until you fix your thyroid, we can't fix your pcos. There's. There's no way. And then we talked a lot about her adrenal, like, her sleep. She's not sleeping when she's supposed to. And so in her, I kind of. I laid out everything. And what we did with her is she's actually going to get to go to days. I wrote a little letter that actually work.

She's going to get to go to.

Days on March 14th. She's super excited. She's going to go to days. But we gave her some progesterone to help her actually sleep, right? Help her feel better. I was like, we've got to get you started on your thyroid medicine. You've got to take it consistently. So we addressed her progesterone and her thyroid. I talked to her about inflammation, and we can talk about this. We talked a little bit about GLP1 therapy to kind of calm down her inflammation and help with all of that. And. And then just getting her. Her stress and her sleep schedule back to where it needed to be. That's kind of what we talked about. But you have to. It's. You got to. People get frustrated because a lot of times it is a lot of things at once. But it's like if I just fix your thyroid and I don't fix your adrenal and I don't fix your sleep, I mean, it doesn't work, right. Yeah. And so you, you have to do all of it. And it's not always what people want to hear. But I also told her, if we fix your cortisol and we fix your thyroid, your adrenal is going to kind of fix itself and then you're not going to need this progesterone. Right. And then you're going to get pregnant. So it usually you have to kind of lay everything out, give everyone everything that's going on. And in her, her insulin wasn't super high. If it was, I would be like, you must, we must get you on a good exercise program, a better diet and a microdose to GLP1. So you have to kind of tackle it all at the same time.

Yeah, no, I'm, I see the parallels in thyroid too. It's like if I fix someone's thyroid but I don't fix their adrenals, they're not going to feel even remotely close to the same as they would. And then if I fix their thyroid and they have a raging hormonal disorder or raging hormonal dysfunction, again, they're not going to get where they want to be. So I completely see it. I want to circle back to the six types that you mentioned. Three or four. Can you run through all of them again?

Yes. So there is insulin resistant pcos. So that's like the kind of classic type that you think about somebody who's a little bit overweight. They've got high insulin levels, they've got the androgen symptoms, the acne, hair growth. You know, they're just the typical what we learn in school. So we call that the insulin resistant PCOS type. There is an, actually a hypothyroidism type. So you can develop pretty significant PCOS just from having overt, untreated significant hypothyroidism. So that's where you come in, people like yourself. And you see a lot of these people, I'm sure as well, because when their thyroid's not working well, again, it, it affects so many things, their sex hormones, their insulin, things like that. There is an adrenal type of PCOS where your adrenal gland is just so shot that your adrenal is not making androgens appropriately. And so you have issues like that, this shift worker, things like that. So there's an Adrenal type, there's a thin type pcos which are the thinner people who maybe a lot of times you're not, you're not flagging them as pcos or. But when you look at their labs, they have symptoms. So they have elevated liver enzymes, fatty liver, they've maybe got a little bit of an elevated insulin level. A lot of these thin PCOSers are like the type A personality people, right? The people, it's like, it's like you and I, the people who are like dominating in the world. We're running businesses and we're busy and we're just go, go, go, go, go. And we're not really listening to our body. The people who are just, I, that's who I see a lot with these thin pcos. Because we're shooting like our adrenal glands are shot, right? Our adrenals are shot. Then maybe our thyroid stops working, then our hormones stop working and so we develop this like PCOS type picture. So that's another type. There's an inflammatory type of pcos. And so that can just be any cause of inflammation. I see a lot of times high insulin levels in these people that are causing it. Sometimes like post Covid, I would see this when people got significant inflammation after Covid. But anything that drives inflammation can cause PCOS type symptoms. And then there's actually a type of PCOS where it's just kind of, they call it a post infectious type pcos. So maybe you've had. And it's. Some of those are kind of similar and like go together overlap. But those are kind of the different types of pcos that I look for. And so when you start looking for them, you'll find them. And it's almost like they have these little avatars and, and sometimes people are more than one and a lot of times it runs together. What I find is it depends on how long they've had PCOS that's been undiagnosed or untreated, right? So if you are an advocate for yourself and you are like something is wrong and you find the right doctor and this hasn't been going on forever. A lot of times you'll have one type. But in these poor people who go to doctors and they're like, I hear this all the time. Well, my doctor told me four years ago I might have pcos, but she was just like, eh, whatever, or gave me birth control and it's like, well, do you have it or not? I don't know. They didn't tell me. Well, four years is a long time for stuff to be not working correctly. Right. And so then I think that's when you develop these different types of PCOS that kind of compound on each other. But those are the main types that I see.

How interesting. I feel like you should make a quiz like, what type of PCOS are you just saying? That would be brilliant. People would love that. And then if someone is resonating with the symptoms you described, the signs that you described, what do you feel like their next step is? Is it like lab work? I mean, obviously you can go to the doctor, but what kind of labs would they want to get run? Especially if we're looking at, hey, this could be multiple types of pcos. Where would I even begin to find answers?

That's a really good question. Yes, lab work is important, but just like with thyroid disease, it's the lab work with the symptoms. So I would say you're going to have to find a provider who listens and understands all this as well. Right. But lab work is a great place to start. So I check a lot of lab work. But pcos, specific lab work. What you're going to want to look at is obviously your sex hormone levels. So your testosterone, total and free. I like to look at your sex hormone binding globulin. Your LH is something that you need with your fsh. A lot of times doctors won't do lhs and younger ones, women, because they're like, oh, you're not in the menopausal range. It's important. The ratio of your LH to FSH is very important with pcos. I like to look at estrogen levels and progesterone levels. I like to look at their dhea, so I can kind of see what's going on with their adrenal, their cortisol, insulin. I look at a full thyroid panel like you, a TSH, a T3, a T4, those are both free. Look at reverse T3 and then thyroid antibodies, so TPO and TG antibodies, just so I kind of know what's going on with their thyroid. And then just a basic, like CMP where we can look at your liver enzymes and your kidney function. Because in so many of these people with pcos, they actually have elevated liver enzymes and they don't even realize it because of the high insulin levels. They're developing fatty liver. And then you need to know what your cholesterol is too. That's really important with PCOS because you can have some metabolic dysregulation and when their cholesterol if it's high, I like to look at lipoprotein A levels to see is this a genetic thing or not? That's some kind of just basic lab to start. Although it's a lot, I think you need that to be able to look at the full picture and say like, is this truly pcos? And then that's not the end all, be all. Like I have that and I go over that with people. But then I'm like, what are your, what's, what are your top symptoms? Is it sleep? Was it you're having irregular cycles? Is it that you are having issues with infertility? Are you having acne issues? Are you having gut issues? We have to take all that into consideration. And I think that's the nuance in medicine that a lot of people don't want to do is like, listen, absorb, use our brain and the lab work to help people solve their problems. Right. You have to do all of that.

You do, absolutely you do. It's not always like one plus one equals two and you just check a box and you move on. Tell me a little bit. So this is, this is like a patient empowerment. This is a, an empowerment journey for these people to find answers, solutions. Take me through some lifestyle things that people can do from a PCOS perspective to really move the needle on their symptoms or even like their long term outcomes.

Yeah, I love this question. This is a question where people ask me this. I say, okay, well before I can answer this, we need to take a personal, personal inventory because I don't know you like you. So you need to take a personal inventory if you have these symptoms or you have a disease process. And you need to be honest with yourself in am I getting good, adequate amounts of sleep at the same time every night? Because a lot of times I hear from women, the only time I have to myself is when my kids go to sleep and my husband goes to sleep. So I stay up until 11 or 12 o' clock to do laundry or do whatever I want to do or scroll on my phone or whatever because it's the only time I have for me. Right, well then you're not getting adequate amounts of sleep. So like you have to take a personal inventory. How is your sleep? How is your stress? Are you doing things to de stress? How are you moving your body? Are you doing it adequately? What are you eating? Things like that. And so once you've taken that inventory, then I ask patients to tell me, okay, what are the top two that we can work on? Like what are the two that you think are the rockiest. Right. Because I feel like if you try to do five things at once, you're going to probably not succeed. And. And we can even start with one. But I would say from a PCOS perspective, honestly, two of the top ones are going to be sleep and nutrition. I love movement, I love light, I love everything. But, like, if you're not doing those two things well, your body can't heal itself, and it's not going to make hormones. Hormones. And so just like in that patient we were talking about, she wasn't getting consistent sleep or in a normal rhythm. And then nutrition was. Was part of her issue, too. And she. She did admit that, because when we're not sleeping, normally, we're gonna have odd food cravings. Right? Like, lack of sleep causes not only physiologic hunger, like where you feel hungry, but it causes emotional hunger. So in a lot of people, I ask my PCOS patients, I ask all my patients this, but especially my patients with hormonal issues. When you're hungry or when you're eating, do you really have that sensation in your stomach? Like, ow. I'm. Like, I'm. That hurts. Or why are you eating? Are you eating because you're bored or because it's just you're supposed to be eating? Or because when you have lack of sleep, then we do a more emotional eating. And this is the crazy thing. I love microdose to GLP1s just as much as you do. When I have people who take those and they don't work, that's my first question to them. Is, are we emotionally eating or are we eating? Because physiologically we're hungry. And so from a lifestyle perspective, with pcos, sleep is so important. You should literally, like, if I could write you a prescription with pcos, it would be, you must get eight hours of uninterrupted sleep per night, ideally around the same time. Right. Like, you have to do that. That's something you have to do. And then the next thing I think, from a lifestyle perspective is nutrition. And so pcos, there's a lot of things that float around out there, but with pcos, actually, sometimes intermittent fasting can make it worse, especially if you have the adrenal type. Right? So I tell people, listen to your body. If you're hungry, then feed it, but make sure we're feeding it good nutrients. So protein, prioritizing protein. And with pcos, it's really important to make sure we're eating more protein than carbs because of that insulin resistance that you have with pcos, right, you don't want really high insulin levels because that's going to. When you eat a lot of sugar rich food, a lot of carbohydrates, you're going to get higher insulin levels. And when you have higher insulin levels, that's going to drive your androgens. And when that drives your androgens, you're going to gain more weight. And so it just makes it worse. So I think sleep and then making sure that you are nutritiously filling your body with adequate amounts of protein and then equal amounts of carbs or less carbs. So you don't want to have meals where you have giant amounts of coffee carbs and not enough protein. So I think that's really important with pcos. And then just making sure, you know, a lot of these women get frustrated and they try to maybe starve themselves or just restrict, restrict. And that's not always what we want to do either. We just want to make sure we're giving ourselves adequate amounts of, of nutrition. So adequate amounts of carbohydrates, but maybe in the form of vegetables and fruits or sweet potatoes, things like that. After that. I think exercise is something important to talk about With PCOS and the hit training and the orange theory, the F45, the stuff all these people are doing now, the marathon running, that's not for you. If you have pcos.

Okay, You're a dream or a thyroid problem, that's unsolved.

Yeah. That is not for you. What you need to do is take a nice walk and listen to this podcast every morning.

Okay? Like you need to, you need to.

Walk, you need to be in nature, you need to be doing things that are very calming to you. Can you lift your weights? Sure. But you need to lift weights like bodybuilders. And when I say that, this is what I mean. If you watch a bodybuilder lift weights, they do a set and they rest for a minute, and then they do a set and they rest for a minute. And the rest for a minute doesn't mean we do jumping jacks in between or we run around or we're like. It means we rest for a minute. So like you, you really have to listen to your adrenals and your body when you have pcos. So if you want to lift weights, I want you to lift weights. Don't do anything that's over strenuous and make sure you're resting in between, you know, so hit is not for you. And that's really hard for women to hear. When they're trying to lose weight, because it's like, oh, I'm supposed to get on a treadmill and go for an hour. No, you're actually making it worse. I promise. You're making your cortisol higher, which is making your insulin higher, which is making everything you eat be sworn as fat. And your hormones are off. Like, it's just a big mess. So from a lifestyle perspective, and these thin PCOS girls, they're the worst because they're the type A personality. Like, they're the hardest to change their mindset, but if they'll do it, they do so much better. So I think those three things are really important. And then taking a true inventory on your stress, and if you do have really high stress levels, figuring out how can we start negating the stress or what can we do to help our body not feel so stressed. Even if it's just breathing, right? Even if it's just stopping what you're doing for three minutes, closing your eyes and breathing. One of the things I've started this year is like coffee time with Cassie, or like tea time with Cassie. I will. If I feel myself getting, like, stressed out during the day, I take a minute where either I go in an exam room or I go in my office and I close my eyes and I ask myself, like, how are you feeling today? Obviously not well, because I'm stressed. Right. Okay. What is causing you to be stressed? Have you had your supplements? Do you need some water? Do you need to go to the bathroom? Are you hungry? Like, I just kind of, like have a conversation with myself in my head. And it seems strange, but you'd be shocked at, like, how much better you feel when you're like, acknowledging that, hey, I don't feel well. Why do I. Why do I not feel well? And then figuring out what you need to make yourself feel better and then just taking a minute or two to do that. So just little things like that, I think help a lot.

I'm gonna take notes for myself for that. So thanks. That's a really good idea. Yeah. You get caught up in it, you know? Yeah.

And sometimes it's just like, if you ask yourself, Nicole, sometimes it's like, well, I really need to go to the bathroom and I've been holding it for an hour. That's so stupid. It's like, okay, go to the bathroom. Right? Or sometimes it's like, I'm really thirsty and I just didn't go get water. Okay, we'll go get water. Like, I mean, it's sometimes it's so simple. But you're just like. You're all revved up and in your feelings, and then it's just. It's interesting what we do to ourselves.

It's shocking how. How much those resonate with me, because, I mean, and I think medicine in general, and I'm sure it might even translate to other people as well, but in medicine, we're so adapted to, like, in. Ignore anything that you feel any bodily need that you have and just keep going and let's move on. And then it's like, literally, I'm. It's not uncommon for me to tell my husband at the end of the day, I literally did not have time to pee once today.

Like. Yeah. And that, you know, that's not okay. That's not okay, right?

Yeah. And especially not when we can intervene. We're the only people that can intervene when we create this manufactured stress. So I love the whole concept of finding ways to take inventory and then provide a solution so you don't unnecessarily need to feel like that. Brilliant. Right? I want to transition the conversation into another big aspect that I do want to talk about, which is medications involved in the treatment of pcos or supplements involved in the treatment of pcos. And I know there's a few different categories, right. The supplements, metformin, GLP1s. And I know that you and I, our views on GLP1s very much aligned. But I want you to take us through all of those options and ideas for people. Yeah.

And. And let's start. So we can start with supplements. And then I want to talk about birth control, too, because.

Oh, my goodness. Oh, yeah.

Oh, my goodness.

Do you want to start with birth control and then move in? Okay, let's do it.

Start. So here's the thing with birth control. It is not the answer for pcos. And I did a video about this when I was on a rampage last year, and it got like 2 million TikToks shock abuse instantly. And people are, like, giving me a hard time. Like, yes, it is. If you look it up, that's the treatment for it, is not it? It may be what they teach you in traditional medicine is the treatment for pcos. That is because it normalizes your menstrual cycle. It does not do it in a physiologic way, meaning it does not do it how your body would naturally do it. It's giving you a bunch of synthetic hormones to just almost like, shut your body off so your body's no longer making any hormones. So will it make your symptoms better? Usually. Not always. Sometimes birth control makes. People like women will tell you that made me crazy. But the problem with birth control is they tell you like, this is the treatment for PCOS because it will normalize menstrual cycles. And that's the goal, to normalize menstrual cycles. I agree with that statement. Birth control is band aiding that normalization. It's putting a band aid on something instead of figuring out, like, pulling back the covers and saying, well, why aren't you having normal menstrual cycle cycles? Right? So if you have hypothyroidism, if you have adrenal fatigue and you give someone birth control, they're still going to have adrenal fatigue and they're still going to have hypothyroidism. And now they're going to have all sorts of other fun symptoms because you took their body's ability away to make estrogen and progesterone and testosterone, which are hormones that help us feel better. Right? And so birth control is not the answer. And there are so many, so many young girls on birth control that have just been put on it for whatever reason. Their periods were painful, their periods were irregular. You need to be asking why those things are happening. Because this is the other crazy thing. Women were not. So, like, when we have menstrual cycles, it wasn't meant to be this, like, terrible, awful, painful process. And if you're listening to this and you're like, whatever, I've never had a period that wasn't like, miserable. You have something wrong with you that needs to be addressed, whether it be your estrogen dominant, whether it be you have pcos, like something you're. You weren't like, we weren't made to have menstrual periods that made you debilitated for 10 days. And so really what should happen in life if you're healthy is you should just all of a sudden start bleeding when you would normally bleed. You bleed for five to seven days and then you stop and you go on. It's not, you're in bed, you can't go to school. You're. If you're having these symptoms, there's an issue with the way your hormones are metabolizing being made. Something's going on. And so that's where I get just really upset about pcos is the answer is not to just write someone birth control. Because then what also happens is if you've masked that hypothyroidism, that adrenal issue for 10 years and then somebody comes off of birth control and then they want to have a baby. Guess what? We have a big, big mess. They don't have periods. They don't know why it takes years to fix that. And it's just really frustrating for the provider that's helping them and the patient. Right.

Couldn't agree more. I very frequently have these conversations with my patients who are 10 years into birth control, and I'm like, listen, I want you about to get married in a year. And they're like, well, in a year I'm going to be ready to get pregnant. I'm like, we need to start planning for this at least 18 months in advance. Because when you create this system of physiology that your body now operates by. Right. Skipping in. A lot of these women skip periods. Like, they literally take continuous forms of birth control. Get so they don't have a period for five to 10 years, get off birth control and magically expect that their periods are going to be regular and their hormones are going to flow and cascade in the way that they are supposed to in order to get pregnant. And that is just couldn't be farther from the truth. So I love that you mentioned that. And PCOS people in general have the odds stacked against them to get pregnant in, like, already, but then to layer in that whole other confounding variable makes it so much more complicated.

Yeah, it really does. And so. So that is not the answer. You can do supplements. There are tons of supplements that help with pcos. Anything to help drive down insulin levels and help you from a metabolic standpoint. Things like berberine, things like turmeric, anything that helps from an inflammatory standpoint, Omega fish oils, things like that. Inositol is a great supplement. In people with pcos, you have to make sure you get the right ratio. So there is a ratio that you want to get, which is 40 to 1. This is a supplement that really helps keep your blood sugar levels down, your insulin levels down. So there are supplements that you can definitely take that will help with that.

Right.

There are dietary changes that you can make, which we talked about, which is making sure you're prioritizing your protein and you're not eating a bunch of carbs so that you are getting these big high blood sugar spikes, which then cause you to release a lot of insulin. And so there are dietary supplements. Metformin is something that in the medical literature, they tell you use metformin. I'm in the same camp as you. I like metformin. I use it. I don't use it in doses of 1500 and 2000 milligrams and crazy things like that. I use it in doses of 500mg with dinner because it can cause some GI upset. But I do use metformin and I use it in a lot of the ways you do, which is anytime someone's insulin resistant, I think it's fine to give it to people. Even if. So we have these PCOS girls that are trying to get pregnant, great, let's give them some metformin because we can't maybe be on the GLP ones when we're actively trying to get pregnant. I like to cycle metformin and with people who have had GLP ones and have maybe come off of it. And so metformin is great in PCOS as well. I have a lot of people who say to me, well, I don't want to take metformin, it causes kidney disease. It causes. It does not cause kidney disease. The reason people on metformin get kidney disease is because they have uncontrolled diabetes. And when you have uncontrolled diabetes and you've been on metformin for 20 years, but your diabetes continues to progress, your kidney gets worse. It wasn't the metformin, it was the diabetes. And so I tell people this all the time. We still can give metformin to pregnant people. If metformin caused kidney disease, I promise the FDA would not allow us to give it to pregnant people. So it's not the metformin that does that. So I do like metformin and I like the supplementation. But to your point, the GLP ones, like, let's talk about the elephant in the room, which is the microdose GLP1s. I have seen so many amazing things with GLP1s, with PCOS patients. And I mean like life changing things, right? So when you look at these levels in girls with PCOS, I check a lot of CRPs, ESRs, inflammatory markers, and I will get very shocking results. Sometimes CRPs of 10, like, what the heck? You're like 25. Why is your CRP 10 and then their insulin levels are 20, 30? Well, that's why their CRP is high, because they're so inflamed. Insulin is a very inflammatory molecule. It's one of the most inflammatory molecules, molecules in our body, in my opinion. And I think it's one of the number one drivers of all disease processes. And so if you get these people who have these high insulin levels and these high inflammatory levels from whatever lack of sleep Bad gut, thyroid issues, whatever. And you give them these micro doses of GLP1s, these very small doses, not trying to make them sick, not trying to give them bad side effects. But just like I explain it to my patients, like, I'm just going to give you a little hug. Like this medicine, it's almost like it just gives your whole body this nice little hug of like, like calm down this inflammation. So once you calm that inflammation level down and you calm that insulin level down, all these bad things stop, right? So when your insulin goes down, your ovaries stop overproducing testosterone. When your ovaries stop overproducing testosterone, that drive your insulin down further. Now your ovary is actually making estrogen, which, oh, by the way, is great for your gut. And that actually helps drive down your insulin level even further. Then you start making progesterone, because now your body's like, oh, okay, I can make my progesterone because there's all this excess, excess testosterone floating around. So now we're making progesterone. Now we're able to sleep. Now we're able to sleep. So then our insulin and our cortisol are even lower where our mood is better. And so just so many amazing things happen when you start to lower insulin levels. And this is just hormonally. I'm not even talking about what happens to you as far as a hunger perspective. I'm talking about just straight hormonally, right? And so I have given people microdose GLP1s with insulin levels in the 20s and the 30s and CRPs 5, 10 and a month later, insulin levels have been 5, 6, and CRPs have been like 1. I mean, there is nothing else you can give a human being in. In this world. Nothing.

Nor lifestyle.

Life. Yeah, there's lifestyle. There is nothing you can do, I promise. Because I've tried for 10 years and I am a data, like, I am a lab junkie. My people get so many labs, like, they hate me. But it is wild what you can do by just stopping. And it's because it all starts there, right? The high insulin. That's where it's driving the testosterone. The testosterone is driving the insulin and it's driving the thyroid issue. As soon as you shut all that down, wow. The thyroid's like, oh, my gosh, maybe I can work the adrenal's like, oh, wow, okay, great. And then now just everything works better. And so microdose GLP1s with PCOS, life changing. And then the other thing, so, so now they start, their hormones get better. They start sometimes cycling normally. They're like, oh my gosh, I'm having a period. And then, oh, by the way, the side effect of this is that I'm not starving all the time because my insulin's not high and I don't have this roller coaster with my blood sugar. So now I don't want to eat those Doritos at midnight and I don't want to eat that chocolate bar at 2 o' clock in the afternoon because I'm not having these big dips and these big swings in my blood sugar. And so it's a win, win. And then they actually lose weight. And when they lose weight and they lose fat, we are actually converting a lot of our, we're making testosterone and estrogen in our fat SO cells. But it's bad estrogen, it's something called estrone that actually increases our risk of cancer. And so now that we have less of those fat cells making bad hormones, that's helping too. So it's just like a win, win, win. And if you do it right, these girls don't even know. Like, I have girls who tell me all the time, did you even give me a shot of anything? Like, I'm not sick, I'm not throwing up, I didn't even really know I took anything. But I do feel better. And so it's like if you do it correctly, it's just so powerful. So powerful for these people.

Absolutely. And I love how you ordered the improvements because what I think people misunderstand so much of the time is for pcos, for example, the improvement that people see in PCOS is due to weight loss. But in fact, no, even studies show, independent of weight loss, these meds improve egg quality, egg quantity, they improve the cycling of our ludal and follicular phases, they improve the cycle of us releasing the eggs. Like, this is not weight loss dependent. These meds independently influence our hormones, our inflammation. People say, oh, well, you are less inflamed because you've lost weight.

No.

Like, I have measured someone's CRP after one single injection and it reduced by over 50% one injection. So absolutely not. Like, these are. I found four, four ways in the literature that GLPs influence the inflammatory response in our physiology. And again, they're not weight weight loss dependent. So. And I love too that you highlighted these meds are not, if they're used correctly, they're not causing people to vomit and throw up and pancreatitis and gallbladder. No. Like, when they're used in these conservative, slow, microdosed approaches. And people are not rapidly losing massive amounts of weight way too quickly. People are feeling really, really great. So, anyway, I love that. I do want to ask you in case people haven't tuned into my other podcast or my content where I talk about repeatedly the risk of thyroid cancer and GLPs, as an endocrinologist, I would love for you to speak to that. Yeah.

So I will do that. I want to point out to, to your point though, it doesn't make sense. Like people say this all the time. Well, you're giving somebody a medication like a GLP1 and then you're going to cause all these bad side effects. This is why it doesn't make sense. Our body naturally makes GLP1. I think people forget this. Our body naturally makes GLP1. It stops making GLP1 when we have too much insulin. So if we're eating things that cause our blood sugar to be high all the time, we become insulin resistant. Meaning insulin resistant means you have a lot of insulin. It just doesn't work. So you have all this insulin floating around. It's not working. So your body, it's almost like your body is like, well, I made all this GLP1. I still have all this insulin floating around that's not supposed to be here. So it's almost like your body goes on vacation, right? It's like, I'm not making that anymore. When you give that back in the form of low, like micro dose to GLP1, we're not doing anything. Your body like doesn't know how to handle, doesn't know how to process, doesn't. I mean, it had that. It's just, it stopped making that. Now when you give people massive amounts, like with the treatment of diabetes. And I did clinical trial research on Ozempic, like I am very familiar with GLP1s. Those are massive, super therapeutic doses of GLP1. Your body will never make 2mg of Ozempic. It won't. That's too much. But when you give back to your body these tiny amounts of this peptide that it already made, your body knows.

What to do with it.

Because guess what, guys, it made it for years before it's just kind of went on vacation. So I just wanted to make that point. But then to your point about thyroid cancer. Love this question. Okay, so when we looked at, with Ozempic, with all the trials, the GLP1 trials, when they looked at animals and specifically rats, did rats have an increased risk of medullary thyroid cancer with large doses or any dose of GLP1. Yes. Rats are not humans. Rats actually have a propensity for those type of receptors in their thyroid. We do not. So rats have a ton more receptors for GLP1 in their thyroid than we do. Like by 600 times, I think, is the number. So we are also not rats and we are also not taking this in the doses that like. So we are much larger creatures than rats. I have given these medications to thousands of people. I've monitored my patients just had like you have. There's been tons of monitoring post GLP. GLP1s have actually been around since the 90s. I think people forget about that. Nicole Vieta was the first GLP one for type one and two diabetics in the 90s that you had to take four times a day. And so it was BA and then it went to Victoza and then Victoza was daily, and then now we have these weekly ones like oic and trulicity and Manjaro and TR. I mean, so these have been around for 30 years, literally. I've had patient. I have several patients who have been on a form of a GLP1 for more than 30 years. When you go back and look in the literature, there is not this giant increased risk of medullary thyroid cancer. Medullary thyroid cancer.

It's incredibly rare.

Yeah, it's very rare. And it's a very rare cancer to begin with too. So that's the other thing that infuriates me. You tell people like, oh my gosh, you're going to get this cancer, that this common thyroid cancer, medullary thyroid cancer is not common, people. I have hundreds of patients with thyroid cancer that I treat. I have about four that have medullary. And out of those four, all four of them, they were genetically predisposed. They had an immune mutation. Right. And so it is just not common. It's not common even without the use. But definitely with the use. It's not. That is not factual information. Like, if you look at the literature, it is not, not increasing the risk at all, period. What does increase your risk of cancer, though? And this is where I get on a pedestal and get really, like fired up, you know, what does increase your risk of cancer? Obesity, inflammation, age. That's it. Like, those are your top three cancer risk right there. Obesity, inflammation and age. You can't do anything about your age, but you definitely can do something about your obesity and your inflammation. And these medications make that better. Yeah, I love that.

Thank you for that. And then following up, there's so many, sadly, clinician driven narratives that people with thyroid conditions can't take GLP1s, that people with Hashimoto's can't take GLP1s', that people. And this is sort of a case by case basis, but people with a history of something like papillary thyroid carcinoma can't take GLP ones. I would love for you to speak to in whatever form or fashion you're comfortable this.

So papillary thyroid cancer. That's completely ridiculous. I have tons of people with papillary thyroid cancer or follicular thyroid cancer who are on GLP1s. So none of that is factual information. It's just medullary. And you're going to know typically if you've had medullary thyroid cancer because again, it's very genetic. So if a patient comes to me and they say, I had thyroid cancer, can I take GLP1s? I say to them, well, what type of thyroid cancer did you have? They typically will say, well, I don't know. And I say to them, okay, well, were you told that the rest of your family, your children needed to be, they needed to be tested for thyroid cancer? If the answer is no, they didn't have medullary, I still request pathology reports. But if you have medullary thyroid cancer, it is very well known to you that you're. Because a lot of these people, their children, if they have a type of medullary, I mean, we're doing thyroidectomies prophylactically on kids. So if you have medullary thyroid cancer, you knew or you know. So I have tons of people with, with follicular and papillary thyroid cancer that take GLP1s. I'm very comfortable with that. I'm comfortable with the literature. They do, they do amazing. If you have thyroid conditions. Oh my gosh, you, you know this, these people do amazing because guess what? When you have Hashimoto's, you're inflamed. You're inflamed and your gut doesn't work and your adrenal doesn't work and your hormones don't work and your whole body is just like, it's inflamed. And then you take this medicine and your body's like, oh my gosh, I'm not inflamed. My joint stopped hurting. I'm not swollen. So really, to me, there's not a condition that I don't give this to other than if you have unexplained pancreatitis and it has to be unexplained. Right? Like it's not, oh, I had a gallstone and then they removed my gallbladder. It's not a, I am an, I had alcoholic pancreatitis. If it's truly unexplained, then I have a conversation with those people. We have a pretty in depth conversation. If you truly have a type of hypercholesterolemia where your triglycerides are in the thousands, we have a conversation because if your triglycerides are very high, it can, you can develop pancreatitis and these medications potentially could, could develop that. But I know a lot of these people, I'm going to treat their triglycerides because you don't want triglycerides of a thousand anyways. And then if your triglycerides are controlled, actually what I've found with GLP1s is if you can get someone's triglycerides to under 4 or 500 and control them and then you give them this medicine, lo and behold it gets even better because guess what, they're not eating things that make their triglycerides high and they're not as inflamed. So I have this conversation with people all the time and again it is clinician dependent. But if you understand the physiology of GLP1s, understand what it's doing, understand the potential side effects that could happen and how to help mitigate those side effects. I can't really think of a lot of people who I'm not comfortable giving this to other than if they truly have had medullary thyroid cancer. But that's just me.

I love it. Very, very insightful and I completely agree. It's like, it's so fascinating at this time we're still really largely talking about these almost fabricated, way over blown out of proportion, very limited side effects for a medication that has single handedly the most health benefits of any medicine I've ever seen. With honestly one of, if not the lowest side effect profiles of any medicine I've ever seen. But society is still very, very hyper focused on the narrative of these meds being shown in a negative light. So I so appreciate you contributing to this conversation and helping us evolve a little bit.

Yeah, any to the side effect point that you make this, this might be kind of mean but again going Back to like GLP1 is a natural compound in our body. If you take a GLP1 and I'm not saying super high dose, but let's say we even give someone a microdose or a smaller dose and they get nauseated. My next question is, what did you eat? Because it may be that physiologically you got nauseated because you ate something you shouldn't eat. It's not a miracle drug. It's not like.

Right.

You know, but if. If you drink a bottle of wine or you drink half a bottle of wine and you eat a piece of bread, if you eat things that you probably shouldn't be eating, then you're going to get nauseous. But you probably would have get nauseous, probably would have gotten nauseous if you weren't on that medication. Right. Because again, this is just doing what your body would have physiologically naturally done. So that's why, like, when people talk about this, it kind of makes me a little irate, too. It's like you took a shot and then you thought you could eat an entire bag of Oreos and drink some wine, and then you're upset that you're nauseous. Like, you're going to be nauseous no matter what. Right? So, yeah, so that's just my point on that, too.

Yeah. No. Well, thank you. This has been incredibly insightful. One of my favorite podcast interviews to date, hands down. So I'm so excited to share it with people. Tell us a little bit about where everyone can find you. I know you have a podcast of your own that I would love for people to know about as well, but tell us how people can find out more about you and Modern Endocrine.

Yeah, thanks for asking. So I do have a podcast. We just rebranded it this last week and we changed the name. So it used to be back to the basics. Now it's called Hormones, Metabolism, and you. And so, yeah, so we're on Apple, Spotify, YouTube, wherever you get your podcast. And we're kind of focusing more on hormones, your metabolism, and your gut, because I have this book that's coming out later this year, and it is just kind of centered around our gut and how our gut, health and our. Our hormones are all interconnected. I'm on Instagram, I'm on Facebook, I'm on Tik Tok. All the things, all the platforms is just at Modern Endocrine. And I have a website, modernindocrine.com so that's where you can find me. Just all the avenues that. That you're on as well. I love it.

Well, thank you so much for taking the time today. Thanks for being here. Thanks for being such an advocate for so many people who need it. And I hope to bring you back soon.

Yeah. Thanks for having me. It was fun.