Two Peaks in a Pod
Two female physicians discuss women's health & fertility and how those topics are intertwined with pop culture.
Two Peaks in a Pod
Clomid or Letrozole: Which is Better?
Dr. Amber Klimczak and Dr. Beverly Reed discuss which fertility pills are better: Clomid or letrozole? They discuss how these medications work, how to find the perfect dose for your body, and what the risk for side effects are.
Hi, I am Dr. Beverly Reed.
Speaker 4:And I'm Dr. Amber k Clack.
Speaker 2:And we are two peaks in a pod. Pod. Well, hi. Welcome back everybody. Have you had a good week?
Speaker 4:Yes. We're trying to get into the groove of life, back at work.
Speaker 2:Okay, well I thought maybe today we could talk about. The big head to head competition between Clomid and Letrozole? Yes. I always get this question at my new patient consults when we're trying to formulate a plan for my patient and they always wanna know why are, are you choosing one of these medications over the other?'cause I do usually have a preference for one over the other. And so I thought we could kind of talk about all the reasons why, but first, let's talk about why we would need to use. These medications. So can you tell me kind of why you like to use
Speaker 4:them? Oh, definitely. And before we get into this whole discussion, I wanna, I wanna preface this by saying, we're talking about with your initial plan when we're just trying to. Estimate. Estimate what is the best drug for you? Which one we will try maybe first or for your first few treatment cycles, right? A lot of times I bounce back and forth between these drugs. So before we get a bunch of comments and questions, Dr. K, you said one thing on your podcast, but you're doing the opposite for me. Well, it's, this is what we. Think, right? Yeah. Based off of just like the traditional patient populations. Okay. So we do go back and forth.
Speaker 2:It's so funny you say that because I do get that comment a lot from pe. Mm-hmm. People will, oh, well I listened to your podcast on this, and I thought, oh God, what did I say? Sometimes we film these so long ago. Um, so we are always trying to do our best in any moment, but sometimes things can go over or things can change over time. And remember, we are always trying to customize things according to your body.
Speaker 4:Right. But
Speaker 2:these are just kind of generalizations. Yes. Um, overall,
Speaker 4:yes.
Speaker 2:Um, okay. So, but yeah.
Speaker 4:So I would say the most traditional time that you'll. See us using these medications in the fertility setting would first be patients who don't ovulate at all, right? That's really what these medications were kind of developed for. Actually, one of'em was sort of by mistake, right? Mm-hmm. Um, but we are looking at someone who on a regular basis, is not getting a cycle every month. Suspect that they're not ovulating and we wanna try and get them to induce ovulation. And so that's the most common time that we'll be using Letrozole or um, Clomid. But every once in a while we have patients who are already ovulating and they're still not having success at getting pregnant. And so we might wanna give them one of these medications to try and induce them to ovulate more than one egg in one month in attempt to increase pregnancy rates.
Speaker 2:Absolutely. Okay. You mentioned a mistake. They found this out by mistake. I don't know about this. Can you tell me,
Speaker 4:supposedly someone can, someone can Google this, but I think that, I think the history behind Clomid or Clomophine citrate, um, one of the really common and longest use medications in the fertility world was that they were trying to develop a birth control. Right.
Speaker 2:Really?
Speaker 4:I didn't know that. Yeah, that's, and
Speaker 2:they accidentally got people pregnant.
Speaker 4:Yeah. I think someone, someone Google it and lemme know, fact, fact check me, but. I think so.
Speaker 2:Yeah. Well, maybe that will make more sense when we think about the mechanism. Yeah, I, I, now I can understand that a little bit better. Interesting. Um, okay. Well, I think when you were explaining who you would give these pills to, I think it's helpful for us to really distinguish between those goals. So for some people, we're trying to get them to go from. Zero to one egg that they're ovulating. Whereas, uh, for other people, we might be trying to go from one egg that they already ovulate on their own to maybe two or three. Um, super ovulation is, is what we call it to try to give them better chances of being able to get pregnant. For patients, a good way for you to kind of know which category you would fall in is looking at your menstrual cycle history. If you are not having periods, then you're probably not ovulating. Or if your periods are unpredictable and or irregular, you are probably having ovulation problems, okay? Whereas if your periods are like clockwork. Every 28 days, every 30 days, 95% of the time you are ovulating. And so I think that can help kind of distinguish between those two.
Speaker 3:Mm-hmm.
Speaker 2:Yeah. Okay. We gotta go back to school and we've gotta talk about the mechanism of action for each of these medications. So I guess we can start with CLO and maybe why that had made sense to me that mm-hmm. Maybe they were studying it to be a contraception and then found out that it didn't work that way. Mm-hmm. And you know, in the fertility world, we love our acronyms. Yes. And so the acronym for the Mechanism of Action for CH Clomid, it's called a er, which is a S select, a Selective Estrogen Receptor Modulator. And I think when they probably first started studying it for contraception, they said, gosh, if you can find something that blocks the estrogen receptor. It makes sense that that could keep somebody from getting pregnant. But then what they probably didn't realize is if you block the estrogen receptor, the brain can say, wait a second, something's going on here. And it starts trying to fix that. And I think probably the thing to understand first, which I think is so cool, is that our brain and our ovaries talk to each other,
Speaker 4:right.
Speaker 2:I mean, is that not amazing? And so the way they talk to each other is our pituitary gland makes FSH and lh, and those are hormones that tell the ovaries what to do at any given time. And then the ovaries make hormones that feed back to the brain to tell the brain, did I do the job that you wanted me to do or not? And so what this, what Clomid does is it blocks estrogen. Okay? So the brain thinks there's no estrogen, and therefore the brain says, gosh, I really need to stimulate the ovaries to start making estrogen. And so that is how Clomid uh, works, and that's why it's so effective in getting multiple eggs to.
Speaker 4:Right. Yeah. And the way I describe this to my patients is that CLO and Letrozole basically get to the same endpoint Yeah. But by different routes. Mm-hmm. Right? Mm-hmm. So Letrozole is an aromatase inhibitor. That's a little enzyme that you have in your body that actually is involved in creating estrogen. And so when you block it, you're not making as much estrogen. So then you don't have that feedback to your brain to say, Hey, you have sufficient estrogen around your brain panics and releases more of those hormones, those keys to talk to your ovaries, to get them, um, to release more, um, basically to give your, your ovaries more stimulation. Okay? Um, they do it in different ways, but ultimately we're trying to get more FSH to grow more follicles. FSH is kind of that key to the ovaries to unlock more follicle development.
Speaker 2:You know, this kind of reminds me as you're explaining the mechanism of a patient that I saw recently, okay? Mm-hmm. So you're gonna be shocked, right? So this patient said, I've been seeing a functional, functional medicine fertility doctor. Mm-hmm. And they've been giving me letrozole and it's not working. Okay. And so I'm like, okay, you know, what dose are you on? And we're trying to work out the specifics.'cause it's pretty unusual to have somebody who just won't respond at all. Mm-hmm. You know? And she said, okay, well I take my Letrozole two pills a day, and then that's when I start my estradiol pills. Mm-hmm. And I said, surely you must be confused. Right? Like, you wouldn't take Letrozole and estradiol at the same time. She said, well, yeah, that's what my doctor told me to do. I said, are you sure this person's a doctor?'cause here's the thing, you are totally canceling out the effect of letrozole if you give estrogen at the same time. And I really, that's when you have to know that mechanism of let, uh, letrozole, if letrozole works by making sure your estrogen is low. So that your brain detects that and stimulates the ovaries. Then if you give estrogen, then your brain is not gonna get the signal that there's low estrogen and nothing is gonna happen. And I was just so surprised to see that, that somebody who claims to be a specialist would, would not realize that or know that.
Speaker 4:You know. Yeah, I've seen that too actually, about six months ago I had a patient that was like that. Yeah. But it was such a nice patient to fix.
Speaker 2:Yeah, I know. Like, funny what happens when you give it the correct way. Yeah. Um, but I'll say that's very different.'cause maybe again, some people might be, well, Dr. Reed, you gave me Letrozole estrogen. Okay. But I do it in a stepwise fashion. Meaning first I give you Letrozole. So that you grow your eggs and then sometimes they'll add a little estrogen just at the end to thicken the lining if needed. How do I know if you need that? I do an ultrasound to check your lining. That is okay to do because at that point the Letrozole already did its job to grow the eggs and you're just kind of tweaking things at the end.
Speaker 3:Totally.
Speaker 2:Perfect. Okay, so let's talk about dosing and I'll be interested to hear what you have to say this.'cause I feel like you sometimes you're a high doer
Speaker 4:on medication. No, actually it wasn't until I met you that I really dosed up Letrozole. I will. That is a true statement. I was like, oh wow. People. People really dose around here.
Speaker 2:So how, what are kind of factors you think about? So you, so let's say, you know, you, you've got your patient mm-hmm. And they say, okay, Dr. K, um, what dose are you gonna put me on? Whether it's COVID or Letrozole, how do you determine mm-hmm. What dose to give them?
Speaker 4:Yeah. Um, well, let's start with Letrozole. Mm-hmm. So Letrozole is typically given in 2.5 milligram pills. So we kind of think of the starting dose as 2.5, or that's kind of the lower dose, kind of, we think low, medium, or high doses. That's kind of how I used to approach it, right? 2.55 or 7.5. Those were traditionally really the only doses that I would give patients. Um, and based off of, you know, where I trained and. Experience. Experience with a lot of people, maybe not responding and having to bump up to five. I actually very rarely start people at 2.5 milligrams of Letrozole. It's kind of opposite. So you know, the more sensitive we think you're gonna be, the lower dose we're gonna get you of a medication. Okay? So if we think you're gonna be harder to respond, we're gonna put you on a higher dose. So that's kind of how I approach it. How severe does your PCOS. Look right. Um, what are your, what's the anatomy of your ovaries? Does it look like you're really insulin resistant? Does it look like you have a lot of androgens around in that, um, compartment of your ovaries? So we kind of look at you as, you know, the whole picture with your PCOS or your other condition causing anovulation. See how resistant do we think your ovaries are gonna be? And that kind of helps me, um, to dose them. Now I do have patients that won't respond to 7.5 and naive use. To move to injectables, but then I realized Dr. Reed goes up and past that and has success, which I think is actually a much safer and nice thing to do. So we will go up past, um, that higher dose quite a bit if a patient, um, isn't responding.
Speaker 2:Yeah. Yeah. So for Letrozole, we'll even sometimes go up to four pills a day. Mm-hmm. Or five pills a day. Mm-hmm. Um, so that would be 10 milligrams or 12.5 milligrams. Now here's the thing. We would never start at a dose of high. Correct. And so that's what I kind of always am explaining to a patient when we're treating'em. This is to help you get pregnant, but it's also to help you learn more about your body as we go along. And so I agree, I'll usually start at a five milligram, which is two pills a day, but I bring them back for an ultrasound and if they didn't respond, then I give them three pills a day. And if they didn't respond, then four pills a day. Stair step up to the dose that is gonna work mm-hmm. For your body. And some things I'll factor into is weight. You know, if somebody is very small, I'll usually kind of be more prone to give them a smaller dose. Or if they're very young, um, I'll usually give them a lower dose. Or sometimes patients will tell me, look, I'm worried about taking medication. I wanna be on a really low dose. To start with, or I'm really scared of the risk for multiples. I wanna be on a really low dose. Right. I kind of factor all these things in when I'm, uh, deciding on, on an initial dose, um, as well.
Speaker 4:Right. The higher we go, we're, you know, thinking there's more of a risk that you might develop more than one follicle. Yes. Right. And that puts you at risk of having something like twins or Yeah. Higher order
Speaker 2:pregnancies. Yeah. But I also think mm-hmm. Too. The higher we go sometimes the more prone we are to either side effects that the patient's gonna have. Mm-hmm. Or side effects we see in the uterus and, and, and all of that too. So I think that's why we're really thoughtful with trying to just find the right balance. But I think you and I have both been surprised sometimes. Sometimes somebody you would think would just need a teeny tiny dose, we'll sometimes need a huge dose. Mm-hmm. And vice versa. Mm-hmm. You know? Part of it, it really is just testing it out, um, on your body to see how, how you do and how you respond. But that's why I think monitoring is so helpful. I know sometimes when people are taking fertility pills, they're doing unmonitored cycles, and I always feel like, gosh, you're missing out on so much good
Speaker 4:information. Right. Monitoring, meaning us doing ultrasounds to look and see. Mm-hmm. How many eggs or follicles are you growing? How does your lining look?
Speaker 2:Yeah. What about Clomid dosing? What, how do you decide on that?
Speaker 4:Yeah. If I'm gonna be using, um, Clomid for a patient that maybe is not ovulating at all, then I would consider the lower dose of Clomid, which, which is typically 50 milligrams, although that's not my first treatment. Usually, I usually try and, um, do Letrozole first, but maybe I don't like the response on Letrozole for some reason. I might try 50 milligrams of ch Clomid. Mm-hmm. Now, if you were a person that's already having cycles and I think you're ovulating, I typically. Would not give you 50 milligrams. I typically will start at that a hundred milligram, uh, level of Clomid. So that's like two pills because again, I'm trying to give you a little bit of extra oomph in order to get you to release more than one egg because you're already releasing one on your own.
Speaker 2:Absolutely, absolutely. I'm, I'm the same way too. Um, usually in cases where we call it unexplained infertility, especially if the patient is 35 or over, I tend to do, um, a hundred milligrams too. But if I have patients that are really young, I do kind of stick that 50 milligrams. You just don't wanna end up in a situation where your poor patient has taken medication and then you have to cancel them for too many follicles. So it can vary from doctor to doctor, but usually if I see. Four or more large follicles that I suspect may have eggs and then might cancel because I don't want my patient to be at risk of quadruplets, quintuplets or anything crazy like that. Right. Yeah. Let's not do that.
Speaker 4:Yeah.
Speaker 2:Um, okay. I wanted to kind of mention one of the differences between CLO and Letrozole that I've seen, because I know not all providers are comfortable prescribing Letrozole. I know for us it's so standard. Um, but I've worked with fertility doctors who aren't comfortable prescribing it and some OBGYNs, and I did wanna say why I think that may be reasonable to allow them to do what is comfortable for them, and that is because Clomid is our old, trusted friend. Okay. It is FDA approved for this purpose. Okay. And we've been using it for way longer. Lots of safety data on it. And because the government has given us the stamp of approve approval, most providers feel very comfortable offering you this medication. But Letrozole is not FDA approved for this purpose. And that is important for patients to know that as doctors sometimes we use medications and we call it using it. Off-label saying, look, we know that's not what the primary intention of the medication was, but we're going to use it for this other purpose instead. And so because of that, some people don't feel, um, comfortable doing it. Now, I will say in the fertility world, we use so many different medications off label, right?
Speaker 4:Yes. Very
Speaker 2:commonly.
Speaker 4:Yeah. Yeah.
Speaker 2:Mm-hmm. Um, and I think what really gives me kind of the safety and confidence to use it is that our national organization for fertility, it's called a SRM, put a statement out saying, look, for patients with polycystic ovary syndrome, PCOS. Letrozole works the best and should be standard of care even if it's not FDA approved. And once I saw that, I said, okay, that makes me feel more.
Speaker 4:Yeah. And when we talk about safety data and you know, maybe FDA approval, that's kinda making patients or providers worry about this. What we're worried about is we're giving someone who's potentially gonna be pregnant a medication. Right. And I think the other thing that's really reassuring about Letrozole, it has a very short, what we call half-life, meaning your body processes it and it's out of your. System very quickly. And really there's no risk of exposure to the pregnancy or an unborn fetus when you're taking Letrozole. Interestingly, Clomid can last a lot longer in your system, at least one of the forms of it. So ch Clomid can kind of hang around for a longer period of time than Letrozole. So something to consider.
Speaker 2:Yes, absolutely. And so I guess I kind of jumped the gun a little bit in saying, Letrozole works best for P Cs patients, right? Mm-hmm. These are the other things we're thinking about when we're deciding. Okay. Do we use ch Clomid or do we use letrozole? And that often does come down to the diagnosis. Okay, so way back in the very beginning, everybody got Clomid, but in modern day fertility, what we're oftentimes trying to tease out is could our patient have a condition called. PCOS, polycystic ovary syndrome. But even is giving this diagnosis a little tricky these days, right? Yes.'cause there's so many different definitions or criteria mm-hmm. That you can use to diagnose somebody with PCOS, but we'll kind of run through, um, the common criteria that we would use and probably the most common criteria is made up of three different components. The first component is that you have irregular periods or absent periods. The second component is signs of a hor, um, a hormone imbalance where you have too much male hormone, and we can prove this either with blood test or with clinical symptoms like hair growth on the upper lip, chin, or chest or acne or pimples or things like that. And then the third thing is the ultrasonic appearance of your ovaries. And outta those three criteria, you actually only need to have two of the three. But you also have to have ruled out other rare um, issues that can cause similar symptoms. But if you meet that criteria, I think we both like to go straight to Letrozole, right?
Speaker 4:Yeah, definitely. Yeah. So this is a sensitive subject, diagnosing PCOS. Yes. But yes, I review, this is called the Rotterdam criteria. Mm-hmm. It's probably like one of the oldest and most widely accepted criteria for PCOS. But there are a lot of updates to this, right? Mm-hmm. So A SRM, our governing body released a huge, uh, document mm-hmm. On new updates and considerations for diagnosing PCOS. And it is much more complex Yeah. Than we could possibly even ex. Explain to you in a consult. And so really when we are diagnosing you and looking you at you with a full clinical picture and whether this medication is gonna be good for you or not, you should know that there is a lot else that we are considering. Yeah. Um, and, and whether we think that it would add benefit to your treatment. It's not super black and white to have a diagnosis of PCOS. There's a lot of other aspects that go into it.
Speaker 2:Well, and do you mind if I bring up, mm-hmm. The fact that you were misdiagnosed. Correct.'cause somebody told you you didn't have PCOS Correct. And Correct. You had it. Yeah. Right. So
Speaker 4:we see this a lot actually, and I just had another patient say this to me this week. Mm-hmm. Well, my doctor did a blood test for me and she said, I don't have PCOS.
Speaker 2:Just off of a blood test. Blood test. Yeah. How is that possible?
Speaker 4:Yeah, so you can't rule out PCOS based off a single blood test. Um, and a lot of patients I think, are relying on these markers. Right? And it's just not that simple. It is very complex and I think missing PCOS can be extremely detrimental'cause it's something that is. You know, gonna affect your health for a long time. So, um, when we're thinking about is Letrozole gonna be the right medication to get you pregnant, it's also how are we gonna manage you, you know, once we are treating you when you're pregnant.
Speaker 2:Mm-hmm. Absolutely. Um, okay, so if Letrozole works better in patients who have PCOS, then what about all the other patients that don't have PCOS? What's gonna work better from them? And I'll say there are. Tons of studies, studies, um, going on. But the general consensus is we think that Clomid probably does better for the rest of everybody else. Um, but I'll say, although I'll often start with Clomid, in those cases, it doesn't really matter too much if you end up switching from ch Clom to Letrozole in that population, right? Mm-hmm. They. Do pretty
Speaker 4:well, right? Correct. And that's really leads us into what are the downsides of the medications. So, you know, side effects or downsides of Clomid. We might start with Clomid for you and we don't really like how you responded. Yeah. So Dr. Reed mentioned doing monitoring, right? One of the. Biggest downsides of Clomid is it can thin the lining. Mm-hmm. For some reason, this is the one thing that all my patients know about with Clomid, and so they really worry about their lining. I think it must be on Google or chat GPT when you type it in, because they always wanna know their lining thickness. Yeah. Um, and it can, right. So we want you to have nice, thick lining so it's ready to. See the embryo when the time comes and implantation can successfully occur. So maybe if you have thin lining on Clomid, we might switch you over to Letrozole. Um, it seems that Letrozole has less of that negative side effect compared to Clomid. The other thing that Clomid can do is it can affect your cervical mucus. And so we've talked about this before, but you know, cervical mucus is really important also for sperm and being able to get up to the eggs. So if we, um, are not gonna pair it within insemination or an IUI and. Bypass some of that issue, then Letrozole can be a better option as well.
Speaker 2:Absolutely. And one thing I just wanted to mention, because you heard me say earlier, sometimes if I have somebody where I gave them Letrozole and then their lining was thin and I added estrogen to thicken up the lining later, right. You can do that with Clomid, but we think it probably doesn't work as well because if you think about the mechanism of action of Clomid, as Dr. K said, Clomid tends to last in your system longer, and the problem is Clomid blocks at the receptor level. For estrogen. And so you can give all estrogen, you want to try to thicken the lining, but if ch Clomid is still blocking those receptors at the lining, it's probably just not gonna help. I mean, it doesn't hurt to try it at that point, but more so if I identify that there's a thin lining issue on the ch Clomid, then I say, look, I hope the cycle works for you, but if it doesn't, let's try a different strategy for, um, the following month. Um, I would estimate probably only about 10% of women have a. Really thin lining on Clomid. So most people do great, but it is something we're always on the lookout for as well. Mm-hmm.
Speaker 4:Yeah. Um, and the lining on the Letrozole is interesting. I have a different approach a lot of times with my patients. Mm-hmm. And because Letrozole sort of, you know, wears off as you get. Further into your cycle. Yeah. Um, what I see sometimes is just, it's a time thing, right? You just, your lining needs a little bit more time to recover because your estrogen levels will start to naturally come back up, especially locally around the uterus and your uterus just needs a little bit of time to see that estrogen to grow. So a lot of times, we'll let my patients kind of push a few more days, um, with their follicle. Mm-hmm. And we'll see those. Levels rise. Yeah. And your lining stimulates really nicely. Yeah. Um, but it feels hard to wait mm-hmm. To the patient a lot of times, you know, they really are fixating on their lining. Yeah. But in most of my patients, I will see their lining recover nicely on leal, but not the case with Clomid. If you're gonna have thin lining and I really see it happening, it's hard to recover it.
Speaker 2:Absolutely. Yeah. Um, okay. Well I wanted to see what your opinion is on which has the worst just side effects as far as what a patient would feel from the medication. I'll say I think probably 80% of patients don't have side effects at all to either. Mm-hmm. Okay. But maybe 20% might have some side effects. And so I kind of thought we could talk through what the side effects are of the different ones.
Speaker 4:Yeah.
Speaker 2:Should we talk about which one should we talk about for? I'll let you pick.
Speaker 4:Well, I just think it's funny because a lot of my patients tell me Clomid is really terrible. Yeah. Um, and it's probably'cause more patients have taken Clomid, especially'cause a lot of OBGYNs will prescribe it mm-hmm. Before they even see us. But I personally think of any medication I ever took in my fertility journey. Letrozole is the worst.
Speaker 3:Really?
Speaker 4:Yes. I Tell me, why did you get Letrozole? Had I had terrible hot flashes and it makes me laugh. Um, because I had terrible hot flashes. I have headaches that last the entire day. Oh. And I'm not a headache prone person. And you know, when you do get a rare headache, you go through all of your, I'm dehydrated, I need Tylenol, you know, I need caffeine. I do all the things. And you still have the headache. 24 hours a day. Oh, your sleep is disrupted. You know, you do feel hormonal. And so it makes me laugh though, because a lot of these are the same signs and symptoms of menopause because Letrozole drops your estrogen level down really low. And so I know I'm gonna have to look. I know that I must be one of those people that's gonna really not do well in menopause. You know, we have some. Warrior women that go through menopause. They're like, what? That was nothing. And I'm gonna be the one that's like, absolutely, I need help.
Speaker 2:Well, the good thing is, you know, somebody who can give you some. Yeah. Yeah. I think we'll have to meet each other's hormone dealers once we, yeah. Menopause. Menopause. Although I'm already headed that way, so, um, okay. Well, I would've thought, I would've guessed cloned because I, it's actually kind of funny. At my old office location, I even had a sign that said. CLO made me do it. Yeah, because I mean, oh my gosh. Like, it, it can really cause a lot of symptoms and some are the same, you know, hot flashes, headache, um, but mood swings mm-hmm. I think are such a big one. Did you have mood swings on Letrozole? I'm
Speaker 4:just already like, so moody to my husband that like, like he. I think anytime we were doing fertility treatment, he just had to like just take it. You know, someone has to, I say I like keep myself together throughout the whole workday. Yeah. In front of so many people that someone has to bear my wrath and it's usually my husband.
Speaker 2:Well, I think it's hard because when you're on clo you can be sad for no reason. Yeah. You can be mad for no reason. You can be sad and mad
Speaker:for no reason.
Speaker 2:So if it's somebody close to you, you might wanna give them the heads up. Hey. I'm on some meds right now. It's gonna get better. Yeah. And it does. Once it wears off, you feel back to normal and everything. But it might be good practice for pregnancy though,'cause mood swings are also in pregnancy too. Um, okay. And then we should talk about the risk of multiples.'cause that is probably the most serious side effect when you think about these medications. Um. And so what are your thoughts, just based on what you see? Do you think there's a higher risk of multiples with ch Clomid or Letrozole, or do you think it's about even?
Speaker 4:I would say actually in my patient population, it, both of'em I think are pretty rare. Mm-hmm. Um, but like, as you said, I am kind of a gender dor, so I do get like, you know, a little bit, um, lower rates. Traditionally, I think what people will worry about is the higher dose of Clomid and, you know, purposely trying to induce. More than one follicle. Mm-hmm. You're probably gonna have a higher risk of multiples. Mm-hmm. Letrozole tends to recruit just one follicle at a time. Mm. Especially in patients who don't ovulate. We call that mono follicular development. So slightly lower rates. The studies kind have a crossover when you look at the data on this. You know, so Letrozole maybe seven to eight, you know, up to seven to 10 in some studies, and Clomid can be up to 10%, even 11% in some of the studies, and then lower. So they do have a lot of crossover in the intervals. Yeah. So I think it's kind of minutia, honestly. Yeah, yeah, yeah.
Speaker 2:I do remember when people first started using Letrozole, one of. Selling points is, they said it had a lower risk of multiples compared to clo, but they later disprove that. Mm-hmm. And they said, no, really they're about the same. So yeah,
Speaker 4:that's, that's,
Speaker 2:that's what I think. It's
Speaker 4:just too much. And I feel
Speaker 2:like that's what I see too. Mm-hmm. I think, I think it's about the
Speaker:same overall. Mm-hmm.
Speaker 2:Um, but for some reason that reminded me, another reason sometimes I'll give Letrozole over k Clomid is if I know or suspect they have endometriosis or adds. These are conditions where little bits of your lining may implant in different spots where they shouldn't be like in the pelvis or in the muscle of the uterus. And interestingly, we think these little implants can actually make aromatase and letrozole is an aromatase inhibitor. And so although this hasn't been proven, this is me just trying to use logic. Sometimes I'll use those medications because I'm like, maybe that'll help kind of reduce activity at the site of those implants. Well, um, again, I don't think ch Clomid iss a bad choice. I also use Clomid in those patients as well, but something sometimes that'll be something I'll think about too. Also, I wanna bring up one of the big side effects they teach us about in training for Clomid. Mm-hmm. That we really have to be on the lookout. We don't see very often, but do you know which one I'm talking about? Visual changes? Yes. I've never had it. Have you had it happen, had a patient happen? Well, actually no. I take that back. Yes. I would say maybe. Once every year or two. Mm-hmm. Mm-hmm. I'll see it happen. But you know, they warn us if somebody's having visual changes, they need to stop the medication right away and don't give it to them again. Because if somebody is having that side effect, you do worry. Could it progress to some sort of. Um, blindness or something like that. Now it's more theoretical. This hasn't been proven or anything, but I, we are all very sensitive to that. Mm-hmm. Because of our training. Mm-hmm. And so if you say the magic words, which is, I, my vision is blurry, or I'm seeing flashes of light or something with cl, then you don't get to have cl
Speaker 4:Yeah. You get a big red note on your chart. Yeah.
Speaker 2:Okay, good. Well, should we wrap it up? Yeah. Okay, perfect. Alright. Thank you guys. We really appreciate you guys listening. If you have time, we'd really appreciate if you left us a positive review, even either on our peak fertility, uh, clinic page, um, under Google or just for our podcast review. We'd really appreciate it. Thank you. Have a good week.