Two Peaks in a Pod

Posh Problems: Beckham's PCOS Confessions and How to Spot the Signs at Home

• Beverly Reed • Season 3 • Episode 7

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Dr. Amber Klimczak and Dr. Beverly Reed discuss how Victoria Beckham has opened up about having PCOS and how it affected her fertility. They discuss signs of PCOS that you can look for at home. They discuss the official diagnostic criteria for PCOS. Dr Klimczak also opens up about how she was misdiagnosed in her own personal journey.

Watch this (Season 3, Episode 7) on Youtube or listen on your favorite podcast platform to Two Peaks in a Pod.

https://www.youtube.com/@peakfertility

https://podcasts.apple.com/us/podcast/two-peaks-in-a-pod/id1694248202

Links are in @drhappyeggs IG bio.

Hi, I am Dr. Beverly Reed. And I'm Dr. Amber Clack. And we're two peaks in a pod, pod, pod. Well, welcome back everybody. Um, this week I wanted to tell you about Victoria Beckham. Okay. I know her. Do you? Okay. You know, her Great Spice Girls were huge. Okay. That's Well, because you're younger than I'm, so I'm like, do you know the songs and everything? Of course. You what I want. What I really, really, of course. Great. Okay. Awesome. Many, many Halloween costumes, spice Girls. Oh wait, you, yes, it. Oh, we're gonna have to put this on your Instagram. And we would fight over like who gets to be posh? Everyone wanted to be the same ones, you know, so, which. Spice for you. I always wanna be baby or posh. Posh is so cool. You know, she's okay. I, you're gonna need to show us some photos, ands put them on your Instagram. Maybe we can have somebody add them to this YouTube video for us. I mean, she's really made it though. I feel like she's kept her celebrity power. Yeah. Yeah. Yes. I've always just admired her. I mean, first of all, she's gorgeous. Mm-hmm. She's so pretty. Um, I love her song. And then she married a handsome soccer player. Oh my gosh. David Beckham's. So cute. Manly man. Yes, yes. Um, and then she became a fashion designer, and I love her style. The nicest clothes, so pretty. Um, and so I'm a big fan, but you know, she's been in the news recently. Um, I guess she and David Beckham have a deal with Netflix, so they've been kind of doing these documentaries about their life and so she is becoming more vocal about her past, and I think they've traditionally been pretty private. Um, but she did open up about a number of things. Um, but as I was kind of learning more about her, I saw she's actually opened up about having had PCOS before and I was really surprised. I'm surprised. Yeah. Yeah. She's never, you know, she's never really talked about it. Um, too openly, I guess, except for maybe just mentioning it way in the past. And so, um, so I was surprised and went to learn more. And so really what she shared is that it was really painful because she'd had, I think, maybe a couple boys, couple kids, but people kept doing that thing that When is your next one? Mm-hmm. You know, four people who haven't had their first baby yet. I know it's so annoying because people are always asking, when are you gonna have a baby? When gonna have a baby? And you think, oh my gosh, if I could just have a baby, people will leave me alone. Leave you alone. Yeah. Once you have your first one, then they're gonna keep at, when is your second one? When is your third? Third? Are you done? That's what we always get. Are you done? Exactly. Yes. Um, so poor thing in her case here, she's this famous celebrity and people are just. Always hounding her. When are you gonna have another one? Are you gonna try for a girl and everything? And finally, at some point she's like, yeah. I mean, I've been, I've been trying, I'm having fertility issues, I'm trying to do fertility treatments and everything. And ultimately thank goodness she was, um, able to conceive again and have a child. But I do think that must be so hard to be in the public eye and, and have to kind of those questions. Little girl. Yeah, she had a girl. Okay. She had a little girl, I think her name is Harper. Um. Um, and, and so I think it's, but I do think it's helpful when people share, so then you don't feel alone or anything like that. But I think the reason I was surprised that she had PC Os is a lot of patients with PCOS can really struggle with, um, losing weight. Sometimes they can be overweight or even obese. And, um, and of course she's sort of dealt even publicly with the opposite of even potentially, um, having an eating disorder or anex. C and everything so I can understand how it may not have been blatantly obvious in her case, but I think it's so important for us to understand. PCOS comes in all shapes and sizes. Definitely. Yeah. And certainly should not be overlooked. Yeah. And and sometimes even really severe cases of PC Os don't fit that traditional mold. Yeah, absolutely. So I feel like in the medical field, sometimes during our physical exam, we'll look for clues of PC Os, but we have to be clear, you cannot look at a person and decide. Do they have PCS or not? You really need to do further testing. Yeah, absolutely. This is, I mean, this is something that happened to me, right? For years. So I have an older sister, um, and she struggled with fertility and so she had always said to me, oh, I think you should get checked, you know, which I tell my patients a lot. I think this is actually really nice when you do have sisters, right? Mm-hmm. Yeah. Let your sister know if you have something going on, right? Yeah. That's your most genetically related person, probably. Yeah. Right? So. If you have going, she's like, I really think you might have ps. Mm-hmm. Like you should talk. And when I talked to my obgyn, very dismissive, you know, unfortunately, um, was told, I can tell just by looking at you, you don't have PS. And that's just simply not true. Yeah. You definitely cannot look at someone and determine whether or not they have. PC Os. Yeah. And this was before you were even a doctor, right? Yeah. Is this when you were younger? Yeah, I was young and I was like, okay, great. Yeah. Little did I know what was coming from me later. But now that you're an expert in pcos, looking back, does that make you mad? I think it makes me realize that we have a lag, right? Mm-hmm. Like that We need more education. I mean, my goodness, if an OBGYN isn't aware of, you know, lean PS and other insulin disorder, then. Failing. Yeah. I think, um, at, you know, educating in medical school and residency mm-hmm. There's, you know, forever I think there's been complaints about mm-hmm. And, you know, especially ob-gyn residency that maybe it's really focused more so on obstetrics. Mm-hmm. Right. Really OB heavy. Mm-hmm. And maybe things like menopause and fertility are overlooked. Mm-hmm. Um, a lot. And so I think if we can't even have enough information out there for specialists Yeah. Then, I mean, what about your basic family medicine and primary care doctor? They probably are even less exposed. It's, yeah. Yeah. So it seems like you don't hold any ill will towards him. Yeah. I kind of feel like I'm mad at, yeah. About it, but certainly he meant no harm. Yeah, I think he was trying to give you reassurance but also really kind of led you astray and perhaps, you know, left you without the opportunity to treat any bothersome signs or symptoms. Okay. So you did mention Lean PC Os. Can you tell our audience a little bit more about how Lean PCS, like what do you mean by that and how is that different from my other ps? Yeah. Yeah. So I would say when we think about more traditional PCOS. Patients. Mm-hmm. Um, we tend to think of overweight or obesity, really playing into that factor and it bringing along with it metabolic syndrome, weight gain around the middle. Um, like Dr. Reed mentioned, difficulty losing weight. Um, increased waist to hip ratio. However, 20% of patients who are ultimately diagnosed with PCOS will actually be lean, meaning their BMIs will be normal or maybe even on the thin side. Um, and can still struggle with anovulation, non ovulating, having, um, you know, particular appearance of your ovaries that we call a polycystic ovary appearance. Um, and then having those androgen symptoms, symptoms of higher than normal male hormone levels, things like acne. Um, hair growth, other bother bothersome symptoms that, you know, you might be listening and thinking, I have some of those things, you know, and that you don't fit the exact mold of what you thought a PC OS patient would look like. Absolutely. Um, okay. Well if we can't just look at a person to decide if they have PS then how do we know if somebody has PC Os? Right? And so I think maybe I'll first just start off by saying. PCOS is an acronym that stands for polycystic ovary syndrome, or some people will say pcod polycystic Ovary disease. But either way, I think we all agree it's a terrible name. Mm-hmm. For this disorder. Yes. And so there are actually people trying to get together to change the name. Okay. If you had to come up with a new name for PCOS, what would you name it? That's so interesting. I never thought about it. Um, I can't think of anything off the top of my head. What I like, what suggestions I heard would be maybe poly follicle syndrome or Poly syndrome mm-hmm. Or something. But for our audience, I think it's really important to tell you that even though the name has cyst in it, it doesn't mean that you have cyst on your ovaries. Right. This is why we wanna change the name. And so when we look at an ovary, we can usually see lots of little black circles, and those are your follicles. Those are where eggs come from. And every month, most women get a new wave or actually multiple waves of follicles that pop up. Um, but yeah, if one of those follicles gets really big and it can turn into an ovarian cyst, but that is a different condition from pcos. The people who named this condition, what they were trying to describe is that patients with PCOS have way more follicles, the little black circles when compared to the average person. So when we're doing an ultrasound on just a regular person, we would usually see about six to 10 follicles on each ovary. But with PCOS, usually you see 20 or more follicles on at least one of their ovaries. And so that's where it definitely tends to be a misnomer. And all the time we'll have patients come in, he'll say, well, I was told I had cyst on my ovaries, so therefore I have PCOS. And sometimes we're like, no, that's a different kind of cyst and you don't have it. Or sometimes patients will come in and say, well, I had an an ultrasound and I don't have any cyst, therefore I can't have it. And again, we say, no, no. Again, that's just more of a misnomer and we, um, end up explaining that. Um, I think the hard part about changing the name at this point is there's, so the name is everywhere already. Mm-hmm. If you're gonna Google p you know, it's gonna be hard when people are googling a different term at that point, so, yeah. Yeah, I get that all the time with my patients. I'm worried that I have PS because I had cyst. Mm-hmm. Mm-hmm. Yeah. Now I, I guess we should say too, I mean, certainly if you have pcos, it's possible for you to have cyst every now and then, but that would not be the discrim discriminatory or diagnostic criteria for whether you have PCOS or not. Correct. Yeah. Women with PCs are certainly more prone to cyst. Mm-hmm. Forming cyst, and so we do see that quite frequently. And, and sometimes that's just a good reason to get an ultrasound, right? Mm-hmm. And then they see, oh yeah, you do have PCO os. And you think it was because you have cyst. Mm-hmm. Yes. Yeah. Okay. So here's the next tricky thing about PCOS is what are the diagnostic criteria? Well, we can't even agree on this. Mm-hmm. Okay. And when I say Dr. Kay and I, we actually agree on it. But all across the world, there are different organizations that have shared with the world what they think the criteria should be for pcos. And because there's different organizations with different criteria, you ultimately could end up with a patient who says, well, this person says I have it, and this person says I I don't have it. Right. Isn't that so frustrating to hear that? Extremely frustrating. Yeah. But I also am. You know, I think we should be inclusive and maybe mm-hmm. I think PC Os is really something that we don't wanna miss. And if you That's true. Even have Yeah. Maybe some of the criteria and not all of it, it still might change our management and treatment plan for you. Yeah. Um, and so I think patients sometimes really fixate on, I wanna diagnoses, I wanna reason. But for us as physicians, we wanna make sure that we're applying the appropriate treatment. Mm-hmm. And not really missing anything. So I think we have a different take on it too sometimes. Mm-hmm. So, mm-hmm. I would say yes. Right. It can be difficult to get a clear answer. Mm-hmm. But I would at least maybe raise the point to your physician if you have concerns about it. Yeah. Maybe you're, yeah. Thinking, I have some of those things, but maybe not all of those things. I think your physician would still like to know. Yeah. Yeah. And I also think too, maybe, and maybe this is the older I get, I kind of maybe don't pay as much attention to the rules, right? Mm-hmm. It sometimes things are presented as very black and white. Mm-hmm. It either this or it's not. Right. Um, but in real life there can be gray areas, right? Mm-hmm. And so I think sometimes it really helps. To have a physician who's kind of trained in these things to really look at your case and just give you the best guidance they have, but understand that there may be discrepancies when, when just talking with other people, because we're all made up of our own experiences, right? Things can be a little bit different. But let's kind of just break down the criteria. So I always think about the big three. So let's kind of start with the first one. And here's what's so nice about this criteria is for some of this you can kind of diagnose yourself at home. Yeah. I mean, you still are gonna need some help, and we'll get to that part later. But the very first part is your pattern of your period. Okay, so most women have periods like clockwork, okay? So your period may come every 28 days or every 30 days, but if you are not having periods, or if your periods are really spread apart or very irregular. That's a red, something is wrong. Yes, absolutely. Yeah. You know, so when your periods are spread out or you're missing cycles, that's usually a sign or symptom that you might not be ovulating. Mm-hmm. And so that's typically the reason why, and that's one of the first things we look at to diagnose PC Os. Absolutely. But I'm always very careful to let patients, and maybe even other providers know too, sometimes maybe just a primary care provider. You never wanna assume that a woman with irregular periods has PCOS. Do most of them have PCOS? Yes. But are there plenty of other more rare conditions that the patient may have? Absolutely. And so it's super important in that case that you see a specialist of some type, whether it's an ob, GYN, who's willing to do further testing on you or a fertility doctor to know and understand why are the periods spread out or non-existent? Why are they irregular? Um, because other conditions such as. Running outta eggs, um, too soon or even, um, hypothalamic problems where your brain is not giving appropriate signals to the or other conditions that can also cause similar, um, irregularities in the period. So importantly, although you may be able to get hints of PC Os at home. You don't wanna just self-diagnose and not get fully evaluated for any of those other things too. Yeah, and here's another key point about cycles. Mm-hmm. I think especially with modern things that we do nowadays with our health and our wellness, I always listen to my patients to hear. Have you ever in your life had a long period of time where your cycles were irregular and then maybe they have regulated? Mm-hmm. So here's some things that you might have done. Yeah. That have actually corrected your cycles. Mm-hmm. But it doesn't mean that your PC Os is gone, or you still don't meet this criteria for PC Os. So. Having a history of a point in time of having irregular cycles is actually really important information for us to know too. Yeah. Sometimes my patients have kind of overlooked this in their history, right? Mm-hmm. So for example, you had weight loss surgery. Mm-hmm. Right? Mm-hmm. That is a dramatic change. Mm-hmm. In your metabolism and can actually change your cycles. Mm-hmm. And so prior to your weight loss surgery, did you have your regular cycles and then have weight loss surgery and they've corrected? Mm-hmm. Are you on birth control pills? Yes. Right. Are you regulating your cycles with birth control pills, patients all the time. Tell me. Yeah. I have regular cycles. Yes. And then I find out they only have regular cycles when they're taking birth control pills. Right. Those are fake periods. Yeah. And look, it's great to be on birth control pills. They're great for pcos, but Exactly. We don't wanna misinterpret your data. So when you're telling us. Yes, I have normal periods. I think that's a really good point you brought up, right? We need to know if you're on birth control pills for that. Absolutely. Um, GLP one agonist, same thing. I've had patients that for years have had irregular cycles, and we'll probably talk a little bit more about why this is, they get started on GLP one agonists. And all of a sudden have, um, regular cycles. Yeah. And Metformin can do this as well for you. So some of these insulin lowering medications will regulate your cycles. Um, what else I've seen, you know, even, you know, sometimes patients taking some supplements mm-hmm. That can help regulate their cycles. They don't take their supplement like ol have their regular cycles. Mm-hmm. So just some more modern things that my patients will do. Yeah. That, yeah. I have regular cycles, but maybe not exactly. Yeah. Yeah. Okay. So the second criteria is interesting because you can actually meet this criteria one of two ways. So the first is that you have symptoms of essentially too much male hormone in your body. Okay? So we as women, it's normal to have. Some small amount of male hormone in our body, and this is usually through androgens, such as DHEA and testosterone. But if your levels get too high, you can start to have symptoms like hair growth on the upper lip, chin, and chest, or skin breakouts like acne. And so if and when a patient reports these things to me, oh yes, I have acne. Oh yes, I have hair growth. I can actually allow them to meet this criteria without even doing any blood testing. And I kind of love this part because to me it means we're listening to our patients, right? Mm-hmm. Um, sometimes people really like things to be proven with a lab test, but I'm like, look, even if a lab test is normal, you have to understand how is her body responding to the hormones in her body? And if she's having these symptoms coming around that shouldn't be there, that's important for us to know. But I do think it can be a little bit challenging because sometimes people may say, well, you know what? My family, everybody has hair on their face or, or you know, even the women, that's normal. But remember, PC Os can actually be genetic too. So it could be, well maybe a lot of people in your family have PC Os or I do think it's true that certain ethnicities are just more likely naturally to have some of these symptoms too. So admittedly, sometimes that criteria can be a little tricky too, right? Yes, very tricky. And in fact. Speaking of ethnicity, I would say my Asian population and patients actually are the most overlooked. Mm-hmm. Because, um, Asians are actually very, they're less likely to grow body hair in response to these things. So I think an Asian polycystic ovarian syndrome woman is very likely to be missed actually, because they. Won't have these symptoms. Yeah. And then we get in and do their ultrasound and see some other, um, things going on with their fertility and becomes clear. Yeah. Yeah. But I think the other tricky thing about that too is sometimes women may be, for example, on birth control pills for some other reason. Well, birth control pills, again, are great for pcos. It can help. Suppress the androgens in the body and it can improve acne and hair growth, which is great. But also if you have a patient who hasn't gotten that diagnosis yet, it may kind of mask that as well. Mm-hmm. Um, but the other way, so if, if your patient says, well no, I never have any skin breakouts and I never have any hair growth issues, well, there is another way we can assess for that. And that is by checking some additional labs. Looking at the DHS and the testosterone levels in the blood. I would say for most of my patients, they more so meet the criteria with the clinical criteria we discussed. Very few of them are meeting it based on lab criteria alone. But is that, has that been your experience too? Yeah, yeah, yeah, definitely. Yeah. I'll say that. For PCOS, we are checking some of these things, but we can't rule PCOS outer or PC os out or in based on just one lab test alone. So notice how we're talking through all this criteria as we're going through this issue. Um, okay. And then the third criteria is ultrasound. Mm-hmm. So can you tell us a little bit about, you know, when you're doing an ultrasound, what are things that make you think somebody may have PCs? Mm-hmm. Yeah. So, um, you might have Googled or seen a picture of your own ovary on an ultrasound. So ovary on ultrasound, you know, typically a circle and you know more and, you know, oval around in shape. And then you can see small resting follicles on the surface, or small little follicles. Um, women who have PCOS, their ovaries tend to be bigger in size. A lot of times they're more oblong in shape. So, um, instead of being more round can be like much more of an oval. Um, and they tend to have a lot more resting follicles than your average patient. And they can be, but don't have to be kind of pushed out to the. Side periphery of that ovary. We call this the string of pearls effect. So you can imagine that it kind of looks like a little pearl necklace lined up all around the outside of the ovary. Um, and there's a good reason for that. Like a lot of the androgens are made in the center, that s part of the ovary. And so that part gets really, really big. And so your follicles appear to be all on the outside or the periphery. So we'll do some measurements, we'll counter follicles that are resting there. When those things are high and big, then we're thinking PCOS. Now, this actually brings me to another tricky part of the criteria, which is they recently changed the number of follicles on your ovary that you have to have to have pcos. So I, and again, this is just part of me getting older, I guess mm-hmm. Is when I was young, um, they used to say you had to have. 12 or more follicles on an ovary to be considered a polycystic ovary. Now they're saying 20 or more follicles. They do say, it depends on how nice your ultrasound machine is, because the newer ultrasound machines, which is what we have, we have very nice ultrasound machines, can probably. See the follicles better than the older ultrasound machines. So they say if you've got the older machines, you can still use the older criteria, but if you've got the newer machines, usually you're talking about 20 or, but I say it's a little hard for me knowing that history, when sometimes I'll see a patient and I count and I get like. 18 follicles, right? Mm-hmm. And they're in between that 12 and the 20. And I'm like, okay, but if you saw me five years ago, you would've met criteria. And now we're saying you don't meet criteria. You know? And, but again, it's kind of like, well, you've gotta look at the overall history. Maybe the other thing is, we know the follicle count can change from month to month too, right? So I, I do think sometimes in those cases I'm like, well, it's a little borderline. Let's just kind of. Keep this in the back of our mind as we're going through the process. Yeah. I think age is so important here too. That's true. I think experience of your physician. Mm-hmm. Um, again, I, yes, we like to use specific criteria to help diagnose our patients, but I certainly use 12 quite often. Mm-hmm. Because I'll say the patient population that often we're. Mm-hmm. Looking are older women. That's because that's by time women are ready to have a baby. Like our average patient a lot of times are 33 to 42. You know? Yeah. You're scanning a 39-year-old and they have more than 12 follicles. Yeah. I, I mean that's really high numbers for 39-year-old, so you have to kind use the patient's age. Yeah. As opposed to a general ob gyn might be more commonly seeing young women in their twenties, right. Yeah. Who are gonna have actually really high follicle counts naturally. Mm-hmm. And I think that's where that. Count for us to make sure that we're not over right, because it could be normal for a young, healthy woman to have a lot of follicles on her ovary. Yeah. But I'll say one of the great things about the criteria we use for PCOS is outta those three criteria we just talked about, you only need to have two out of the three to meet the criteria for PC Os. So if I do have a patient where I'm feeling it's a little borderline. But she has irregular periods and she's got acne and hair growth, then she can still meet that diagnosis overall. So I think that can be comforting. I think what also can be challenging is just if they're a little borderline in all the categories. Mm-hmm. And they're just like, ah, you know? Um, but also what's really important, this is part of the criteria too, is you have to have ruled out other causes of similar symptoms. And so we primarily do this through reviewing the history and doing blood work. So a lot of times people think, oh, if we're checking, for example, a testosterone level, they think we're checking, oh, is it elevated for PCS? The real reason we're checking the testosterone level is to make sure that it's not sky high and an indication that there's something more concerning going on. So very rarely you can have somebody with a ovarian tumor that is making testosterone and then causing irregular periods and hair growth and acne and things like that. So we're ruling things out like that. You can have an adrenal, um, either hyperplasia or tumor that can also cause very high androgens, which would cause irregular periods and hair growth and acne. Um, and so you may not realize it. Um, here's another one. The 17 hydroxy progesterone is a lab test that work, um, also doing to make sure you don't have a more rare condition that could be causing the exact same symptoms. So you're probably like, oh my gosh, why is my doctor checking all these blood tests? It's because we're just ruling out the things you may have never heard of. Yes, exactly. Yeah. Um, and a note about testosterone, definitely, you know, really important point to mention because it's almost like a screener that use, we're just ordering what's called a total testosterone level. Um, and you know, not to get too much in the weeds here, but a lot of times patients will tell me, oh, well I thought I had PCOS, but my doctor checked my testosterone level and it was normal. Mm-hmm. Same thing, right? There's a different type of testosterone or a free testosterone that's actually causing a lot of the symptoms that you're experiencing, and you can actually have an elevated free testosterone, but your total can be more so normal. Mm-hmm. You have one lab. Yeah. From someone. It doesn't mean that maybe this isn't affecting you. Yeah. And then, um, I feel like we're really getting in here with all this detail. I like it. Um, I think it, sometimes it's helpful to think about some of the other tests too. We might even just need to do treatment as a whole other Yeah. But let's think about. Fsh, lh. Sometimes this can be a hint as to what's going on. So FSH and LH are hormones that come from your pituitary gland in your brain to stimulate your ovaries. And interestingly, many women with PCOS have a pattern. Where their LH is much higher than their fsh, and this really probably gets to the underlying nature of why there's even issues to start with, right? Mm-hmm. Yeah, absolutely. Yeah, so I think sometimes if you're borderline, you could always consider checking that ratio to see if that leads you in one direction or the other. This can be helpful if we're also trying to distinguish between somebody who maybe has too low of fshh, so let's say. We know that's not what we would typically see with a patient who has PCOS, and then we're thinking, oh, maybe their problem is that their brain is not making any signal at all to stimulate the ovaries. Whereas with PC Os, they tend to have lots of lh. LH is really what stimulates the stroma, that central portion of the ovary that ends up making a lot of andross, a lot of testosterone, which then kind of creates this whole, um, state of PC Os anyways, so. Um, and then another, uh, kind of cheater test is what I would say is your A MH level. Mm-hmm. So AMH is a blood test called anti hormone, and it's actually made from the follicles and the ovary. So if you have a normal number of follicles, you'll probably have a normal AMH level. But if you have way more follicles than normal, then typically we can see a much higher AMH level. Now, people have had some disagreements over the years as to what type of A MH could indicate concern for PC Os, but I usually start thinking about PCOS if I see a level of about five or more. Do what? Do you use a cutoff or what do you think? So as RM, really that really big. Um, yeah. Well, admittedly I have not read all of it. Yeah. But, but they did have the number of 3.5 in there as a suggestion as well. Okay. Mm-hmm. And again, I think it's just so age dependent. True. Yeah. Um, and even just, I know this, again, it's just kind of like a feel when you look at someone's age Yeah. Um, in their follicle counts and you know, altogether. Mm-hmm. But, but yeah, I mean, it, you really, if you have. Five. Mm-hmm. Right. That's pretty safe probably at most ages. Right. But even some young women in their twenties, that might be normal for them. Sure. So it's really hard to just use that level. Yeah. Yeah. Absolutely. Makes a lot of sense. Yeah. Okay, good. Alright, should we wrap it up through the week? Okay, good. Alright, well thank you guys so much for listening. We'll do our next episode on if you have P os, what are all the different. Treatments you need to think about, whether it's in terms of your just health in general or in terms of fertility. So we'll talk all about that if you would be so kind to leave us a positive review either on YouTube or our podcast website or our peak fertility website, we would greatly appreciate it. Have a great week. Bye bye.