Two Peaks in a Pod

Hormone Harmony: Your Roadmap to Mastering PCOS Treatment

• Beverly Reed • Season 3 • Episode 8

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Dr. Amber Klimczak and Dr. Beverly Reed discuss how to best control PCOS symptoms. They also discuss the best PCOS treatments to help conceive.

Watch this (Season 3, Episode 8) 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 Reid. And I'm Dr. Amber k Clack. And we are two peaks in a pod. Welcome back everybody. So last episode, we were talking. All about PCOS and we, you know, we're talkers. We know we got caught up. We were supposed to talk about how to diagnose PCOS and how to treat POS all in the same episode, but we just went on and on just talking about the diagnostic part. And so we are doing part two now. So now we're gonna be talking about treatment. PCOS is a big subject. There's a lot. It's true. I know. Really, I mean, we could talk even longer about it. We could have multiple more episodes, but, um, but yeah, let's try to get it all into mind for treatment. Okay? Okay, so Dr. K. Let's say I'm your patient and I come to you and I say, well, my OB GYN diagnosed me with PCOS and I'm freaking out because I Googled and I saw all these bad things about PCOS. So, you know, what do I do? I'm not even trying to get pregnant right now, but now I'm panicked. Like, gimme some advice here. Yeah, yeah, absolutely. Definitely. See this patient. Quite frequently. Right. Um, and so I usually start with just basic lifestyle measures that you can take if you have a recent diagnosis of PCOS. Um, I think something that really helps me with these patients is I try and meet them where they are. Mm-hmm. So one of the first questions I ask them is. Tell me about your lifestyle now. Mm-hmm. Right? Mm-hmm. So that I can really listen and see what their strengths are and what we can really add on to, and then what we can improve on. Mm-hmm. Um, and so one of the most basic lifestyle things I recommend for my PCOS patients is walking after meals. Mm-hmm. You may have heard me talk about this before in this podcast, but I think walking is really easy for most patients to do. Right. Almost everyone can walk and I try and give them the realistic goal of just. 10 minutes after every meal. Um, and so that's when your body's really working hard to process what you just ate. So we know that's when your insulin level's gonna spike, and then subsequently when your blood sugar level's gonna go up. And we know that that's highly related to PCOS, which we talked about in our last episode. So if you get up and move around in that 10 minute period, you're really gonna help your body to naturally lower levels and kind of save some of your insulin. You're so inspiring. I just ate lunch and now I'm like, can I just go on a walk right now? Yeah. Podcasting. Um, I, one of the things I find very interesting are these continuous glucose monitor devices that you can now actually just by yourself. Um, I've actually used one myself and there's this great social media account. She's called Glucose God. Um, and you can follow her. And she really shares what her blood sugar does when she eats different meals or when she does, uh, different activities. And what happens to her blood sugar is exactly what Dr. K is describing where. If she eats a meal, of course her blood sugar can go up, right? But if she eats a meal and then walks, the blood sugar will come down faster. Um, and so if you did kind of maybe not eat as nutritiously as you would've planned or wanted to, a walk is a great way to try to reverse some of that anyways. Um, but, and you said walking is easy? I feel like it's not easy. I've been trying, I've been trying to walk and it's hard to fit it in sometimes. Right. Okay. You're right. I mean, physically easy. Okay. If you told me I have to do high intensity exercise Yeah. For 30 minutes every day. That's true. Im a PCS patient. I'd be like, dream on. That's not gonna happen for me. Okay. And do you walk. 30 minutes a day? Um, no. Okay. Okay. But day. But I would hypocrite, I would love to. It's in your future plan. Yes. I would love to. It's on my todo list. What's the, what's the device under your desk? I, I have a little bicycle thing, but it's, it's from, does that count? It's from China. It doesn't work. Okay. Okay. Um, yeah, some in the beginning, I, I would see her sometimes pedalling away, right? Yeah. So, but maybe you need one of those treadmills that go under your desk. And you could just be walking while, while charting. Yeah. Yeah. Okay. I know. Well, and I think you just feel a lot better. Mm-hmm. So one of the questions when I'm investigating my patient's lifestyle, I ask them is, do you have the afternoon slump? Mm. Okay. So afternoon slump, I think is really tough on PCOS. Mm-hmm. Patients because we just don't process glucose the way other people do. Mm-hmm. And so when you. Eat that big load for lunch and then you don't get up and move around and help burn it. You get really sleepy and tired in the afternoon. Yeah. Um, and I think it's really, you know, hard to work when you feel like that. So I do think that that after lunch walk helps quite a bit with my patients. Absolutely. And you know, I've, um, read before too that walking is the most powerful antioxidant you can have. Better than any supplement that you can have Antioxidants get released in your body when you're walking. And I think what's also maybe important for PCOS patients is sometimes PCOS patients can be more sensitive to cortisol spikes in your body. So you know how sometimes people are doing these high intensity workouts, they call'em HIIT workouts, and they sound like, oh my gosh, you're working really hard. That's gonna be great for your health. But actually sometimes workouts like that. May have the potential to be bad for your health because if you get a big spike in your cortisol, your stress hormone, that can actually make insulin resistance even worse. And so even though I don't think it. You know, is not what you would think. Sometimes walking in certain patients is better than going into overdrive with these high intensity workouts too. Yeah, absolutely. Mm-hmm. So I think walking after meals is a really nice, you know, way to go about it. Mm-hmm. Of course, now if you can do more than that, it's not gonna be detrimental. Right. So, um, doing three, four days a week of higher intensity, at least where you're getting out of breath, that's how I describe it to my patients. Exercise is really important as well. For me. Yes. Yeah. Awesome. Um, okay. And then this can kind of lead us to talking about nutrition'cause you kind of brought up, you know, walking after meals, but I think, which meals, what are we eating? How often? This is a really important thing to talk about too, but I think the very first thing I wanna say about nutrition is this is usually a moment when I get to talk to my patient and just tell them. Maybe what you've been experiencing your whole life is about to make sense because sometimes my patient, especially if she has been trying to get pregnant, is there with her partner and, and when I tell her, look, in my experience, I can have a patient with PCOS follow the same diet and the same exercise regimen as somebody who doesn't have PCOS. Yet when they are working on weight loss, they will not lose as much weight as the other person. Um, and sometimes when patients hear that, they finally look at their partner and they're like. See, right. Because sometimes they've been working so hard, they've been trying to eat as healthy as they can. They've been exercising and the weed's not coming off. It sticks to them like glue and they almost feel like they have to prove to other people. Like I have been trying and it can be so validating to hear that it is not your fault. This is your PCOS, which is largely based on genetics. But just because it's harder to do doesn't mean you can't do it. It's just you probably need some better advice on specific things that we know seem to work really well for patients with PCOS. Yes, absolutely. Extremely validating for our patients with PCOS sometimes the first time that they've heard that, and it really does. Mm-hmm. Go back to, it's not just a calories in, calories out, like, you know, we've been taught for so many years. Yes. Right? Mm-hmm. But you're having. Higher than normal insulin levels around that makes it very difficult to lose weight. Yes. And whenever your body has sugar, your insulin levels go up. But insulin actually causes weight gain, especially weight gain around the abdomen. And sometimes you may notice other causes of high insulin levels. You can get skin tags on your neck. Some people get skin darkening on the back of their neck or on their, um, inner thighs and groin area. So if you. Seeing those signs, those can be hints to you that you have insulin resistance going on. Because what happens is if your insulin is high all the time, your body becomes more resistant to insulin. And as it becomes more resistant, your body has to keep take making more and more and more of it to have the desired effect. And so you really end up kind of snowballing yourself into, um, an unhealthy state really is what it ends up being. Yes. Yeah, definitely. So, um, you know, I think this is another area where, you know, we kind of got screwed Yeah. In our generation, right? Yeah. Because the way that you really need to be eating mm-hmm. If you have PCOS is some of these foods that you thought were taboo when you were younger Right. Or we've been told in the past were maybe not so good. For example, high fat diets. Mm-hmm. High protein diets are actually. Really good for women with PCOS. Mm-hmm. Um, and, you know, maybe you hear about low dairy, low gluten, these other things. Right. So it's, it's really how you go about putting food into your body that's important for PCOS. Mm-hmm. It's limiting those. Simple sugars and simple carbohydrates. But right when we were being raised in the eighties and nineties, everyone said low fat. Low fat. Mm-hmm. So we got so high in carbohydrates Yeah. With some of these substitutes. Um, and really I think, has driven a lot of people Right. To more insulin resistance. Absolutely. Absolutely. So, you know, my recommendation typically would be to follow a. Mediterranean diet. And when I say Mediterranean diet, sometimes it's hard'cause people are immediately looking for where's the list, where's the list and everything. And it's really more of just a concept. And the concept is that for your protein, you want to stick to seafood or lean proteins. You wanna avoid processed meats and high fat proteins Overall. And then you wanna have lots of vegetables, maybe a little bit of fruit. And if you choose to do carbohydrates, and I do think particularly if you're trying to get pregnant, you should have some carbohydrates, but you wanna keep that smaller on your plate and you want to focus on complex carbohydrates. Carbohydrates that are harder for your body to break down because those give you. Less of a blood sugar spike, which will give you less of an insulin spike, which will overall help your insulin resistance, right? Yeah. So you always wanna mix your foods, right? You wanna have high fiber when you're eating carbohydrates, right? That's that complex combination. So it slows down that rate at which you process what you're eating. Absolutely. And um, you know, there are a lot of kind of trends and fads going on right now. I do recognize that low carb is a big one, and you notice I said. Limit carbs, but I still want you to have some. And the reason why is I did see a study that I felt was concerning where they looked at women who did low carb diets and they looked to see if there were any problems. And they did actually have a higher risk of having babies with birth defects. And the criticism to this is some people said, well, maybe it's because many carbohydrates are fortified with. Folic acid, and we know folic acid can lower the risk of neural tube defects, birth defects. And so they thought maybe that's why, but no, in the study they compared to women who were taking folic acid and they also had a higher risk of birth defects. And so my opinion based on this data is, although low carb diets. May be appropriate in other circumstances when you're trying to get pregnant. I really feel like you need to nourish your body with some healthy carbohydrates as well. What do you think? Do you agree with that too? Yeah, absolutely. The way I describe to my patients to get their carbohydrates. Lots of vegetables have carbohydrates, right? Yeah. Fruits with the skins on them. Mm-hmm. Right. And then whole grain. Mm-hmm. You know, if you're looking at breads, pastas, things like that. Yeah. If, even if it's just rice, I think brown rice would be better than white rice. Um, again, anything that's gonna take your body longer to break down would be beneficial overall to, to your nutrition. Um, another big fad right now is keto. Right. Everybody. Keto. Keto. High fat. High fat. High fat. And I think it's. It was good for us overall to learn not to be afraid of that. Okay. But I also think you've got to have some balance. Some people take, you know, keto diet and they're eating a pack of bacon for breakfast and then five hot dogs for lunch. And you know, that's not appropriate either. You really need to have some of those lean proteins and seafood if you're able to eat seafood, um, as well. Yeah, you hit one of my trigger buttons. Oh, so you, you mentioned white rice. Yeah, so I do always counsel my patients about white rice. Mm-hmm. I actually tell my patients to try and cut it out entirely. Okay. Yeah. You, you've worn a continuous glucose monitor. Have you ever seen what your blood sugar does after white rice? Yes, because I got really mad at Chipotle'cause. To eat it, Chipotle all the time. I love Chipotle. Um, and yeah, I, I don't do well on rice, but you know what, it does depend on what you eat it with too. This is another thing you can learn from glucose status if you follow her. If you pair carbohydrates with protein, you get less of this. Spike where, whereas if you were just to eat a bowl of white rice, it will probably go a lot better. Yeah. White rice is crazy. Yeah. I cannot believe mm-hmm. What it does, I mean, I personally have watched mine'cause I did finger sticks and stuff during pregnancy. Mm-hmm. And really, it's kind of scary. Yeah. Yeah. Yeah. Um, but another thing to consider is the calorie part of it you brought up. It's not just calories in and calories out, and I totally agree with that, but sometimes you do need to combine the approaches. Um, so even for me, when I try to eat a Mediterranean diet, if I'm not kind of getting to my health goal that I want, sometimes I've went back and I've. You know, tracked my calories and I thought, oh gosh, I am eating a lot more calories than I should in a day. And so really kind of combining those approaches I think can be helpful is seeing what your overall calories are while making sure you're getting enough of the nutritious foods overall. Yeah. Yeah, definitely. Yeah. Yeah. I remember actually, we were talking about this in another episode'cause I was telling you about how on my continuous glucose monitor, I eat popcorn and my sugar spiked up and you're like, how much popcorn did you eat? Right.'cause any food, yeah. If you eat, a lot of it has the potential, just like your sugar right's, dangerous moderation into it. I know it's so. I'm awkward. I can eat the whole thing. Um, okay, so we talked about nutrition. We talked about exercise. Wait, you know what? On nutrition, I wanna talk about one more thing.'cause this is also very popular, intermittent fasting. Mm-hmm. Have you ever done fasting before? No, I can't because I have to have cream in my coffee. Okay. I can't do it. I can't live without it. Okay. All my joy Yes. Comes from my coffee in the morning. Okay. Well, I mean, I've certainly tried before. It's so hard'cause I get so hungry and then, you know, I get hangry. Right. That's hard to fast anyways. Yeah. Um, but it's interesting because there, um, there is some positive data for fasting, particularly in men. That it may be really good for your health in certain situations, but I think we have to remember as women, we are not just little men. Mm-hmm. Okay. Our bodies are different and it also probably depends on what our goals are. Okay. We are very fertility focused and I will tell you what we have learned in the fertility world is fasting is not good for your eggs. Okay. And I think it makes sense about how our bodies were designed when we were cave women. If we didn't have enough food for ourselves, then it is advantageous for our reproduction to be turned off. So that all of our nutrients can be shunted to our vital organs, like our brain and our heart and our liver and all of that. Um, but now that we're in modern day, if we're fasting, those same things could happen. And so what I found is it really is important to make sure you are getting all of your meals every single day in order to make sure your ovaries have everything they need in order to nourish your eggs as well. Mm-hmm. Yeah. Yeah. And then I also just wanna say one other thing, which is we've been really kind of talking about weight loss, but with you,'cause you shared your journey with PCOS. Not every woman with PCOS needs to lose weight. Right. But they can still have insulin resistance issues too, right? Yeah, absolutely. Yeah. So that's why it's just important how you're eating, right? Yes. So that's why I really like to listen to what people are already kind of. Into and what their lifestyle is like. But a lot of times, even the lean PCOS patients, their diets are not so good. Mm-hmm. Okay. I'm guilty of this, so yeah, we all are. Um, okay. So let's say I'm your patient and I'm feeling so much better. You've like helped me figure out a good plan for my lifestyle, but I'm still not ready to get pregnant, but I'm having some symptoms for PCOS. I am growing a mustache. I have skin breakouts. I, I'm just not happy with this. So can you help me with this? What, what can you help me with? Yeah, absolutely. So I would say the number one first line treatment for PCOS. Symptoms if you're not trying to get pregnant, would definitely be considering a birth control pill. Um, and depending on how severe your symptoms are, um, we might even continue do a continuous regimen, birth control pill where you're kind of taking it all the time and you can take maybe just a couple breaks a year on those placebo pills to manage your symptoms. Better birth control pills are amazing'cause they suppress some of those, um, hormones coming from our brain that's really driving that male hormone production from our ovaries. That's why you're getting the symptoms of acne and hair growth. Um, and they actually can help to increase something that binds up a lot of that, um, hormone that's circulate, circulating in your blood. Um, they're very effective in this setting, although I know there's a lot of women out there that will be listening sing. But I hate birth control pills. I don't wanna go on birth control pills. I usually tell my patients. That we sometimes have to try on a few different birth control pill brands or types before you find one that really matches with you. But most people can find one that they tolerate and really even love. Mm-hmm. Yeah. Do you have a favorite brand name? Mm-hmm. Well, um, brandings? Yes. So Yas and Yasmin. Mm-hmm. I think mm-hmm. Um, the type of progesterone that's included in those really works well for PCOS symptoms. So that's usually what I start with when I, um, put my patients. Patients on OCPs. Yeah. And I know a lot of people are really into low dose medication, which I think is great. And I will say all of our birth control pills in moderate times are way lower doses than they used to be, you know, 40, 50 years ago. Um, however, you do wanna make sure you're on a high enough dose to get some improvement, right? So YA is a lower dose birth control pill and sometimes people like that, less side effects and things like that. But if your symptoms aren't getting better, sometimes it is reasonable to increase to the higher dose. Pill to see if you can get better suppression of the male hormone in your body that could be causing all these symptoms for you as well. I do think it's important to know too, when you start birth control pills, it does take about three to six months to see a big improvement in some of, in some of those symptoms too. So you wanna make sure you give it long enough to even have a chance at working. For you. Mm-hmm. But I think it's great. It's also nice if you would like to regulate your periods. If you take them in a way, um, where you take some sugar pills, um, for each, each part of every month and you can have a period, or, I mean, if it were me, I'd be like, Hey, why do I need to have a period? You can again, take'em like Dr. K was saying continuously, um, to keep a period from happening. But either way. This is protecting your lining of your uterus. We're gonna talk about this later, but women with PCOS are more likely to have problems with the lining sometimes. And so this is very protective to be on birth control pills when you're not trying to get pregnant. Mm-hmm. Yeah, absolutely. Okay. So I think the other thing that women really struggle with often is, you know, the acne and hair growth. Mm-hmm. Um, and maybe they found a birth control pill that's working for them, but not. Getting rid of it entirely. Mm-hmm. Um, and so there is another medication that we'll often use in the setting called Spironolactone. Um, this actually was for start as a blood pressure medication. Mm-hmm. Um, and you know, it's a diuretic medication, but it also targets those androgen levels. It's extremely effective. Um, there's probably some women that are listening that just take this because it makes you have beautiful. Skin. Um, there's a, I think a lot of influencers and beauty people take spironolactone just at a low dose. Yeah. Um, it really does make your skin look nice. Yes. Yeah. Yeah. Now, importantly, spironolactone can cause birth defects if you were to conceive while taking this medication. So most doctors will require you to be on some. Sort of contraception if you're gonna take this medication. Now, if you're already taking birth control pills to treat your PCOS, then birth control pills and spironolactone are the perfect combination for you. But if you're not taking birth control pills, make sure you have oth some other reliable form of contraception so that you don't put yourself in a situation where you are feeling worried because you accidentally got pregnant while taking that medication. Can I just also take a side rant onto my pet peeve? You know this about me. I can't stand pellet pushers. People who sell testosterone pellets. Mm-hmm. Okay. They always try to convince all women. Did you coin the term pellet pushers? No. Should I? I like that. I need a t-shirt. Um, but pellet pushers. Sell pellets and they try to convince everybody, men and women, that all of their problems in life are because they have low testosterone. If you just let them put their this pellet in you, then you're gonna feel better. Um, and hey, you might actually feel better. I mean, athletes used to take or maybe still do illegal steroids so that they, you know, feel better, more energy and everything, but they, it's dangerous for your health. It's not good. Um, but here's what's bananas. There are some people who sell you the pellet. Then you get hair growth on your face and acne. So you complain. Um, and then they say, well, you should start spi Lactone. Oh gosh. To get rid of the symptoms that they caused. And I've seen patients, I'm looking at their medication list, testosterone, pellet, and spironolactone, and I'm like, so they're selling you this pellet? Oh my gosh. And then they're blocking the action of the ping. Oh gosh. It's bananas, right? Yeah. So, uh, okay. That was just my side ran. Sorry. Well, they can't get it out, so I mean, I, at least they're trying to help the patient that they put it into, um, and then No, but they'll go put another in after. Oh, God, no. They'll, yeah. Yeah. Oh my God. Um, and then, so aside from these, also, there's just topical things you can do. Mm-hmm. Right? You can do laser hair removal. Mm-hmm. You can, um, electrolysis Yeah, electrolysis, um, you can see the dermatologist and get some nice, um, things to put on your face to kind of help with acne and, and all those too. So there are other, um, things that you can do to try to help those things too, right? Yes. Theder planning. Yes, yes. Yes. Relaxing. Yes. Um, okay, so now, so your patient left and she's been super happy for like five years, and then she's coming back and she said, Dr. K, it is time. It's baby time. I wanna get pregnant. And so what would you suggest for her at this point? She's on her birth control pill pills in her spironolactone. So what would you suggest for her For next steps? Yeah, so obviously we wanna take you off of your birth control pills in your spironolactone if you're trying to get pregnant. Usually what will happen, especially as the pills kind of get outta your system, your cycles will go back to what they're based. Line will be with PCOS. That means you might not get a cycle. Mm-hmm. Um, or it might be a really long time before you get a cycle. So then I recommend that we get our patients started on a medication to help trick their ovaries into ovulating for us. The number one medication that we'll use in this setting is something called Letrozole. Um, Letrozole is first line treatment for what we call ovulation induction in PCOS patients. We have nice studies to demonstrate that. Lets, results is a pretty easy pill to take. You only have to take it for five days at the beginning of your cycle, and um, like I said, it kind of drops your hormone levels down so that we can convince your ovaries to ovulate and release an egg For us, when we do this in our practice, we're doing this with ultrasounds and. Blood work monitoring to make sure that in fact you are responding appropriately. Make sure that we see a follicle there, that you're gonna ovulate, and then we can usually just pair that with timed intercourse and tell you kind of take the romance out of it and tell you when to have intercourse. Yeah, yeah. You know, and every now and then too, we'll see, um, a patient with PCOS who is ovulating on her own and, and, um, having cycles, but sometimes it's just very irregular. And so I am, um, sometimes a fan of. Some of the home monitoring you can do these days. Now I understand there are very fancy fertility monitors these days, and I'm not even saying to get like a really crazy expensive one. Um, but sometimes when for PCOS patients that I think could be helpful is the clear blue digital advance because. It kind of lets you know if your estrogen levels are starting to rise and then if after that you get a LH surge. Um, and I think that's important for patients with PCOS because in patients with PCOS, sometimes you constantly have high LH levels and so normal just kind of strip testing or regular ovulation kits. May not work for you because you just don't know if you're getting a false positive. But the nice thing about the clear, uh, blue Digital Advance is that it is pairing an increase of estrogen followed by an LH surge. So I think you have a better chance of picking that up. But that's only, again, in women with PCOS who are having periods. So like sometimes I'll have a patient who's like, well, I do have a period like maybe every six weeks or something, so you might be able to pick it up that way. But if you're never having periods or they're once every three months, honestly, I wouldn't even waste your time getting any kind of monitoring. I would just come see us right away and we can just help you.'cause you're, you're not ovulating if you're having periods every three to six months. Mm-hmm. Mm-hmm. Yeah. Absolutely. So, yeah, so sometimes we do letrozole. I think monitoring at home, um, even, you know, if your OB GYN is prescribing it to you can be helpful too. Sometimes we might not like the way that our patients, uh, respond to Letrozole, um, or we're just not getting a good response. So there is another medication that's been around probably for, um, you know, a longer time called CLO or Clonapine Citrate, and that's another medication that we can use to help your ovaries to ovulate. Um, the reason why we don't use that one. First line typically in PCOS patients is'cause we just have a study to show that Letrozole is more likely to induce ovulation and have higher pregnancy rates. But Clomid can also work too for a wide variety of patients. Yeah. One, one kind of situation in which I am giving this as my first line is when I've had a patient who already had a baby with CH Clomid before. Mm-hmm. You know, the Letrozole data is overall newish. Mm-hmm. And so sometimes people will say, well, I had my last baby with. Ch clo in a hundred milligrams or something. And so it makes it really hard for them to accept that there's a newer or different medication mm-hmm. That may work better.'cause they're like, how can you work better than what worked for me the first time? Right. Yeah. Um, and I think that's such a reasonable logic. So I think that we're both really flexible in that and we love shared decision making with our patients. And um, and I would be totally fine with that too. And hey, if it's not working, then you just switch to the other, so, yeah. Mm-hmm. Yeah. I would say also, um, you know, another medication that's. One of my favorite medications, so you would know this if you're one of my patients, is Metformin. So as actually as soon as I see my PCOS patients, a lot of times in my new patient consult, I'm kind of a metformin pusher. I am. Okay. Um, and this actually stems from, I did it like as. Some bench research with metformin back in the day. But I think metformin is a wonderful medication. Um, it's really nice because it's safe while trying to conceive safe during pregnancy. Nothing safe during pregnancy, right? Mm-hmm. Yeah. It's heavily studied in pregnancy, um, and can even have some benefits for you in pregnancy, but it's a nice medication'cause it does keep insulin levels. Low. Mm-hmm. Um, and it really can kind of be working for us in the background. I like for all my patients, maybe to just be taking even a low dose of metformin, even if it shows that you're not pre-diabetic or diabetic. Mm-hmm. I think Metformin has a lot of benefit. It can make you more sensitive to these medications that we're talking about, like Letrozole and Clomid help you to be more likely to ovulate in response to them. Um, it can help you actually with a little bit of weight loss if you really have that insulin driven weight gain. A lot of my patients will go on metformin and it's like life changing to them that all of a sudden it's much easier for them to lose weight and it's extremely anti-inflammatory, which is really nice, um, in this setting as well. You might be selling me Dr. K. Mm-hmm. I will say I have not been as bored as onboard with Metformin. Metformin. Mm-hmm. Mm-hmm. Maybe it's'cause I personally tend to be a little bit whir. Yeah. And I feel like the side effects can be pretty rough. Right. So common side effects I would hear from my patients on metformin is that you can get nausea. Sometimes vomiting and you can have diarrhea. That's no fun. Especially if you're at work or something. Right? Yeah. Um, and so I actually have not been, uh, probably as generous with mm-hmm. With prescribing mefor. Of course, I would always do it by request. Of course. If somebody's pre-diabetic or diabetic, yes. But if they're not, I tend not to routinely give it. But I am, um, intrigued by some of the data that's coming out right now about metformin and longevity. So even aside from fertility, some people are on it just to try to live longer. Um, and the other thing I brought up to you the other day is I saw some research about ovarian scarring or fibrosis, and they think that this can contribute to fertility issues. Not so much with PCOS necessarily. Um, but, but some people are kind of, at least. Theorizing, maybe Metformin can soften the ovaries a little bit if that's going on. Just based on data showing that metformin may soften liver fibrosis. Now that is really kind of making a couple jumps there. That may not be the case. Um, but I do feel like I'm dabbling in Metformin a little bit more than I used to, but maybe I just like to go on the lower side'cause you know. Mm-hmm. I wanna make my patients feel sick either. Yeah. Let's talk about tolerating metformin, because maybe you're one of those patients that is like, yeah, I really wanna try that. Sick. Right? Yeah. So here's my tips that I do for my patients. There's different formulations of metformin. Mm-hmm. First of all, and I think definitely the extended release will have less side effects overall. Your insurance doesn't always cover the extended release. Mm-hmm. But if you can get it, definitely recommended extended release. The key is that you have to take a low dose. Mm-hmm. For about seven days in a row. Yeah. Yes. You might. Experienced some upset stomach, um, in that seven days. But almost all patients after seven days of exposure will start to feel better mm-hmm. And tolerate it. Then you just gradually can increase your dose if you need to. Mm-hmm. Um, so I usually start at 500 if my patients aren't doing well without letting'em have'em. Half it and do two 50. Mm-hmm. Okay. And then just slowly build your way up. Usually my patients who aren't pre-diabetics, they don't need a ton of it, right? Mm-hmm. Yeah. So even low dose can really be helpful. Mm-hmm. Absolutely. Um, sometimes if people aren't ready to try metformin, um, or if they are having side effects. A supplement that they can consider that you can actually just buy over the counter is my own acetol. It actually has kind of similar benefits to Metformin, but I think that the effect is just not as strong. Maybe the effect is only about like 10 to 15%. Um, so that might be nice if you're kind of like, Hey, I want to have. Something that helps a little bit, but I don't wanna go full on Metformin. Yeah. Um, okay. Let's say your patient has tried Letrozole or Clomid or both and they're not getting pregnant. What are some of the things that you think about, in particular in PCUS patients? Okay, so in PCOS patients, we know that sometimes you might have a period of time where you're not getting your cycle on a regular basis. So that means you might have a little bit of low level estrogen stimulation with almost never seeing any progesterone that's a problem for that inside lining of your uterus. And you've probably heard me talk about this before, but we want to protect your uterus by giving you progesterone and having you shed that lining on a regular basis. So PCOS women oftentimes will not shed their lining on a regular basis, and with that low level of estrogen stimulation can actually cause some abnormalities to grow on the inside of your uterus. The most common thing. C are like small polyps, maybe even larger polyps or more rarely things like hyperplasia or cancer. Um, and so sometimes we'll consider doing a saline infusion sonogram. That's that special ultrasound. When we push saline, salty water through the inside of the uterus can open up that cavity so we can get a good look to see. Is there anything hiding in there like a polyp that could be disrupting early pregnancies, getting in the way of implantation or getting you pregnant? I have a good analogy for this. Mm-hmm. So let's think about our front yard. Okay? So if you are mowing your front yard every week, it's gonna look great, but if you're not mowing your front yard ever, you're going to get these big weeds that pop up. And stick up above. That's kind of like what polyps are, right? And so the way to mow your lawn is to have your period every month, right. Um, but if you're never getting your lawn, no, that's when we're gonna start seeing all those weeds popping up. Okay. It sounds, sounds sexual in some way. Yeah, I can't, I can't figure it out. But getting your lawn mowed, just get your mind outta the get doctor k. Um, and so, so that's my analogy for you. Now, the only exception to that is if you're on birth control pills and your lawn is never getting mowed, you don't have to worry because your grass is not growing anyways. Like the birth control pills kind of just keep you stable. This analogy, if they're on birth control pills, they're probably getting mowed more often. Um, but I do think that's important because sometimes people feel these and hear these conflicting messages. They'll be told, if you are not having a period. That's so unhealthy. That is true if you're not on birth control pills. True. But if you are on birth control pills and you're not getting a period, that is actually okay, because birth control pills are progesterone dominant, progesterone is keeping your lining nice and thin. It's not going to be getting into trouble while you're taking those birth control pills. Okay, perfect. Now what if you've done everything, now you've done all the testing, it looks great. We've tried, you know, all the medications, they're still not getting pregnant. Do we have any other options? What can we do? Yeah, I mean, usually if we've gone through some ovulation induction cycles and are not having success, then I open up the conversation with my patients about advancing treatment to some of our, um, more effective treatment options like IVF, you know. For the PCOS patient, unfortunately the egg quality can be affected, and so when we are inducing ovulation, we're really just releasing one or two eggs per month. Sometimes that egg is just not good enough, right? Mm-hmm. To actually make it to the finish line, and so IVF is an extremely effective treatment option for women who don't have success with those lower treatment. Treatments because we're pulling the eggs out of the body and we're actually finding the one egg or few eggs that are capable of being fertilized and ultimately making it to an embryo so that you can have a baby. Absolutely. And I always think it's so ex. Siding when A-P-C-O-S patient gets to do IVF because the good thing about their PCOS is they tend to produce a lot more eggs at one time than maybe the average person would be able to do so. Although sometimes we have to worry about egg quality problems, at least they have a lot more chances usually to get good quality eggs when they do IVF as well. Absolutely. Okay, good. Well, I think we got through all the treatments Yeah. In one episode. Yes. Even know we're talking a lot still. Um, and so we'll go ahead and wrap it up for the week. If you guys would be so kind to leave us a positive, um, review or subscribe to our YouTube, um, you could leave reviews either on our podcast page or YouTube page, or even on our Peak Fertility clinic page. We would greatly appreciate it. Hope you have a good week. Have a good one. Bye bye.