Episode 16: Why Is PCOS Now Called PMOS?

In this episode, we talk about the viral name change from PCOS to PMOS and why it’s sparking so much conversation online. We share why this shift feels validating for so many people who’ve struggled for years to get clear answers, and we unpack the kinds of confusing, oversimplified claims that flood social media around this condition. We also explore why the name change matters beyond semantics, what concerns some patients have about it, and what we wish more people understood before falling into the “cure” and “root cause” rabbit holes.

00:00 Podcast intro
01:20 Episode topic reveal
02:02 Patient diagnosis delays
03:38 Sonia personal story
07:16 Social media claims
09:36 Why it went viral
15:28 Nugget of truth
17:51 Backlash and concerns
22:11 Defining and diagnosing
22:33 Rotterdam criteria
30:09 Ruling out other causes
32:54 PCOS subtypes explained
41:34 Biomarkers and testing
46:19 CRP Inflammation Confusion
48:13 Metabolic Biomarkers Breakdown
49:21 Vitamin D Iron Testing Debate
52:38 Guidelines and Sleep Apnea Risk
54:49 Birth Control Not a Band Aid
01:01:15 Fertility Timing and REI Referral
01:03:38 Lifestyle Basics Fiber Exercise Sleep
01:08:50 Medications Metformin to GLP1s
01:16:18 Weight Stigma Habits Over Pounds
01:20:34 Who Should Manage PCOS Care
01:24:32 How to Talk to Patients
01:27:35 Resources Wrap Up Disclaimer

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You're listening to The Anti-Social Doctors Podcast hosted by me, Sonia Singh, a board-certified internal medicine physician with a master's in nutrition and a special interest in health anxiety. And me, Rebecca Behrens, a board-certified family medicine physician with a special interest in disordered eating. We're also millennial women, anxious moms, and curious humans navigating social media. We've seen firsthand how these platforms can be powerful tools for education and connection but can also make us unwell. This podcast is meant to be the antidote to your doom scrolling, a solve for the anxiety, stress, guilt, shame, and confusion that comes from social media's messaging around health. In each episode, we discuss a health-related topic trending on social media with curiosity, nuance, evidence, humility, and compassion. This is not your average debunking podcast. We wanna explore not just what is trending on social media, but why. Why are so many people drawn to this? What is the nugget of truth here? What are the facts? What can we learn from this as patients and doctors? No shame, no blame, no snark. We're so glad you're here. Hey, Rebecca. Hey, Sonya. So we had to quickly start recording 'cause we were already off and away- talking about this topic. As per usual. As per usual. And this is a hot one. We're actually gonna try to move this up and release it soon because it has been such a big topic of discussion in the health, wellness, medical space. So tell us about the topic and the patient story for this week's episode. Yeah our topic today is the recent name change of PCOS to PMOS. And for anyone listening who doesn't know what those mean, the pr- the previous name was Polycystic Ovarian Syndrome. It has been renamed to Polyendocrine Metabolic Ovarian Syndrome. This is actually really important, and I think the patient stories will explain why. So this is actually not one patient, but this is, A lot of my new patients, like a lot of them. And I diagnose patients with PCOS, now PMOS very frequently. And for many of my patients, they've had symptoms for years. They've seen multiple doctors. Someone's maybe said "Eh, maybe you have it," and someone's "Eh, no, I don't know if you have it." And so they're very confused. They never get any sort of formal diagnosis or explanation of the condition and the c- potential complications and potential treatments. So many of them have resorted to going online and doing their own research, which that's what we do th- these days, and especially if you're not getting the information you need from professionals. And so there's a lot of tips on social media that people see regarding diet, nutrition advice, which, as we've talked about on this podcast, is frequently inaccurate and supplements they should be taking that they need to lose weight and, how to lose weight. And it's been amazing since this name change happened how many of my patients who I have diagnosed with PCOS in the past are reaching out to me like, "I'm so excited about this. I feel like this is gonna have such a huge impact. My friends are talking about it who didn't really think about this stuff before." And, I'm really hopeful, and my patients are also really hopeful that it's gonna reduce the negative experiences people have in trying to get this diagnosis and the delay of the diagnosis and how they're seeing their experience now reflected in the literature. So it's really cool. I'm excited about it. I've also seen some negativity around it, so we'll talk about that, too, but that's the story. Yeah, I had no idea there was backlash against this. I did not either until I started readin- reading about the condition. Yeah, so I'm definitely excited to learn more. And this is a situation where I've been on the patient side of this, so I feel like I, I have my own perspective. I almost feel like I have more patient side opinions on this than doctor side opinions. And I actually, I think I shared this in a previous episode. I can't even... I don't remember which one. It might have been the birth control episode, 'cause we did talk- Yeah about this condition and the birth con- Now I don't even know what to call it. I'm like, okay, P- PMOS. PMOS. Yes. It's just, it just- the tongue in the same- Yeah, I'm not, I'm still not used to it. I'm still not used to it. It's hard to say. But anyway I think I talked about it in that episode where I had gone to see a dermatologist when I was, 16 or 17 for laser hair removal. It was, my big wish for graduating. I was like, "Mom, before I go to college can I please get laser hair removal?" And I went to a very ritzy practice in a part of town that probably does not see a lot of South Asian patients. And the dermatologist looked at me and was like, I think you should go get checked out for at the time, PCOS. And he actually did say, "A gynecologist or an endocrinologist and talk to them about whether you might have this condition." And so then I went to see a gynecologist, and I recall her talking to me about my periods and asking some questions, and then she ran some labs. And then I remember her looking at the labs and just being like, "Eh, you might have it. You might not." And then she gave me some birth control pills, and my mom was very scandalized by that, but she was like, "We're gonna call them hormone pills. It's a hormone treatment for a hormone condition, and, her periods will be even lighter, and she will have less hair on her legs, and it'll be great." And that was like 25 years ago. And I basically, other than trying to conceive and being pregnant, have been on birth control since then. And I think my experience was unique in that- The intervention was very helpful for me for the things that were bothersome to me. I still, you're my PCP, and we still are not completely clear on whether I have this condition. But I guess for me it worked out. Later in life I did not have trouble conceiving. I did not have i- issues with insulin resistance. I have not had issues with my weight. Many of the other things that go with this condition, I just haven't experienced. Maybe 'cause I don't have it. But I do remember the experience in that week that she was like, "Yeah, maybe you have this thing," of going home to the primitive internet, and typing in polycystic ovarian syndrome into Yahoo or AltaVista- or whatever thing we were using- Ask Jeeves at the time on my gargantuan desktop. And I remember looking at the images, and I s- I- there were just these horrific images of ovaries with cysts on them. And, this was long before I was medical, and I was like, "Oh my God," "that's what my ovaries look like?" "That's what my insides look like?" I remember thinking "Oh my God, my insides are grotesque?" I just, I had this very intense experience of thinking I had that diagnosis, and I lived with this anxiety for two decades of "Maybe I won't be able to conceive," "maybe I will have a lot of trouble getting pregnant." I didn't know, and my OBGYN was always like, "We'll see. You'll try." "You'll just go off your birth control and try." And so yeah I have a lot of empathy for people who have been in that situation and it has not worked out for them when, they, it came time to try for a baby, or they decided to go off, or they had bad side effects to the contraception or whatever it is. So anyway, that's a little bit of my story, and I'm happy to I, I wanna learn about this and think about how it might relate to me as we're going through this. So anyway, I'll let you go on and talk about the claim. Yeah. As you will hear this was definitely not a unique experience that you had. This is frustratingly a very common experience. And hopefully that is set to change now that the, there's been more attention brought to the issue with this recent name change. So in terms of the claim, what I'm gonna start about with the claims is just the common claims that I see on social media marketing of various wellness products and programs and whatever. And and then I'm gonna get into explaining what PCO or PMOS is some of the newer information that's i- in the last several years come out and influenced how we're treating and managing it. And then how that reflects on how the name change is so important. And then we can talk a little bit about, Why some people are upset about the name change or concerned. And then we'll go from there. In terms of the claim, I think a common thing that I see is this "Oh, PCOS is all about your insulin," or, "PCOS is all about your..." And I'm saying PCOS 'cause that's what things are saying pre- it was at the time pre- name change, and also because I have not gotten used to saying PCOS yet. Oh or it's "Oh, it's all about your weight." And then they'll say "Oh, this is, there's a cure. Just go keto. Just lose weight. Just take this supplement and everything will get better." So those are the oversimplica- oversimplification claims. Then there's these claims of "You can reverse it," or, "You can cure it naturally." Which of course sounds very appealing if you're someone that's been told you have a chronic condition. Or if you're someone who's not sure if you have a chronic condition, but you're like, maybe if I have it or not, maybe I can just reverse it if I follow the advice of said person on the internet." And then there's a lot of claims around "Your doctor is hiding the truth. They're just masking your symptoms with birth control. They're not getting to the root cause," et cetera, et cetera. As if the root cause is something that we can fully address, which I will get into. And goes along with a lot of the other claims that we see about a lot of other medical topics on social media. Have you heard any other claims, Sonya, or seen anything else that res- you think of when we're talking about this? No, I think you hit the main ones. I think the idea of root cause comes up all the time with PCOS. It just feels like people have this black and white concept of either the doctor's gonna give you birth control and they're just masking the symptoms, or somebody's gonna look at the root cause, and I think when you actually explore what does it mean to look at the root cause and what are the root causes that, that we might find then, it becomes a lot more of a complicated picture. So yeah, I'm curious to see what you found in your deeper dive. Yeah. Okay, so for our next section, why is it viral? I think PCOS has been viral for a long time on social media. Like I said there's always been a lot of content, at least in my algorithm, about PCOS because it's a condition that predominantly affects women, and they already feel dismissed, unheard, ignored by the healthcare system, and it is also significantly underdiagnosed. Yeah. So there was a study which was a survey essentially of people in, I think, actually online PCOS support groups. So which I guess maybe is a little bit of bias in terms of if you're on a support group, you probably are not happy about your care. But anyway according to the people on this support group it... and their, overall averages of what they saw, it often took over two years and seeing at least three medical professionals before receiving a diagnosis. And only 35% were satisfied with their diagnosis experience, and just 15.6% were satisfied with the information they were provided at the time of their diagnosis. So- Yeah, those are pretty damning numbers. Yes. Not great stats. I'm curious if you know the prevalence 'cause I also think it's not a rare condition. This is like- no. The prevalence is average like 9 to 13%- Oh, okay. So yeah, like one in 10 of the population of women. Yeah. So that's very common. And I thought I had copied this stat actually, but one of the articles I think it was somewhere around only 2 to 3% were showing up in, in medical record reviews w- having the diagnosis on their chart. I need to find that study, and I'll put it in the notes. I can't believe I didn't copy that into my notes before when I was prepping for this 'cause I was like, "Oh my gosh, that's horrible." That's clearly so low compared to the actual population of people who have it and they're just not being diagnosed. Right and of course, part of that may be that maybe the people that have it are not getting care, and so then they're not getting diagnosed. But I think more than likely they've had some degree of care by someone. And probably mentioned some of these symptoms before, and it was just never considered or never evaluated. And so it's a, an experience that is as you have personally experienced, very frustrating, very long, very confusing. And people are not getting a lot of information, and so as you did, they're going online. And now we have a very different online marketplace than what you experienced when you looked online, right? If you type in PCOS on your Instagram or your TikTok, all sorts of things are- Oh, yes going to appear. Some true. And some not so true. And just adds to the confusion and frustration that people are experiencing. So this recent name change is getting a lot of social media airtime right now. And so I think right now it's particularly viral because this is like a recent thing- that came out, and it obviously is prompting a lot of discussion among people who treat PCOS, who have PCOS, Sorry, PMOS. I'm P- I'm gonna do that a lot this episode. So my apologies in advance. And, And also just people selling products that they claim to do things for PCOS. And so I think, this was actually a really interesting process that they went through to change the name. It's been discussed for a while that the name needs to change because the PCOS, i- polycystic ovarian syndrome, it makes it sound like it's an ovary problem. And it doesn't fully capture the complexity of the condition that involves not just the, menstrual symptoms and the ovarian cysts, but also metabolic dysfunction, and also mood disorders, and also sleep apnea. There's a lot associated with PCOS that's really not captured by a diagnosis name that's focused on the ovaries. And there's actually similar metabolic abnormalities in men who have PCOS-like polygenic risk scores. So genetically- Oh, how fascinating. These genes that are seen are... They affect men, too, in terms of me- metabolism. Obviously, they don't have ovaries. So it's not something that is producing ovarian cysts in men, but it's likely a polygenic condition that is not just about the ovaries and has metabolic effects for the person- as a whole, whether they're male or female. Oh, that is a really fascinating concept. Yes. There is a cor- some male corollary to this that- Yes just looks a little different but is the same physiology. That's really interesting. Exactly. So essentially, this is a condition of genetic predisposition that is then affected by both environmental and lifestyle factors, okay? No one can change their predisposition. Yeah. Those genes are just there. And in fact, with epigenetics even the environment of people generations before you could be affecting- your expression of these genes, right? And so it's... You are not, as an individual, in full control of this condition. Of course, you can manage the lifestyle factors as best you can. The environment factors, maybe you can address, maybe you can't. We talked about this in our clean beauty episode. Hard to know if any of that is affecting people. But that is the key point of this name change is this is a complex condition that affects multiple endocrine systems, and it should be treated appropriately. It should not be something that we just focus on the GYN implications and ignore all of the other implications, and I think that that has contributed to the confusion that people have around it because even a lot of physicians, I think, don't fully understand all those potential risk factors associated with PCOS or they don't think it's that important. And they feel like, if your period's regulated, everything's fine, and so I think that's where a lot of people get that experience of "Just take birth control." Which is, again, I'll get into this, important and not something we should overlook in the treatment of PCOS, but also not even close to the whole picture. Yeah, okay. Let's get into it a little bit. I'm curious to know tell us what the... We always try to talk about the nugget of truth. So what is the nugget of truth- Yeah, so- in some of these claims that people are making about PCOS? Yeah, so I think the nugget of truth is- People are genuinely going to the doctor complaining of symptoms and struggling to get a diagnosis and an explanation and treatment. That's happening. It is well documented in studies that is happening. Yeah and you have anecdotal personal experience. Yes. I've seen numerous patients who tell me the same story, like very similar to what you just told me. And it's very frustrating. And so I think the, the claim of "Doctors don't know what they're doing, they're just putting you on birth control to mask symptoms," that's both not true and true. At least in the patient's experience of it, right? And I think, a lot of patients, when they have trouble with their periods specifically, they're gonna go see a GYN. And this is no shade to GYNs. Love GYNs, but I think GYNs are not as well-trained or focused in addressing these other metabolic complications. And so I think part of the like they're just masking it with birth control the GYN is treating you- for PCOS with birth control, which is i- in many cases appropriate. But maybe some stuff's getting missed or not addressed- fully. And then maybe when you go to their PCP, they're like that's a GYN problem, so-" "the GYN's handling," right? And so it's this sort of pin- ping pong- No one person is owning the condition. Yeah. Yes. Yes, and so that, I think, is contributing to some of the claims that are being made, 'cause if no one's owning it, and if no one's giving you the full explanation of treatment and the full understanding of what's going on it makes sense that people are gonna post stuff on social media and claim to have a fix 'cause they can sell to you. And it also makes sense that people are, like, just looking for answers on social media- and looking for people who are sharing their experience of having the diagnosis, because they're not getting a lot of that from their doctors. And I think that's where sort of the nugget of truth in the social media content comes from, and I think also why- this name change was so important because- it's bringing to light the recognition that we as a healthcare system are not managing this condition well. We're not even diagnosing it a lot of the time. Yeah and we're also not y- giving patient the information they need or the treatment that they need in many cases. And I do think it's changing, but I think that this sort of resurgence of discussion about it is going to help. Now, what I will say, I guess in the claim... I'm just gonna add this to the claim section while we're here because it's, there are people who are worried about this name change- creating more harm than good. So there's people in the, PCOS support community that are concerned this is gonna create more confusion because now it's with the name change, does that mean the diagnostic criteria change? Does that mean the treatment changed? Are people gonna go back and review this and relearn it, or are they just gonna refer everyone? Who are they gonna refer them to? And I think there's also concerns that renaming it is gonna affect funding and research and even grants and things that are available 'cause it's everyone has to change everything. So I think that's where some of the concerns are coming from. And I think it's fair for people in that community to be concerned 'cause they have experienced already not great experiences. And so if we're changing things yes, it could be better, but they're also worried it could be worse. And I think that's fair concern to have. I wonder if added to this nugget of truth is and you've done a deeper dive on this, so I... You could tell me I could be wrong. I thought there are some lifestyle interventions and even some supplements that have small amounts of data that I do talk to people about. I'm always "There's some limited studies showing X, Y, and Z," 'cause I think so many people are, looking for any alternative to just going on a birth control pill or spironolactone or whatever the other meds that are being offered are. And, I don't think that conversation happens, and just in the same way for autoimmune conditions, a lot of other things, it's just important to say lifestyle matters having a healthful lifestyle is helpful for most conditions, and I think when we leave that part out, we give people this sense that meds are the only thing that you can possibly do. Yes. Yes. And I think a lot of doctors probably assume that's implied, that it's like, "Yeah, and you should continue to try to get enough sleep." Yeah. "And you should control your stress, and you should try to eat a nutritious diet, and you should be moving your body, and you should..." But they don't explicitly say that, and so then I think it's tempting when you see these very hyper-specific things online that are like, "Here's the protocol. Here's the supplement stack. Here's the whatever," that becomes so much more attractive if no one has even mentioned it to you. Yeah. Then, it makes sense to believe oh they didn't even talk about it they must not know, yeah. So I- Yeah I think there's truth in that we fail to have that conversation oftentimes with people for a variety of reasons the practice setting, how much time you have, how much data there is on it, the fact that it's not very specific often. There's so many reasons a conversation's not ha- again, this is not to hate on doctors, but there's a lot of reasons that conversation doesn't happen. But I do think there's some truth that there are things besides those very few medications that probably patients can do, but they don't get talked about, absolutely. And so when we get into the actual treatment guidelines, which I'm just gonna say I was so happy with when I read them. They really... We'll get into it later, but I was so thrilled. I think the the issue you're talking about of they're not explaining explicitly to the patient, how lifestyle helps, there are- actually some supplements that have some data, which again- we should talk to patients about that because they think- that we just don't know if we don't talk to them about it. And then that way we can all say "Here's a supplement you could take. Here's one that I don't know really if it's really worth it." Yeah. That kind of thing. Yeah. And I think it gives them so much more- information to make decisions on, and if you don't give them the information, they're gonna get it elsewhere. Yeah. And it could be from someone who's trying to sell them something- rather than someone who has their best interest at heart. And so I think that's that's definitely part of the nugget of truth behind some of these posts. I'm thinking back to that initial encounter that I had, and the OBGYN that I saw I, I actually thought was wonderful. I saw her for many years, and my parents knew her, and we were like VIPs. We had a lengthy luxurious appointment, and she kept asking both of us if we had more questions. And I just keep thinking about the fact that it's not like I walked out of there feeling like she rushed me out or whatever, but I still just didn't really understand what was going on. Yeah. So I, yeah, I just think even when the person is trying to do their best, I can see how for a condition like this it's just so easy to walk out and feel like you still don't know. Yeah. You don't have an answer, and it's very unsatisfying. Yeah anyway, So let's talk more about the facts including context and nuance. So I guess that starts with just what is or was PCOS? How do you define it or diagnose it? Yeah. So the diagnostic criteria have not changed with the name change, so I just wanna be clear about that. So it is the same condition. It is the same condition. It is a name change. Just a change in the name. So hopefully that relieves any confusion there. The Rotterdam criteria are the most common criteria that we use to diagnose it. There's some others as well, but they're a little bit more complicated, require some different tests. And these are solid. So you have to have two out of three of these symptoms to be diagnosed with PCOS. The first symptom is irregular cycles. So irregular cycles means if you're one to three years after starting your period, your cycles are less than 21 days or more than 45 days. If you're three years after starting your period to in the perimenopausal period, your cycles are less than 21 or greater than 35 days, or you have less than eight cycles per year. Or if you are at least a year past starting your period, longer than 90 days for any one cycle. If you have never started your period by the age of 15 or w- more than three years past the breast development. And then so if any of these are the case, any of these irregular period symptoms, you should consider a diagnosis of PCOS, and you should assess it appropriately. And if you have one of that symptom, that's one out of the three. The next symptom is hyperandrogen- androgenism. And hyperandrogenism can be either clinical, meaning, like symptoms that the patient- is experiencing, or it can be biochemical, meaning done, like pro- proven on lab tests. The clinical symptoms are primarily hirsutism. That's hair growing in a more typically male pattern, like on the upper lip, on the chin, chest, back- which is more typically male. The amount of hair can vary with different ethnicities, of course. Yeah. But it should be, relative to other people in that ethnicity, there is increased hair growth in this pattern. And it's a pattern, right? It's not just like you have more hair generally. Yes bush your eyebrows or whatever. It's like- it's where it's growing you're, you have a pattern growing- Yes in a weird place, right? Or I don't wanna say weird, but just not typical, okay? Yes. And then the other thing is acne. So if people who are told they have hormonal acne- that's a red flag because it- hormonal acne, PCOS causes hormonal acne. It's related to elevated levels of these androgens. And if you're having significant acne, specifically around your periods, if you're having acne on your chest and back, not just the, typical sort of breakouts that, that most teenagers will get it's more extensive acne, than others, that can be a symptom of hyperandrogenism as well. So that's... You can just have those two and not have done any tests- and, you do have to rule out other causes of these things, of course, which I'll get into, but probably that person has PCOS. Then- Okay, so this is an important fact here, because from what you just said alone, a person just having a conversation and an exam with a doctor could potentially officially meet the criteria for PCOS even without necessarily doing any labs or doing an ultrasound. Is that- Correct fair to say? Correct. But you do have to rule out other causes- Okay of those symptoms. So without additional testing, you would not have necessarily ruled out all the- Yes other potential causes, but you could easily meet this criteria- Yeah without additional workup is basically. Correct. And- Okay and this is typically how I end up diagnosing patients. They come in and I'm like, "You probably have PCOS. I'm gonna do some labs- Yeah to rule out other causes." And then I do said labs, and I'm like, "Yeah, you have PCOS," and then it's done. That's all you need to do. And You don't have to do any labs to diagnose PCOS other than to rule out other causes. Okay? So importantly, if you just have irregular periods, that is not enough. Correct. And if you just have hyperandrogenism or clinical signs the acne or the male pattern of hair, that also is not enough. Correct. Okay. The... And then if you don't have clinical hyperandrogenism, but there's irregular periods, you can also test the androgens. So testosterone, DHEA sulfate. And that can be helpful in sh- proving biochemically that there's hyperandrogenism. 'Cause sometimes the symptoms, it's eh, could be, maybe not. I don't know. There's a little bit of hair, but is it really... yeah and there are, actually standard atlases that you can refer to, to compare the hair growth. But, again, I'm sure those are not ethnically diverse enough to be completely valid. And so I think that would be something that I typically add to my labs when I'm ruling out other causes just 'cause, like, why not? Yeah. Gives me some more information. You do wanna make sure you're using LC-MS assays over the direct immune assays- 'cause they're more accurate. Okay, so we have had two symptoms, irregular cycles, hyperandrogenism. And do those need to be tested on a particular time in the cycle? No. Okay. Yeah. All right. The only time you would wanna consider doing labs at a particular time in the cycle is if you're trying to confirm whether someone has ovulated. So maybe if someone is trying to conceive and they are having regular periods, they still may not be ovulating. Oh, I see. Okay. And if they're, if they've been trying to conceive, they have some questionable features of PCOS and you're trying to figure out if they're actually ovulating you can do that progesterone on day 21. And importantly, these tests would not be valid, the results would not be valid if somebody was on hormonal birth control. Correct. Okay. Correct. Yes. Which relevant for you. But Yeah, which is why I've just never been appropriately tested for 20 years. That's the thing. It's hard. The older you get, the harder it is to diagnose. And down, because- Especially if you get towards the perimenopause period, 'cause I'm like now you're having irregular cycles, but you're also perimenopausal." So I'm like, I don't know. So and then, and the it's just, it's harder. So it's so much better if we diagnose this early so we can intervene early and help that person minimize their risks associated with it. But that's a separate soapbox. Okay, so last of the three symptoms is polycystic ovaries, and this is not oh, I had an ultrasound and I had a cyst on my ovary, or I had two cysts on my ovary. This is 20 cysts in an ovary. Yes. I think this is a very common misconception- where patients will be like, "I had a, an ultrasound and it had a cyst." And I'm like, "One cyst is actually basically normal" yeah. That is normal. You probably should have one on one of them. So- Yeah I think it's very common that people will say, "Oh yeah, I did have a cyst," and think that means this. But yes, as you're saying, it means... But also important to note that it's completely possible to have this condition with no cysts on your ovaries. Yes, and that is so important because people feel, either they're never tested properly and evaluated properly, or they get, they order an ultrasound and "It was normal. You don't have it." That's not true. You could still have PCOS- and have a normal ultrasound. You don't have to have the polycystic ovaries. But say someone who maybe has some hyperandrogenism is having regular cycles but is struggling to conceive, they may have polycystic ovaries. Yeah. Yeah. And you just, you may be reg- still having regular cycles but not ovulating, right? And I think it's it's important to consider the ultrasound, but the ultrasound is not required for diagnosis. I did have an ultrasound, and I had one cyst, and I was 16, and I was like, "Oh, I have this weird growth on my ovary." That is literally what I thought. And I was kinda like, "Okay it's not that monstrosity that I saw on- on Google or what, on Yahoo." But she... I don't think anyone ever was like, "Oh, by the way, that's completely physiologically normal." Yeah. It was... Was this was what? The early aughts? Yeah, like 2003 probably. Yeah. It was a different time. Not that I'm saying that people are doing that much better now, but I feel like we're doing that much better. The fact that somebody was concerned about the condition and then somebody actually did labs and did an ultrasound and had an appointment with me and talked to me about it I feel like they were ahead of their curve considerably. They were ahead of the curve. Yeah. Yeah. Okay. That's the diagnosis. And in terms of excluding other causes, to go over what those might be, we would wanna test things like TSH and prolactin, 'cause those could indicate other hormonal issues that might contribute to irregular periods. Okay. You can also do a 17-hydroxyprogesterone, FSH, LH. That can help look for other types of Cushing syndrome, adrenal tumors, things like that. And then importantly in my population hypo- hypothalamic amenorrhea or irregular periods or hypogonadotropic hypogonadism, basically meaning due to very low body fat or intensive exercise that's not adequately fueled, the hormone axis is shutting down to try to protect energy consumption and preserve energy. And so that can cause irregular periods, and it can look a lot like PCOS in- so that's why again, eating disorder screening that I'm gonna harp on about forever, very important to understand. 'Cause if someone is not eating consistent, regular meals and they're very physically active or if they've lost a lot of weight or their body fat percentage has gone down significantly, even if their BMI is normal- this could happen to them. And you can also look at LH and FSH. That'll tell you if they're suppressing that axis. So for people with very low body fat presenting with that hypogonadotropic hypogonadism, you should see some aberration in these labs? I- if they're- That is the case if they're having hypothalamic effect, yes, you should see some aberration in the LH and FSH. And usually the estradiol is also low. Okay. Oh, okay. Interesting. Yeah. So then they might have primary amenorrhea or irregular periods because maybe they're not ovulating 'cause of this- Correct the axis is messed up. But would they have any hyperandrogenism? So maybe. Acne- very common. You could have acne- I see. Yes and have irregular periods, and it's like- okay it could be PCOS, but what else is going on? Yes. Okay. So it's just, you can't just assume PCOS and not look for other things. Yes, interesting. Okay. But It's most likely to be PCOS unless- Yes there's these other things going on. Okay. 'Cause again, 10% average of the population has it. Yeah, which is a lot. Yeah. Yeah. I think in other times in my life every time I've met a new GYN provider, I've been like, "Hey, by the way, this thing, I don't know, maybe I have it, maybe I don't." And I feel like a lot of times they look at me and they're like, "Eh," "You probably don't," because I've never... I've always had a very normal BMI, And then I've been on birth control with controlled other symptoms, so I, I don't have the obvious acne. So I, there's probably some inherent assumptions being made, just in that. So yeah, that's interesting to talk about how even at the other end of the spectrum you could present with a similar phenotype and- Yes. Yes for a totally different reason, okay. Yeah. Okay, tell us more about these... So I just learned about this recently, the subtypes, the different subtypes of- Yeah PCO- P- PMOS formerly known as PCOS. Yeah. It's like the artist formerly known as- It's the artist formerly known as Prince, yeah. That's the only thing I can think of when you said that. Okay. The disease formerly known as PCOS. That's easier for me to say than PMOS. Yeah, true. True. Okay. So yes, there are subtypes of PCOS that have been identified that can help us better understand an individual's risks. So basically, PCOS is the catch-all term for this syndrome, but there's types within this syndrome. And this was a a study done where they basically used, It's 11,900 affected women across, and validated this across five international cohorts. And they clustered a series of clinical variables associated with PCOS. And they found that there were four subtypes with similar clustering of symptoms. And each subtype was roughly about a quarter of the types of cases. So roughly evenly split between four different subtypes. And so again, this just goes to say this is genetic. And everyone's experience of it will be different based on their specific genetic types that they have, and it, that results in different markers like metabolic health markers issues with fertility, issues with, hyperandrogenism. So it can look different in different people. Which is again why you can't make an assumption based on looking at someone, regardless of their BMI- what's going on. So there's the four tub- subtypes are first is hyperandrogene- androgenic PCOS. This one has the highest risk of second trimester pregnancy loss and dyslipidemia or abnormal lipids like cholesterol. This one typically has high testosterone and DHA sulfate and some mild metabolic abnormalities on labs. The next one is PCOS with obesity, basically people who have a higher body mass index. I really don't like that term for lots of reasons. I would say this is PCOS with glycemic abnormalities. Okay. Because these are people who have elevated fasting glucose and fasting insulin, at the highest risk of type 2 diabetes dyslipidemia and hypertension. So abnormal lipids and high blood pressure. They also have the lowest live birth rates. And I hate the term obesity anyway, but this is the population that I think gets blamed a lot. They're just like if you just lost weight-" If you lost weight, this would... And I'm like, the reason their BMI is higher is because they have higher insulin levels. That is a symptom of the condition. That is not a choice. That is not a behavior. That is a symptom. And so it's crazy to me to tell someone just stop having that symptom." That's... Yeah. You can't do that. We touched... So we touched upon this in the GLP-1 episode where I think the prevailing assumption among most physicians even is that this is a chicken or the egg thing where they're like the obesity the excess adipose tissue is causing this metabolic dysfunction which is then causing insulin resistance and blah, blah, blah." And so that is the problem. And so if you can just, restrict your calories and lose some weight- then you will solve this thing. But- Yeah what you're explaining is that it the cause out the other direction which is that these people already have metabolic dysfunction with higher- fasting insulin, and that results then in an easier weight gain and more weight gain. Yes. But yeah. And then it's, and then it's a feed forward cycle. Perhaps that perpetuate the cycle. Yeah. Yes, it does because the, as you gain more weight you become more insulin resistant. And so it's a spiral. And but yeah, it's like I, I can't think of another condition that people have where we're just like, "Just stop doing, stop having that symptom." That's just crazy to me. And these are the people who often will end up in the situation of being told you just need to lose weight." And so then they go on a really significant diet and restrict their calories, and then they cycle their weight up and down 'cause that's not sustainable, and they have weight cycling. And that just worsens these metabolic health outcomes that they have, as we talked about- in the GLP-1 episode. And Yeah. This one is important to understand and important to treat appropriately with appropriate lifestyle guidance. 'Cause, yes, you can improve your glucose levels if you have insulin resistance. There are lifestyle things that you can do. But you can't tie that to lose X number of pounds, because the amount of restriction someone's gonna require who has this profile- to lose weight is going to be extreme. Yeah. And so we should treat them. We should not just be like, "Just stop doing that." That's not appropriate. Okay. Next one is PCOS with high sex hormone binding globulin. So this one has pretty good reproductive outcomes, the lowest incidence of diabetes and hypertension, and the lowest b- BMI amongst the four subtypes, and it primarily shows, it p- it primarily has lower LH and testosterone levels compared to the others. So as we've been talking about you, I'm like- "This is the one she has." Because y- you know, you didn't have any trouble with reproduction, no major- Yeah metabolic issues, right? Yeah. Sorry, I'm HIPAA sharing your stuff, but you already share your... that's okay. I'm fine with it. I'm already putting it out there. I know. We're all out there. But yeah, so- I'm actually wondering if I have the first type you talked about, because this is interesting and I never thought about this, but the very brief time that I was off birth control when I just changed schools and I hadn't gotten a new doctor yet during that time, as part of our lab medicine class in medical school, we checked each other's lipids. We did the- Oh we did the assays, and mine was, so high, and I freaked out, and that's part of the reason then I went and I was like, "I need all of the labs." And- M- it's I think my LDL was, like, at that time in the 130s, and my HDL was, in the 90s. So she was like, "Oh, your total's really high, but you're fine. You don't have any other risk factors. It's not a big deal. Work on your diet. She- she was very casual about it, and I was like- Great. Great advice oh, okay 120s, 130 it's not that bad. But ever since then, I've always been on birth control or pregnant, and every time I've checked my lipids, my LDL's like 80, 90. It's much better. I've never gotten that high before, and that was when I was, like, 20, 24. Oh, interesting. And active and eating pretty good. I guess I was eating more restaurant food at the time, but I... So now I'm like, I wonder if I went off and rechecked my lipids if maybe I would have a more dramatic delta. Yeah. More dramatic effect. If you went off, we have a whole bunch of additional tests we could do- that we're gonna talk about, that you could then, I know, but when I go off I get acne. You do. Which is a sign of my hyperandrogenism. Yeah. So it's like- Anyway, okay it's is it worth it? I'm glad I did not, I'm glad I did not read about these subtypes before I became pregnant, because I would've been freaked out about this second, third trimester pregnancy loss fact, yeah. And yeah, it's... We'll talk about that in a second. Okay. Okay. And last one is PCOS with high LH and AMH. So this one has- the greatest risk of ovarian hyperstimulation, which would cause the cysts, the multiple cysts. It says lowest remission rate, and I do have to say the way they described remission, it wasn't remission. It was like some of the markers got a little bit better. Okay. And I was like, that's not remission. They're just a little bit better than normal. But when they're saying remission, are they saying without a treatment? Or they're saying this thing spontaneously goes away? So that was what was very unclear to me. Okay. I was just like, I don't know what that means. But I will say I have a patient who I suspect has this type, and they have required a lot more medication than I would've expected- to improve some of their markers. And so if you have this type and you're, really struggling to... it doesn't matter what you do, it just really persists, is how I took, what I took away from this. Like- the, it's harder to treat. It's just- Yeah the androgens are higher and all that. But yeah, this one, this type is distinguished by high levels of LH, FSH, and AMH, which is anti-Mullerian hormone. And just as an aside of the anti-Mullerian hormone there's some discussion of using that instead of ultrasound- okay to assess for the ovarian hyperstimulation or whatever and the cysts. But it's it's something that it's not easy to make like a reference range because- it changes over your lifespan. So it's like it's less accurate in teenagers 'cause they're like, still going through puberty. And then as you're getting older, as, as you become closer to geriatric pregnancy or perimenopause that level tends to go down. So the reference range is a little bit tricky. So it's not like commonly used, but it, some people do use it, and there are some uses for it. So in that case, a high AMH would suggest a more dysfunctional ovary? Yes. Okay. Yeah. Okay. All right. So anyway next thing I wanted to cover was some of these additional biomarkers that, again, were used in that study to identify the four, subtypes. And can also help us inform our management of individual patients. 'Cause again, because there are different subtypes not every person's gonna have the same symptom profile, and so there may be different things that are more of a priority in them than others. And so the this was actually in a different study. It was called Biomarkers to Inform the Management of PCOS, and this was based on a review of systematic views. So they basically identified 63 biomarkers that were abnormal in women's, women who had PCOS versus people without PCOS. And of these, they felt that 22 core biomarkers could help evaluate the multisystem impact of PCOS and best inform individual management for patients. Can I just tell you, I am picturing a telehealth startup, s- Oh, this one already exists being generated, like it- This startup already exists. It's, is there one that's only for PC- PCOS? Yes. Or... Okay. Yeah. Oh, because this is just a gold mine for somebody who's looking to make some cash. 'Cause they can just say "Look, your doctor is not looking into this. We can do 22 core biomarkers." And this translates really well into a marketable service for people. Oh, absolutely. And you know what? I've gotten patients from this service. Oh, okay. And they're not satisfied? Not that they referred them to me, but no, they came to me 'cause they were not satisfied. Oh because again, you get the testing, but no one's explaining it to you. What it means? You'll get a pretty printout, but it's like what if you have a question? And yeah. So anyway I have several patients who came from this place to me because they were like, "I need more discussion of this." And I will say also that a lot of patients that I have a history of eating disorders, and they're again, being told "Just lose some weight, and then this-" will all get better." And that's, not helpful. The core biomarkers. So these are divided into different sort of systems. So the reproductive system, DHEA, prolactin, sex hormone binding globulin, total and free testosterone, and AMH. And so often we would see most of these or all of these to be elevated and the sex hormone binding globulin To be low. Okay Mostly. But again, there is that subtype that has high. So prolactin, that's interesting. When they say high, th- I'm assuming they just mean high relative to controls, but not pathologically high. So I have seen a number of patients with PCOS who have slightly high prolactin. Oh, okay. And so we do the whole hyperprolactin workup, and we don't find anything. And so I've had conversations with endocrinologists about this. Like, "Is this a PCOS thing?" And they're like, "Yeah, I don't really know why." I'm like, okay. It's all connected somehow. So poor- poorly understood, but yes. Okay. I've, and I've seen that quite a lot actually. So then we have metabolic mo- biomarkers, so this is things like total cholesterol, triglycerides, lipoprotein A, HDL, LDL, and non-HDL cholesterol. And so generally speaking, they have h- high all of these except HDL, which is the good cholesterol. They typically- have low HDL, and I see that a lot. I see that a lot in the patients, and they get very frustrated 'cause do all the things, and they can never get that HDL up. And this is really interesting because, okay, so lipopro- these other ones, total cholesterol, triglycerides, these are all in a standard cholesterol panel that most people would get you know- with their annual labs. Lipoprotein A has recently been added to some major society guidelines, and so I think we're gonna start seeing people d- ordering that more often. And the recommendation is to check it once in a lifetime because it's genetically determined. So it's very interesting that they have found that, in patients with PMOS slash PCOS, that this thing is elevated because, again, that, that kind of implies this is not just a conseque- like, an all... I think a lot of people- Yes assume this is all a consequence of the weight that they're carrying or that they may be carrying, and w- we know lipoprotein A is independent of that. So- Yes it's an independent marker of cardiac risk. So- Yeah yeah, that's interesting. Yeah. And I think, it is a genetic cond- and there's only so much that you can control by lifestyle, and that's the thing that I really try to drive home to these patients is they're often trying so hard and getting no return, and so then they just do increasingly extreme things to try to control it- because they just keep hearing "If you just lose the weight, if you just lose the weight." And this is why there's a higher risk of eating disorders in people with PCOS. And we'll get into that more later. But next thing I wanna cover is increased inflammatory and oxidative stress biomarkers, so CRP and fibrinogen. Which again is likely related to the, glycemic, And if you have elevated insulin, ele- elevated glucose, there tends to be some inflammation that accompanies that, and I think that's probably where that's coming from. And I do see that a lot. Yeah. I see a lot of patients with PCOS who have this borderline high CRP- Yeah and we're like, "Do you have a rheum condition?" Yes. But the rheumatologist can never find anything, and they're like sometimes this joint hurts," and we look at the joint and there's nothing. And it's just it's hard to know where it's coming from. But I see several of them who like, we just can't get that number down. And so that's one that, that's important to, to be aware of. And I actually would love if there's any endocrine or rheum specialists listening to this that have any insight on what I'm supposed to do with that, please let me know. 'Cause no one that I refer them to can tell me. We should... you're gonna talk more about the management strategies, which I'm looking forward to, but I think the CRP thing is important to, to come back to because inflammation is such a boogeyman in the wellness world. And I think people get very alarmed when they see a lab value like that. Yeah. Or they hear "Oh my gosh," "it's associated with inflammation." And then if you start looking up what can I do for inflammation, that's a whole other rabbit hole that you can fall down. And yeah. Yeah, anyway, I'm curious to hear what the evidence-based strategies are to manage that- Yeah A- and I will say relevant to our fiber episode, which I don't know if that'll be released yet in the order we do this, we'll have to see. I have noticed it more in patients who struggle more with fiber. You mean you tend to see the higher inflammation in patients who struggle to get enough fiber? The higher CRP in the patients who struggle to get enough fiber. Yeah. So- Maybe that's related. But in any case. That makes sense, right? Because, I mean- Yeah we know that what is generally an anti-inflammatory diet is like- Yeah a diet that is low in ultra processed foods, high in whole foods and plants. Yeah. And so those are also things that are- Has, has lots of fiber more likely to have fiber. Yeah. And so I do think that's part of it and but again, I don't know. So I would love- Yeah for someone who knows more than me to tell us. And go ahead and write a comment on our Substack, and we can share it. Anyway, so that was the inflammation one. The next one's glycemic biomarkers. So this would be, like, an elevated HOMA-IR score, which is comparing your fasting insulin to your fasting glucose and spitting out a score of your insulin's inappropriately high for your glucose level. And that basically tells you there's a degree of insulin resistance. Or if you can do a formal two-hour glucose tolerance test. Now, you'll notice on here A1C's not on here. Yeah, that's interesting. What's up with that? So you can have insulin resistance and have a normal A1C- Oh, especially when you're younger. Because your body's compensating. Like- your pancreas can keep up. It's just pumping out more insulin. But eventually it will not compensate, and you will develop Type 2 diabetes. Yeah. And so I, I think it's really important when you have someone who you know is at risk to at least get a sense of, like, how it, how bad is this insulin resistance right now, and and address it. And obviously that includes some lifestyle management, but it also can include medication. Next piece is cardiovascular biomarkers. So this is really just blood pressure. The lipids have h- have already addressed That side of the cardi- cardiovascular disease the glycemic biomarkers have already addressed that side of cardiovascular disease. So the blood pressure is the other piece of that. And then the last one is vitamins and minerals. It's much more common for these patients to have low vitamin D- but also high iron and ferritin. Interesting. Yeah. And of course not always. And I will say, some of these patients have really significant problems with their menstrual bleeding and h- can be anemic as well. So a normal or a low iron doesn't mean they don't have PCOS 'cause they could be losing a lot of blood. I've definitely seen a lot of patients who have very heavy bleeding when they do have cycles, but their cycles are so irregular. And they have anemia as a result, so just to be clear, all of these tests that you're mentioning right now, it- these are not tests that are required to make the diagnosis. These are not tests where every patient with PCOS or PMOS needs to go get these tests. These are just tests that have been linked or there's some correlation with PCOS or PMOS and could potentially be used to guide- Correct clinical management, but are not n- necessarily needed for every patient. Yeah. They're not all required, but I think if- To help identify the subtype. And I really think the the vitamin D issue is so common. And we actually, we know that having prediabetes and low vitamin D increases your risk of developing diabetes, and that supplementing vitamin D when you have low vitamin D can help reduce your progression from prediabetes- to type 2 diabetes. I saw that in a ACP article- Oh, that's so interesting a couple months ago. Yeah. I need to find... I don't know. That article is literally one I read on paper at my house, so I need to find that study. That's funny, 'cause insurance hates us checking vitamin D sometimes. They really do. Oh my gosh, it's bane of my... I'm like... and honestly, the Endocrine Society is like, "Don't check it." But also I'm like, but sometimes you need to check it. And I think in someone who has metabolic health issues, it's important, because we need to correct their vitamin D. And especially, in a teen as well, may- that's a critical time of bone density development. I think it's important. But it is expensive. I think that's the primary reason- that it's not recommended- is because in terms of cost benefit, like it's an expensive test. But you and I both do the client billing. Yeah. By the way, it's $11 at a- wholesale pricing here in Texas. Exactly. It's actually not that expensive. It's not. But for whatever reason the labs bill the insurance like $600 or something. And then, yeah, understandably they don't wanna pay that. So that's a whole other topic for another day. But yeah I, personally, always get these metabolic tests, the glycemic markers, the lipids. I generally do get the androgen levels, just 'cause it's helpful for the patient to feel like affirmed. That there's truly something going on. It's not in my head. Yes. And also, like sometimes it's normal, and then that feels invalidating, but I, then I tell them like, "It doesn't have to be abnormal." Yes, it's okay. And and then yeah, again, with the subtypes, like if you wanna try to stratify with the subtypes, it can be helpful there. And what their risks might be. Okay. Yeah. I try not to order CRP, but a gon- a, a lot of these patients have like inflammatory disease-ish symptoms, polyarthritis or chronic diarrhea or like things like... And I'm like, "I don't know, could be something inflammatory going on," and I end up having to check it, and then it's always high. It's very- 'cause again, no one no- no one can tell me what to do with that information. And then yeah, blood pressure obviously we're doing on everyone. So a lot of these we're doing. And I think the thing for me is just let's make the diagnosis, and then let's figure out if there's any issues, and if there's brewing issues, let's monitor it and follow up on it. Okay, so I'll get into the recommendations from the 2023 International Evidence-Based Guideline for the Assessment and Management of Polycystic Ovarian Syndrome. And so this was in 2023, so it was still called PCOS, so when I say it, it's okay now. All right. One of the key things with the guidelines is understanding the increased risk of metabolic conditions, sleep apnea ovulatory dysfunction or reproductive issues, uterine cancer, which I haven't talked about yet- Yeah but I'm gonna talk about in a second. Yeah, that's important. And mood disorders. So we need to be assessing patients with PCOS for all of these things, because they may not bring it up. Sleep apnea, I see so many patients pCOS who have sleep apnea and have probably had it for a very long time. When I talk to them and I get the history, and they just never brought it up. They just were like, "Ah, I snore. My family snores. It's no big deal. I'm tired, but my work's stressful, I'm busy." And they just totally don't pay attention to it. And of course, sleep apnea increases your insulin resistance. It increases your blood pressure. It increases chronic stress and leads to anxiety and depression. I have this pocket theory that sleep apnea is the, one of the root environmental things that's combined with these genes contributing to people getting PCOS. It's obviously not the case every time, but, I see it so much that I'm like- this is... We should be at least asking questions about sleep. Okay if not doing a sleep study, but we should at least be asking some questions. And do you see the sleep apnea in patients of, quote, "normal BMI"? Yes. I do. And I have a patient who remembers at least through college and, or late high school having significant snoring, and really struggling, and never was really evaluated for it. And by the time they got to me, they had diabetes. They'd also never been diagnosed with PCOS. But they clearly had PCOS and by the time they got to me they had diabetes. And they were in their Mid to late 30s, I think. And so it's, it's something that I think if we can address it and intervene on it earlier that's, that was potentially preventable. But it was just not fully assessed and addressed. Yeah. And maybe it wasn't preventable. There's also anatomy involved in sleep apnea that sometimes it just is what it is. But I think we should be asking more questions. So in terms of treatment, I'm gonna start with birth control. Birth control is not for masking symptoms. It's not just to regulate your period. It can help treat hyperandrogenism symptoms like acne, which you alluded to. Yeah. And it also is to protect the uterine lining. If you are having irregular periods and you're not regularly shedding your uterine lining, you can start to have buildup of the uterine lining that can become what we call hyperplasia, and eventually dysplastic, and eventually uter- endometrial cancer. So it is very important if you're having very irregular periods, like less than eight a year or those super long stretches it is important to protect the uterine lining. And it doesn't have to be birth control pills. It can be a progesterone IUD but that's not gonna help with the hyperandrogenism symptoms. So that's why birth control is so often recommended. And again it's not because we just wanna mask the symptoms and cover it up and not figure out... it's treating the condition. Okay. So I think we should spend a moment longer on this, 'cause this is such a big point of contention where I think people's perception is if I can never come off of it if I go on it and I'm never gonna come off of it, then that's not a treatment. That means it's a Band-Aid. W- what would your response be to that? I think you have experienced, you can come off of it, but the symptoms will come back because the condition did not go away. I know, and they would say see, that's not a treatment. You didn't fix the underlying root cause." It is not a curable condition. Okay, so that is the part that I think So you have said this and, but I just wanna drive it home again that this is very much, it seems, a genetic predisposition that then manifests or doesn't manifest, or manifests in different ways, perhaps in conjunction with environmental and lifestyle factors that are coming into play. Yes. So if you're saying I wanna know the root cause and I want to address the root cause," you'd have to try to change your genetics, which- Yeah you most likely cannot do. Yeah, we don't have gene therapy for that yet. Yeah. Maybe in the future. Cannot do. Or you will have to think about what potential environmental or lifestyle factors may be contributing in your case, and when we say environmental, it may not be just swapping a product. It may be like- Yeah something that happened in utero. It may be like something that- Yes happened, To your grandmother, yes. So it's not it's not necessarily just a matter of cleaning up your environment that is, the root solution to this. And I think it's a little bit semantics when someone's just but it's not treating the root cause," and it's it is treating the problem with the physiology that is giving you the s- the symptoms, these symptoms. Yeah. And yes, it is true that it's not a cure, but it is still a treatment. And, I, again, this idea of it being a Band-Aid, I think comes up a lot, but what is the goal of treating any medical condition, right? It's to improve your quality of life, improve your functioning, help you achieve a goal that you have conceiving a child or whatever. And I think it... Calling it a masking a symptom or saying it's a Band-Aid is a little the, it's not a fair characterization in this case. Yeah. Yeah. And, we do need to study this more. Yes, you're right. There may be other things we could do- Yes that we just don't know yet. Yes. And it would be so great if we could find said thing, but w- that means we need to study it and we need to fund studies for that. And so I think the other piece of renaming this condition is, again, we don't really study women's health conditions super well. Okay. So it's a metabolic problem And so it is of high priority to study. And so hopefully the name change also helps with funding. I know there's concerns that it will h- make it worse, but I'm hopeful that it will help with funding. It affects fertility, so if we want women to have babies, we better study- apparently that's what we want the thing that 10% of them might have that is preventing- Yeah them from doing that. I think it's important to study. And, obviously we did a birth control episode. There's risks, there's benefits. Some people would choose not to take birth control. And we, it would be great if we had other things to offer them. Now, I will say, we do have another androgen blocker option. So there's actually a couple, but the most commonly used one is spironolactone, which is an androgen blocker and can help reduce the hirsutism, the hair growth, and the acne. And that it's actually also a diuretic, so it may slightly lower blood pressure, not super much though. And it's something that has to be monitored 'cause it can cause high potassium levels by retaining more potassium, and it is not safe in pregnancy. So it's not something you could take while trying to conceive, but you also couldn't take birth control while trying to conceive, so yeah, there are other options if birth control is not something for you that will treat hyperandrogen symptoms, but it will not protect your uterine lining, so you still gotta do that. So really, it sounds like if one of your concerns is hyperandrogenism, you do have two different options, but the birth control actually treats more issues- Correct and overall has potentially more benefit than the spironolactone would. Yeah. Yeah. Going back to the endometrial cancer, so you talked about how women with PCOS may have a higher risk of developing endometrial hyperplasia if they're having long periods of amenorrhea and skipping periods. What can we do about that? So we have to protect the uterine lining. Now, what I will say is, like some people are able to improve ovulation and improve their menstrual cycles with medication and lifestyle or even sometimes with just lifestyle. Again, it's gonna depend on the person and, like, how strong of genes they have for this. But some people are able to get their periods regulated just with lifestyle changes or with lifestyle plus a medication. But if you are doing all the lifestyle and all the medication and you're still not having periods- We gotta protect the lining. We gotta do IUD or- progestin-only pill or birth control pill. Gotta do something. Are you gonna talk in detail about the lifestyle changes? I am. Okay. All right. Yes. Okay. I'll let you do that when you're ready. Okay. And the last thing I wanna say w- since we're talking about the sort of periods and re- reproductive health stuff as I mentioned before, you can still have anovulation even if you're having regular cycles. So even if you have maybe regulated- your cycles with lifestyle changes, you may still not be ovulating. Okay. And so for these patients, and this isn't something they explicitly said in the guidelines but they did talk a lot about the options for fertility management in these patients. I feel that they should be referred earlier to REI if they are trying to conceive than we would, someone in the general population. Because the sort of guidance in the general population, at least through my training, which, I don't know, maybe- If you're having periods, you're ovulating- Yep so just try. Yeah. And you can try for a year, and if you haven't tried- You can try for a year and then come back. If you've tried for a year. If you haven't tried, if you've tried for a year and you still haven't conceived, then go to REI. Now, if someone has PCOS, that doesn't make sense. We know they have an issue that could have- impact their trying to conceive, so why would we make them wait a year? That would not make sense. So I personally, if they're like on a time crunch, like they're in their early 30s and they're like, "I want three kids," I'm like we gotta go." So I'm just referring them straight to REI, right? But if you're in your mid-20s and you're "More or less I fair about it," like I would maybe give it max six months, and then- I would refer to REI. But again, this is just me. This is not like any f- official guidelines. This, and this comes back to then the importance of just establishing the diagnosis, yes. 'Cause I think if, like for me, I guess it worked out, but if I definitively had a diagnosis and then I tried for six months and it didn't happen, I was that woman in her mid-30s, yeah, you're like, "I gotta go." Would've been helpful for me i, in that situation for a gynecologist to be more urgent in telling me that "Okay, maybe we need to look into this," yeah. And I think a lot of people are afraid to go to REI, or which is reproductive endocrinology and infertility because they don't want IVF. There are so many things they can do before IVF. Yes. So if you're a patient who is struggling with this, don't let that stop you going. Like they are the best person for you to be seeing. Yeah. Because they have additional training in both the hormonal implications of PCOS and also the other factors that affect fertility- Yeah to do a full assessment. Like they can do a semen analysis. They can as- assess the male factors as well. Yeah there's a lot that can be addressed, but personally, I think if you have PCOS, we should be taking that very seriously and not wasting your time. Yeah. 'Cause you have a limited reproductive window and there's no reason to waste your time. Yeah. Okay, lifestyle. So I'm gonna talk about this stuff now. So this is a condition that can be improved or managed somewhat with general lifestyle habits, but it is a chronic condition based on genetic factors influenced by environment and lifestyle. You cannot fully reverse it. You cannot cure it, as we talked about. There is no special diet that specifically helps, and this is coming from those guidelines. You don't need to be low carb, you don't need to be keto, but you need to eat a balanced diet. And as we've talked about in other episodes, you need adequate protein. You need adequate fiber. You need to eat regular meals throughout the day. You need to avoid skipping meals and then coming home and being starving and like eating a very large meal or, eating a whole bag of chips on the couch watching TV, right? Basic healthy habits will help to manage this condition. I think particularly it is important to ensure adequate fiber for these patients because as we talked about in the fiber episode fiber is important for not just bowel movements, but also for regulating glucose and cholesterol. And so it, it will really help for these patients. And as you mentioned, the sort of plant forward diet, lots of whole grains and fruits and vegetables. Again, adequate protein for your needs, whether you're sedentary or if you're working out regularly, you wanna make sure you have enough protein. The, in terms of supplements there is the most evidence for inositol and then vitamin D, which again, a lot of these patients have vitamin D deficiency. And inositol is a supplement that does have some evidence for being helpful with insulin signaling and improving glycemic control. Quick question about inositol. Do you think there's benefit in it for people who do not have evidence of insulin resistance? I didn't look that deeply into their studies of where they were pulling the data for the inostral for that recommendation. It was not a strong recommendation. Yeah. I I'm looking back at the guideline right now. Yeah, it says potential for improvement in metabolic measures, yet with limited clinical benefits in ovulation, hirsutism. Okay. So mainly- So mainly it has potential benefit with- Yeah because I think there's a tendency on social media especially to oversell the potential benefits of a supplement. And so I, I think when people even hear "Oh, there's like a supplement that can help with PCOS," in their mind they probably have this perception of like it's going to help with my whole condition. But I think with inositol, my suspicion was that it's very, the benefits are limited- Yeah to one category. That was my understanding too, 'cause it's a, it's involved in insulin signaling. So it makes sense to me that it would only affect- that component. In which case you may be considering metformin for this patient, and that is a far more evidence-based Yeah recommendation. So- Yeah really, this whole inositol thing is not a, "Oh my God, what your doctor's not telling you," Yeah. Yeah. 'Cause like we've got actually better ways to treat that problem if you have it. Yeah. And then I'm gonna go next to exercise. So the same exercise recommendations that we have for everyone. Yeah. 150 minutes of activity. They g- you know, you need some some resistance training, some cardio. Resistance is particularly helpful for these patients because if you're building more muscle mass, that's improving your insulin sensitivity. Oh, and but I will say these patients may struggle more with- To build muscle mass building muscle mass. Although if you're hyperandrogenism maybe that's easier for you. I don't know. But I think that it's- There doesn't need to be any specific protocol of exercise or specific exercise you have to do. It's just the same recommendations that we have for everyone else. Because if you do the best you can from a lifestyle standpoint you will be able to get your best outcome, and then you'll see this is as far as I can get. And if you're still struggling, there are medication options. Next thing I'll talk about is sleep. So sleep is super important, as I mentioned, and patients with PCOS do have a higher risk of sleep apnea. And I think that we do not talk about sleep in rushed primary care visits unless that is the whole reason for the appointment, right? If someone's coming in for an annual, we're not necessarily asking all those questions. There's probably a review of systems forms that they gave you, and you checked chin, and you just checked any sleep problems, and you're like, "No." But, it needs to be more of a conversation. And I find that, like, when I'm talking to patients about this, I'm really eliciting the history. I'm asking them specifically "Do you have headaches in the morning? Do you feel tired early in the day, even if you've gotten enough sleep the night before? Do you snore? Has anyone ever told you they, you, they, you stopped breathing in your sleep?" There's validated screenings you can use. And I think that it's important to do this, especially if a patient has PCOS. But even if they don't have sleep apnea their sleep quality and quantity still matters. So good sleep hygiene minimizing caffeine, especially after morning all of that will be helpful to improve sleep quality and quantity, which is important for overall health. Medication-wise we talked briefly about metformin. That is the best evidence-based medication that we have for managing the metabolic effects of PCOS. It is off-label, though. It's not a FDA-approved indication. I think we all feel comfortable enough with metformin that we're not worried about it. I know there's some medications where people are really not comfortable with deviating from the FDA-approved criteria, but that is one that that is helpful. And I, I honestly think... and this is just me, this is not the guideline. I think we should be considering it earlier when someone- has evidence of insulin resistance. I don't think we should be waiting for their- glucose to go up to- Yeah pre-diabetic range. I'm just like, "Why?" There, there is evidence for metformin. So the specific guideline says, "Metformin alone should be considered in adults with PCOS and a BMI greater than 25, or metabolic outcomes including insulin resistance, glucose, and lipid profiles." Oh, so they're saying anybody with a BMI over 25 even. Yes. Okay. And, again, I don't love BMI, but I think if you tested those patients, they would have- Yeah some insulin resistance. Yeah, they're just saying that if they have this condition and they are above BMI of 25, that they probably have insulin resistance. Yes. Yeah. But, you can also just test it. Yeah. And metformin alone could be considered in adolescents at risk of or with PCOS for cycle regulation, acknowledging limited evidence. So there is even some evidence of regulation of cycles just with metformin. So that's something you can try if someone doesn't want to do birth control. You could try adding metformin and see if it can help regulate their cycles in conjunction with their lifestyle impact. And I think it's likely to help with... Isn't, doesn't that help with increased rate of conception when trying to conceive? Is- So- What's the story on that? I didn't pull this study, and I should have, but I looked this up before. Metformin improves ovulation and conception, but it doesn't improve live births. Oh, interesting. At least in the study that I looked at. But this would be something, again, to ask your REI if you have PCOS and you're struggling with conceiving. I think that's a very important reason to talk with them about whether you need any help to- Yeah make sure this pregnancy, not just that you conceive, but that it is, becomes a full-term pregnancy. Yeah. Because this is a condition that's affecting your reproductive system, so I think it's important. And I think there's this blame that people have of "Oh, I just didn't do a good enough job doing what I was supposed to do." Especially, if you have a second trimester loss, or any miscarriage it's just devastating. And it's this is a medical condition, we should support you with it. There is some emerging evidence for GLP-1s, SGLT2, and TZD medications. So these are all medications that impact glucose. So the GLP-1s, obviously, they impact glucose production in the liver in addition to their appetite suppression effects. SGLT2 causes a increased loss of glucose in the urine to bring down glucose levels. And TZDs improve insulin sensitivity. So these are all options if the patient cannot tolerate metformin, which is the b- biggest evidence-based option. I will say I have a lot of patients who don't tolerate metformin for one reason or another, and have chosen that they wanna go on a GLP-1. And I find that for patients with PCOS, they just need a little bit. A little whisper a little whiff. It, we don't have to do a lot. 'Cause the thing is, we don't wanna cause a bunch of problems with a medicine, with a bunch of side effects if it's not necessary, right? And I think especially because I'm not trying to get X amount of weight loss to happen, a little bit goes a long way to improving the metabolic profile. I guess one of my questions would be, and we talked about this in the GLP-1 episode, that weight loss for weight loss sake is not- necessarily a health benefit. But I do wonder, like we talked about how there's this feedback loop of- people gaining weight because they have the- Yes underlying insulin resistance, then that perpetuating more insulin resistance. So I do wonder if maybe the weight loss achieved with GLP-1s for somebody with PMOS is maybe actually more beneficial, than weight loss for somebody who does not have. So I actually think They may lose more weight just 'cause we treated their condition that was causing them to have gained that weight. 'Cause I have a patient, they did lose a pretty significant amount of weight, but it was on a teeny dose. A teeny dose. And so again, it's if we treat the condition- The body will likely settle back to its more comfortable set point, and that might be a lot of weight loss for some patients. Yeah. But I don't think we should push it by restricting i- on top of that where we're, really gonna cause issues with lean mass loss, for example. And again the evidence for this in PCOS is still very limited. This is not something where I'm like, "Everyone with PCOS, if they can't tolerate metformin, they should go on a GLP-1." That's not what I'm saying. And I think- we also have to be very cognizant of the weight cycling risks. Because these patients are going to be at a higher risk of those metabolic weight cycling things because we know if they start a GLP-1 and lose some weight and then they stop the GLP-1, they are very likely to regain- yeah Past where they were. And if they get into a weight cycling that's less healthy than just gradual or sustained gradual weight loss or sustained weight. And with GLP-1s, especially in someone who is maybe in the reproductive period, of course we have to stop a GLP-1 before trying to conceive. We don't have studies in use in pregnancy, and I don't think anyone's gonna do that study. Until enough people do it by accident, where you don't realize what happened. No I'm sure it's happening every day, but- Oh, it's happening all the time. But we just don't have the data, right? And If you're gonna be off and on that might have some issues. I'm curious if you think starting people on birth control, since it does, address some of the underlying hormonal physiology, ever ends up helping people reduce their insulin resistance or lose weight, or does it not seem to affect that axis? I've always thought of it n- that addresses that segment- Yeah, that- of the symptoms, and then, you can do all these other things to address the insulin resistance part of things. But I don't know, I was curious if it is all interconnected, if perhaps... Because when you address the insulin resistance, there's some positive effect on the ovulatory and, Correct dysfunction, right? Correct, yeah. But I'm just curious if it goes the other way at all, and maybe it doesn't. Yeah, I don't think so. Yeah. That kind of makes sense. But yeah, and I don't see anything in here about it, unless I'm missing it. But I think it's mostly, like you said, there's those two separate axes. But I think it's more likely that the... 'Cause the insulin resistance worsens the hyperandrogenism, which worsens the ovulatory dysfunction. Yeah. So I think it's, that's why it, Metformin might help that way- It goes that direction but it may not go the other direction, yeah. I guess that is a little bit more in the line of saying what is the root or what is the primary problem? Yeah. And the primary problem is more the insulin resistance and the metabolic dysfunction, which comes back to, In- why are we gaining? In a lot of cases. In a lot. But there are some people who don't have that as much. Okay, great, yeah. They have more of a, more of a, Yeah either androgen or- Perhaps me, yeah. Yeah. But I think in a lot of cases, I think- Yeah that is, is probably what's happening. And that's why I feel we can't just look at someone's A1C and be like, "You're fine," because- if they have PO- PCOS, they probably have insulin resistance. Like, why are we gonna wait for it to get worse? And yes, there's lifestyle stuff. Of course it's ultimately their decision. But I think a lot of patients would choose to be more aggressive on the insulin resistance to save themselves the risk later. And there's some evidence supporting that, right? Last thing I wanna talk to, talk about is just this idea of, oh, just lose weight, and it'll get better. First of all, of, weight loss is not a behavior, so someone can't just lose weight. It's not a thing where you're just like, "Let me just lose weight today." No, that's not how that works. The behaviors are what matters, and the behaviors of following healthy habits, getting enough sleep, being physically active that may result in some weight loss. The combination of doing those healthy habits and addressing insulin resistance with medication may result in some weight loss. But again, the weight loss didn't treat the condition. Now, for what you were mentioning where someone maybe they have insulin resistance that's caused weight gain- that made the insulin resistance worse. Maybe it will reduce the insulin resistance, but it- still didn't cure their PCOS. They still have it. And it's very important to- Focus on the behaviors, and then add medication to address it if behavior changes alone are not addressing the medical complications. What I was so excited to see when I read this guideline was that they specifically called out the issues of body image concerns with eating disorders, mood disorders, and the impact of weight stigma on these patients. Because as you alluded to I think a lot of these patients go into the doctor's office and I've seen this in a lot of my patients. They go in, their BMI is on the higher end. They're, reporting all these complaints, and they're just being told if you lose weight, it'll go away." No evaluation, no discussion. A lot of them, it's "Just take this GLP-1." And that's not how we evaluate and treat a condition, right? And it disproportionately impacts these patients especially if they're at a higher BMI. And those are the people who are in that subtype that has the worst metabolic outcomes. So they're the people who most need support and help with their metabolic health. Yeah. And we're just... a lot of doctors are just like, "Eh, just lose weight and it'll be fine." So I think that's really important, and I was really happy to see that they called that out specifically in, in these guidelines. And so they actually specifically said "Body image concerns and eating disorders are common, and a weight-focused approach rather than a habits-based approach is more likely to be more harmful." Habits-based approach. Okay. Yeah. So- I haven't heard that phrasing before, and that's helpful to think about. Yeah. So it's healthy habits behaviors. Yeah. What are the behaviors you can do? 'Cause weight loss is not a behavior. And for a lot of these patients who have high insulin levels, they will have to restrict immensely to be able to lose weight- with high insulin. So why not treat their insulin resistance in conjunction with, behavioral modifications, and that's gonna give them... it makes their efforts more effective. Because if they're trying and trying and seeing no improvement, Of course, that's, they're going to feel very down about that. They're going to have a lot of body image concerns, a lot of shame, and they're gonna feel very defeated, and they may just give up. Yeah and so- Yeah you're essentially setting someone up to fail when you- Yes send them out with that advice. Yes. And so I think it's, important to, to keep that in mind with these patients in particular. And they do have an increased risk of eating disorders, so we should screen. That was not in the recommendation specifically, but we should do. Okay, so what do you think we can learn from this conversation as doctors and humans? I think from the doctor side, we should take this opportunity with the name change to re-educate ourselves on the condition. Because even I consider myself pretty good at managing PCOS, but I learned some things. And I think, it's a condition that deserves more attention. It's a large percentage of the population that has it, and it has pretty significant impacts. And so I think we should, familiarize ourselves with how to diagnose it, how to treat it address wakes, weight stigma and bias that we might have. And then we can provide better care for patients. And I think for the patient side I think the increased awareness amongst patients from this social media explosion about this name change is hopefully a good thing in terms of making them aware of how to advocate for themselves. And hopefully some of the things we've talked about in this episode will help people also advocate for themselves. But I think the other important thing is social media may be a tool to learn and advocate, but it's not going to replace a proper evaluation and treatment. So DIYing, not recommended because you should get a full assessment. What doctor do you think is most appropriate to handle this condition? So I'm biased. Who should own this? I'm biased, but I think family medicine should own it. Okay. Because we can see them from adolescence when they are going through puberty and these symptoms are starting to become evident, and then we can continue to see them for the rest of their lives. And, we can get GYN involved if we need to, but we probably don't 'cause we can put in IUDs and we can prescribe birth control. We can do endometrial biopsies if we're worried about hyperplasia or dysplasia. And we can manage their metabolic health conditions and we, we do a lot of mental health work also, so we can help- manage anxiety and depression in conjunction with other mental health professionals. So I personally think it's family medicines, but I'm very biased because I'm family medicine. Good thing you're my PCP. But I think, I think the other thing is it's really unfair to expect a GYN or an endocrinologist to manage this by themselves. Because neither of them has training in the full picture. Endocrinology has a lot of training, but they're not putting in IUDs. Yeah. But, I think, Endocrinologists obviously are the experts in PCOS, but it is not possible for 10% of people to see an endocrinologist regularly for their care. That's a good point. That is a good point. And it's not necessary because this is not complicated. Yeah. It doesn't require you to be a full-blown endocrinology specialist. It just requires you to approach the patient with a knowledge of all of the potential complications and what you need to be monitoring, and then treat them. But of course, if someone is not comfortable or feels like they are not- able to handle it, I think I would start with endocrinology- Yeah to get a more full assessment. But if bleeding issues are happening, obviously GYN is very helpful, especially if the patient if there's any concern for uterine cancer. Obviously they need to see gynecology if you're not doing your own endometrial biopsy. But yeah. Yeah, I think this is where a lot of the problems arise because realistically there are gonna be a lot of family medicine doctors even that are not comfortable or don't have the most up-to-date information and knowledge about- the condition. And so in that case, it is gonna have to be a team-based approach. Yeah. And just in modern medicine, that's very hard to do people are in different systems. They're using different medical record systems. They're not communicating. They don't have the time or bandwidth to communicate with each other. Yeah. And I can absolutely see how patients fall through the gaps in that. Absolutely. So I really honestly, I think this is a case where we have to be the ones that shore up our knowledge and Yeah stay up to date and educate ourselves on this. Otherwise, that's gonna continue to happen, and people are- Yeah gonna continue to go to social media and start, going down more dangerous, potentially useless paths,- Yeah in trying to treat this condition. Yeah, and I think, that is our responsibility as doctors. Yeah. And I think if you're in primary care, This is just your job, and it sucks because people who work in employed primary care environments, as we both know, they do not have time for this. Yeah. To just stay the bare minimum up to date it's really difficult on top of the 100 inbox messages and- Yeah refill requests and portal messages and new results and squeezing in patients double-booked. I get it. I get why it's not happening. I'm not blaming the doctors. But it is affecting patients. So I think, for patients to be able to advocate for themselves I think I think the best thing a doctor could do is not dismiss someone who tells you they saw something on social media. Because they probably did it 'cause they were looking for help, and if they come in and they're like, "Hey, I saw this supplement on social media for PCOS, what do you think?" Instead of being like, "Don't buy things you buy, see on social media" be like, "Let's talk about the supplements that might be helpful and how they might help." And if you truly don't know, I think we were all taught the Rotterdam criteria. I know I were. Yeah, at least do that bare minimum. That hasn't changed. And then refer them to someone who can manage it better which, maybe endo, maybe GYN, maybe both. Yeah but we gotta do it. So how would you talk about this with a patient? What are the key things that you think we should be communicating when we're talking to somebody about this? I think the first thing would be to tell them, "I believe you" 'cause I think a lot of times these patients are told that what they're saying is not true. Particularly patients that are, higher BMI and have tho- a lot of those metabolic complications more severely, they'll often come in, be like, "I've tried everything. I can't lose weight. I barely eat anything, and I just gain weight." That is true. That's true, and I've heard doctors say in my training "That can't be possibly be true." Yeah. "Look at you," and that's just not helpful. So I believe you. Let's investigate the cause of your symptoms." "Let's get the history. Let's assess, your full menstrual health, your sleep, your current diet and exercise your work stressors, life stressors," 'cause that obviously has an impact as well. And then I think- Make the diagnosis. 10% of people will have it. And then at that point, once the diagnosis is made, I think the communication of the diagnosis is super important. I think I actually have had patients who I've diagnosed with PCOS and they still didn't realize it. So I think I, I think you just need to very clearly say "You have PCOS." Yeah. Because initially when I'm talking to them about it before I do the additional testing to rule out other things, I'll say "I suspect you have PCOS. I'm gonna do some additional testing." And then when I come back and I talk about the additional testing, sometimes I think I'm like, maybe I'm not saying it clearly enough and I think it's frustrating too when, They have clinical criteria that's been met, to which I say "I suspect you have PCOS." And then the labs come back- Okay and they're all normal. Normal, yeah. And I'm like, "Okay, so you don't have another cause, so you have PCOS." Yes. But I think they still think it's equivocal. Maybe. Which I can understand. They're like, "Oh, but the labs were normal," yes. Yeah, but the labs were normal. But no- Yeah it's like the labs were normal, so you do have PCOS. Yeah. That's right. There's no other cause for your symptoms. And I have been guilty of this also. I am sure that I have equivocated or not said it clearly. So I think we have to tell people "You have PCOS." "Here is what we need to do about it." And then, I'm gonna include in the in the resources at the end here some patient-facing articles about PCOS. Because if you don't have the time- Yeah don't tell them, "You have PCOS," and then nothing. Yeah. 'Cause then they're just gonna go on TikTok and put in PCOS, and God knows what they're gonna see. Yeah. Give them "Here are some things to read. If you need to do any additional tests, like if you wanna do some of those additional biomarkers let's get these additional labs, and then I wanna follow up with you at X time, and we can talk about your questions." And then you have some dedicated time to really get into it, and after they've read it, they'll probably have more questions. But at least you've sent them to a place to get information, instead of just- sending them into the ether. I think that's also... those resources are also great for people who maybe just don't feel comfortable doing all the treatments, maybe they don't do IUDs, or they don't do... like you said, Yeah one person may not do all of the things necessary. But just being able to give them that doesn't take that much extra time, to point them to a resource. And at least then you've directed them somewhere, that's great. Where can people go for more information? Where can they find those things that you just mentioned? I'm gonna be putting all of the resources that I mentioned, the articles that I talked about today that I referenced and some people to follow on social media on our Substack. And so you can find that Substack at www.theantisocialdoctors.com, no hyphens or anything. And you can also subscribe there for updates, where you'll get all of our new posts emailed to you so that you can quickly access them whenever they go live. Okay. That was an awesome episode. Thanks, Rebecca. Yeah. Thanks, Sonya. Hey, guys. Last but not least, we have a very important disclaimer. This podcast is intended for educational and entertainment purposes only. 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