PCOS, or polycystic ovarian syndrome, is a common diagnosis that affects a lot of women, especially when they’re trying to conceive, and unfortunately, most of us don’t know too much about it. What does it look like? How does it affect our bodies? What causes it? Or how can we manage it with lifestyle changes and medications? This topic we are discussing today is near and dear to all of our hearts. Our guest today, Dr. Kimberely Thornton, is an RMA physician, a board-certified reproductive endocrinologist, infertility specialist, and a board-certified obstetrician and gynaecologist, and has served as a faculty member at Mount Sinai Medical Center.
PCOS, or polycystic ovarian syndrome, is a common diagnosis that affects a lot of women, especially when they’re trying to conceive, and unfortunately, most of us don’t know too much about it. What does it look like? How does it affect our bodies? What causes it? Or how can we manage it with lifestyle changes and medications? This topic we are discussing today is near and dear to all of our hearts. Our guest today, Dr. Kimberely Thornton, is an RMA physician, a board-certified reproductive endocrinologist, infertility specialist, and a board-certified obstetrician and gynaecologist, and has served as a faculty member at Mount Sinai Medical Center.
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Speaker 2:Hi everyone. And welcome to fertility forward. We are part of the wellness team at RMA of New York, a fertility clinic affiliated with Mount Sinai hospital in New York city. Our fertility Ford podcast brings together advice from medical professionals, mental health specialists, wellness experts, and patients because knowledge is power and you are your own best advocate. Dr. Kimberly Thorton and RMA physician is a board certified reproductive endocrinologist and infertility specialist, and a board certified obstetrician and gynecologist and served as a faculty member at Mount Sinai medical center. Dr. Thornton completed a research fellowship from the Howard Hughes medical Institute at Florida state university, where she graduated cum laude with honors. She went on to earn her medical degree at FSU. And while in medical school, she was elected by her peers into the gold humanism honor society in recognition of her services to others, as well as professional virtues of compassion, integrity, and relationships with patients. Dr. Thornton completed her residency in obstetrics and gynecology at Albert Einstein college of medicine Montefiore medical center, where she also served as the administrative chief resident for subspecialty training and reproductive endocrinology. And infertility was also completed at Albert Einstein college of medicine, Montefiore medical center. Welcome to this podcast, dr. Thorton. Nice to have you. Thank you for having me. I'm excited to join. We're so excited to have you and talk about a topic that I think is near and dear to probably all of our hearts, although I don't know the right language, but something that affects so many people I myself was diagnosed with. TCOs ditto myself as well. Me too. So we all three have that. I mean, that's kind of crazy. So we have three women here, all of the PCs diagnosis, and I think it's so common, but something a lot of people don't know about or they hear it and they have no idea. So let's kind of dive right in and help people sort of understand and shed some light on what TCOs means. So he CLS, you know, stands for polycystic ovarian syndrome for people who don't know in general, I feel like it's a really bad name because it causes a lot of confusion with patients will come to me panicked and they're like, I having trouble. My periods are irregular because I have all these cysts and really that there's all these pathological cysts on the ovaries. It's really that women have a lot of what we call follicles, which are these cavities that normally come to the surface each month. But it's really more of a metabolic dysfunction where it kind of the eggs start to grow. And you see these follicles are quote unquote SIS, and then one isn't really getting released or obsoleting on a regular East S so there's other SQL, like people often will have elevated androgens or male hormones, or they'll complain of acne or hair growth and usually regular cycles. And I see a lot of those people because sometimes they'll have trouble getting pregnant and the majority of the ones I see, but also sometimes people will just come in for an evaluation who aren't even trying to get pregnant because they notice their cycles are very, very irregular. So I don't know if you want me to kind of jump in more and that like medical, that diagnosis, or if you had specific questions or where, where you guys want to go. I know you'd mentioned before that it's, it's a strange name and I'm with you. I feel like it could be quite a confusing name and maybe this could be something that you could speak upon. I believe for a diagnosis, you have to have to have the symptoms that you had mentioned prior the androgen ism and potential the fluids. So not necessarily cyst on your ovaries, but there's a bunch of symptoms and it's not necessarily the cyst on the ovary. So the name I'm assuming it's probably, it should be called something else perhaps, but how can you diagnose it? What do you need to have? That's a really good question. So what most OB GYN views as the diagnostic criteria for TCOs is something called the Rotterdam criteria. Now the Rotterdam criteria consists of three things and you have to test positive for two of those three things. The first one is irregular menstrual cycles, which can be very irregular. Some people will say they never get it, period, or they go multiple months without a menstrual cycles or some women it's just that their cycles are maybe a little bit longer, or maybe they're a month and a half. In general. We talk about the definition being that they typically have less than eight menstrual cycles within a calendar year, but there is some variability on that. The second symptom is what we call signs of elevated androgens. Androgens are basically male hormones, things like testosterone DHAs and so symptoms. And that can either be clinical meaning. Sometimes one of them will say, well, I have hair growth on my lip or on my belly. I'm always seeing or doing electrolysis. Some people will complain a lot, or sometimes it can be hair loss or like all sitting around, you know, the hair line. Some women don't have any of those symptoms, but you can check their blood and they may have elevated testosterone or DTAs levels. So you don't actually have to have both to meet the criteria, either the blood or the clinicals and people do have both don't have. And then the third criteria is what we call polycystic ovaries on ultrasound. And so that's where we get back to kind of those follicles or those potential ads. They look like little black circles. And if you have 12 or more on one that meets the criteria or else also the ovaries are often a little bit bigger. So we call 10 centimeters. If it's that size or larger. Also the criteria for PCOS, polycystic, ovarian ovaries have a very distinct, I guess, look on ultrasound. Sometimes people also say like a string of Pearl signs, meaning that we see all those little follicles or potential eggs, really at the periphery of the ovary. Now PCLs is also a diagnosis of exclusion. Meaning you may have two out of those three categories and need that Rotterdam criteria, but we have to rule out any other potential causes of irregular menstrual cycles or have those elevated androgen symptoms. So things like your thyroid elastin, it's a milk hormone. If it's elevated, sometimes causes you regular mentees. We want to check and make sure that the level of the androgens aren't high, what were their concerning for like a tumor level, all other things that could potentially mimic DCOS. It may not. It's something that's hereditary. So that is a very good question. We actually do not know what causes PCLs for all of our fancy science and research. It's really the, one of the most common gynecological disorders. And we actually do not know what causes it to date. It has not been linked with like any sort of gene that we can test for. And there is no screening recommended genetic wise for this. Although there often is a family history. So it doesn't mean that there will be, if you don't have one, it doesn't mean you don't have it. But I have a lot of patients that have a mother sisters with all very, very similar backgrounds. So that would be a genetic component to it. In terms of PCLs also, do you typically see patients that struggle with their weight or perhaps gain weight more easily? Yes. And it kind of goes back to the metabolic dysfunction of this disorder, especially obesity in the abdominal or truncal area. Women with DCOS have a harder time weight often, and they tend to gain weight specifically in that area. A lot of women with PCOS have something called insulin resistance, which we have a lot of this insulin hormone, which normally tells ourselves to kind of pick up and to use glucose. And so our cells aren't as reactive to it. And so that also kind of goes along with people are more likely to be obese when they have this. If someone is obese, though, it does not mean that they have PCLs it's about 20% of women with CCOs are actually not overweight and are normal weight. So it's not diagnostic. It doesn't mean you have to be overweight to have it, but there are, there are all aspects of it. So if you had a diagnosis, the Pecos does that automatically mean you're going to need assistance to conceive that you want to go to conceive naturally? No, it doesn't. So people often do have a harder time getting pregnant. So the main thing that happens that makes pregnancy harder are pituitary each month. Normally let's say if you're having a natural cycle releases, hormones called FSH and LH should tell our ovary to kind of start to grow an ag. And we usually start to grow this whole group that comes to the surface because as women we're born with every egg we're ever going to have, and then they're kind of sleeping or dormant or what we call immature in our ovary. And then normally this group grows. And our body's kind of like, I like to say, we're not puppies. We're not kittens. It doesn't want the whole group to grow. So naturally it usually selects one egg to continue to grow and get released. Like, can you see those eggs start to come to the surface, but then it stalls there and the one doesn't take off and get released. And so that is why menstrual cycles are often really irregular. Menstrual cycles are irregular. It's almost always a sign that you're not oscillating on a regular basis. Typically have causes what called your progesterone hormones, right. To be elevated. And then you either get pregnant and it's going to stay elevated and you're not going to get a period. Or if you don't get pregnant, that hormone falling down is what brings on your menstrual cycle each month. And so we bought PCLs often do opulate. It doesn't mean that they don't ever there's some severe cases in the sense where people may go months and months and months without a period. But often people will, at some point, it's just that oblation doesn't happen on that regular. They don't usually have their 28 30 day cycles where at mid ovulation happens, mid cycle is eight, 14, 15. And so it can line up and somebody may get pregnant and opulate PCLs and we don't want to be pregnant. You shouldn't think, okay, I don't need any sort of birth control or contraception. You should be very mindful of that, but it can make it harder to get pregnant. I like to say, well, if you're ovulating every month, that's what 12 opportunities a year to get pregnant. You're only going to get pregnant a few months, you know, the few days of the month guess being released. And so that starts to space out over much less timeframes in the year. And that's a plus opportunities. And B it's really hard to time in our force to know to mine things up for pregnancy. So while it doesn't mean someone definitely is going to have trouble, they often do have a little bit more difficult time because of that population. It's interesting. A lot of the patients that I see who have been diagnosed when they're much younger before they're thinking of starting a family, they get diagnosed as teenagers and they get put on the birth control. So the birth control helps regulate their period. And then they decided they want to get pregnant, get off birth control. And like don't even realize that their, their oblation again, sometimes can not be as constant. And then I always wonder why a lot of times the doctors don't always speak about it way back when, when they're teenagers. And unfortunately, a lot of times it happens when they're trying that they ended up going back, whether to see a reproductive endocrinologist or to their GP. And they're like, what's going on with me in general. There's just not a lot of good education. And who probably in the medical field is don't do enough awareness about PCLs. I think that that happens to me all the time. I see a patient who was like, well, my periods were always irregular when I was younger. So I was put on the pill and now I went off of it and they're still, I thought it was going to fix it. They were regular all those years. And now it's not birth control pills are not bad. They are actually really helpful if you don't want to get pregnant with DCOS because they increase something called sex hormone, binding globulin, which is basically what binds your free androgens or your testosterone. And so it drives down and it helps get rid of those type of symptoms. And it helps regulate your menstrual cycles. You're not obsoleting when you're on the birth control pill. So that period is not like, I guess a true period per se, like when you're not on the pill, but it makes you have a withdrawal need because it has progesterone hormone in it. And you worry, if you go too long without having a period over years and years, it's not good for that lining of the uterus will tend to need to go cancer. So birth control pills are great for people if DCOS, who don't want to get pregnant, but sometimes people are not educated well enough to, well, what's going to happen when I go off the pill, what do I need to be thinking about in the future? In most people, some people cycles will be a little irregular when they first go off the pill, but in general, most people within about three months, their cycles really will come back. And so if it has an, at that point, it's really time to see a fertility specialist. And that's how I actually do a lot of young women with really aren't even thinking of pregnancy. Some people really great. They haven't really good, an OB GYN. It's like, Hey, just go see someone to talk about down the future so that they know the things to kind of look out for. I would say, that's something, I see a classic story. I hear all day long. And that's actually what happened to me. I was on, I never even know. And, you know, until I was a fellow in reproductive endocrinology as a doctor and OB GYN, and I didn't even know something was wrong with me. So I totally understand how that can happen to so many other people. Yeah. So crazy. I remember I was in college at the GYN. She said, Oh, it looks like you have TCOs. And like, that was it. End of sentence. End of story. I didn't know what that meant. And then it wasn't until years later when I was trying to get pregnant and then had to go through IVF and I understood more of what that meant, but it was like, Oh yeah, like that's it no information. And it's only been through my own research to figure out how to manage it through diet and exercise and kind of, for me, what works is a combo of Eastern and Western medicine to manage it. But then I find there's such conflicting information and I think people should be so much more prepared. I'm with you. Rena. I have had a similar experience where they diagnosed me, but didn't really tell me so much about it and how it could be potentially managed through diet and exercise. And also they had mentioned that I had something called mild or slim PCOS, and that's still something that's a little bit confusing to me. Is there anything that you'd like to speak on dr. Thorton about that? Yeah. I think a lot of people have this misconception that if somebody is thin that they don't have PCLs and like I mentioned, there's a huge chunk. Almost a quarter of people are not overweight. And I think we know that diet, obviously you're really the expert on this by diet and lifestyle modifications can help them not there unfortunately is no cure nothing's going to ever make it go away, but there are things you can do to make it better or things that you could do to make it worse and worse is going to be carbohydrates or eating a lot of desserts and sugar and all of those things. And so at the core of it, somebody can be thin and still have insulin resistance or still have elevated androgens and have those components. And I don't know if it's really a Milds or slim version in the sense that you have it or you don't have it, but some people are able to manage it better. And I find that I actually encounter some patients that I feel like I've almost self manage them themselves. They're like I always gaining weight. They don't even realize I was doing all this exercise and I was cutting back carbohydrates. And sometimes it just kind of self treated themselves and those aspects. And then of course there's some people who will diet, exercise, do all the right things and still maybe have higher cos associated with more likely develop prediabetes or elevated sugars or still have this regularity. So at the core of it, it's not just like lifestyle helps, but it's not that people have this misconception that I was overweight. So, you know, and this was, they're aggravating it, making it worse, but it was always there at the core, I guess, if that makes sense. It definitely makes sense. And it's interesting because I also feel at least with my patients who are coming in and struggling with losing weight and they come to me and they say that I'm really dieting and I'm working out a lot and I'm still not seeing the weight loss results, but it's interesting, I've noticed. And I, it would be interesting to do more research on it and I've seen some research on it, but in terms of sometimes that heavy, very intense high impact exercise, I don't always see as much success with my patients. And I wonder if that may be, can create more inflammation in their system. And also I feel on my patients who do a lot of low fat foods or fat free dairy, often struggle more with weight loss. And when they action, I know I've spoken to dr. Thorton when you were pregnant in terms of going for a fuller fat dairy, which has less of the testosterone or the androgens in the fuller fat dairy that sometimes patients can see more of a relief. And also when they do a lighter type of workout, that is not so high intensity. I think there, you touched on something, the inflammation, and I know myself the past few months just in sort of like the lifestyle change in the pandemic, prompted me to start researching for myself and then it sort of track what's going on on that patient. And I'm lucky sometimes in that my personal and professional life can bleed together. And so I started really delving into research about inflammation and stress and all that to better serve my patients. And then I uncovered a lot of information about how PCLs plays a role in all of that and everything I've uncovered basically says as much as we love cardio for the stress relief, it's really not serving us in terms of any sort of weight management and strength training is really the way to go in terms of losing weight. But of course you, don't, it's harder to get this sort of endorphins from strength training. So I think probably if you're someone who copes with a lot of cardio is to get that balance. But I think it's contrary to what I think a lot of people do, which is they try to starve themselves and then do a ton of cardio. But that's really the worst thing you can do for sure. I agree with arena, but it's interesting because I think, and I'm sure you, both of you guys have seen this, that just like anything, every patient, every person is different and everyone's needs are different, their diet, their exercise or lifestyle. I'm sure their medication could be a good segue in terms of how do we manage PCLs and I know we mentioned the exercise and the diet, but dr. Thorton, is there a typical protocol that you take? Yeah, so I think we touched a little bit on, well, I kind of put people into categories trying to conceive for not trying to conceive really first line therapy for like we talked about for people not trying to get pregnant really is birth control pills. And if the hirsutism symptoms are really not controlled with birth control pills, some days we think of adding other medications, something called like spironalactone that really drive down those androgen levels, those medicines concert defects. We can not be having somebody on them who wants to get pregnant and birth control pills themselves, and really counterproductive to people who want to get pregnant. So that's really for know that circumstance when someone's ready to try to conceive, we usually have obviously lifestyle management is important as well, but a lot of people, their cycles are still going to be regular, even with lifestyle modifications. And so really after that, we start to think about what we call population induction. That first line medication for PCLs is something called Letrozole, which is an aromatase inhibitor, which basically means this medicine actually kind of temporarily lowers the estrogen level in our blood. And so estrogen comes from our ovaries and our eyes, and it basically tricks the brain into thinking kind of like, well, our ovaries are not working. And so then it gives a booster of those natural FSH, LH hormones. And so we usually can kind of overcome that dysfunction of that group of eggs started to grow, but stalled and get that one to grow. And there is another pill medicine called Clomid. I actually, I find most people are more familiar with Clomid and Letrozole cause it's one of the oldest fertility drugs, and it's been around a lot longer. It works very similar to latches all, but most of the new studies have shown for TCOs Electrosol is considered superior. It has been shown to have higher birth rates and observation rates per cycle. Of course, though, sometimes somebody doesn't do well has side effects. We can always switch out one versus the other, but really let's resolve. If I know someone has to DCOS is the first mean medication I'm going to put them on and kind of go from there. Hopefully a lot of women will conceive after regular oscillation, but if it's a period of time and we're checking, we know AutoNation's happening, the pill is working. Then sometimes you do have to think of more aggressive options. There's what we call Kanata trophons or injection medicines that we typically reserve for IVF because he broke quite large groups of ads. Some women will take that just to have intercourse, but the risk of multiples is pretty high. So it's usually very hard to control these days. We really courage using those for IVF. And that's really our kind of most aggressive treatment options in the fertility.
Speaker 3:I'm going to talk about Letrozole. That it's interesting. How lectures all
Speaker 2:A much newer. I know Clomid was something that I was put on initially before I went to RMA as a patient is because it has less side effects. That it's something that we typically use more now, or is it because we've just seen more success? The main reason we're seeing it more is the studies show that there's just been more success. That's great. The side effects are pretty similar between the two of them. People get hot flashes. You feel like warm the five days you're taking it. So it was a way some people do feel mood fluctuations from the kind of spike and formulas. And there isn't, there is still an increased win rate with these fill medications because sometimes it's the one I drove, but sometimes the second one makes me in there and usually not much more than seven to 10% risk of multiples, but that's still much higher than if you weren't taking patients. So there is still some risks. And what about Metformin? Because I know recently they've been saying Metformin, you can take, I would put a Metformin when I was trying to conceive, but I know you can just sort of take it continuously to manage it if you're not trying to conceive. So Matt Wyman is actually, it's a diabetes medication and it actually makes the cells more sensitive to insulin. So it really helps with that insulin resistance. I don't want to see me put everybody with PCLs on Metformin, but there's definitely a group of women who really do benefit from it. So anybody with UCF, I guess, to back it up a little bit, you are more likely to develop prediabetes diabetes swept down the road. Also other health things that people should be aware of your higher risk for developing cardiovascular disease or endometrial cancer, kind of like we talked about earlier from the long periods of population, but it kind of on this insulin resistance and potential prediabetes diabetes era, it's really recommended that somebody's TCOs has some sort of screening for their sugars or for diabetes, whether its with a hemoglobin A1C, which is a lead test that kind of gives your three months sugar average or what we call a glucose tolerance test where you kind of drink a sugary liquid and they check your blood every two hours after it really should be screened for that. If there's any signs of, especially pre-diabetes, then it's really indicated to start that Metformin. It's not standard that to check insulin levels, but if that were checked in there, even if someone's not in the prediabetic range and there's concerns there, it's also very much indicated to start Metformin. So those are the circumstances where I would say it's always a definite as far as for fertility itself in like making someone ovulate. If the studies really have looked at just taking Metformin or taking Clomid or taking Letrozole and, and really foaming and lectures are both superior as far as getting ovulation and for pregnancy rates over math. But there is some evidence that Metformin can make people a little bit more sensitive to medicines that has a benefit over doing nothing. And especially for those insulin issues, it can be really, really beneficial in helping with that aspect of it. We know that insulin resistance is really what helps drive up those androgens. And so if we can help lower that we can help lower the androgens, which can overall just help improve unlike other diabetes medicines. One of the great things about Metformin is it's not like insulin where either taking injections where we worry about people getting hypoglycemia, low sugars, you know, getting cheeky or passing out that forming does not cause that. So that's a really nice thing about that. People do talk to me about that, but I think Metformin can be great in combination with changing one's diet to make sure that their carbohydrate intake is not an excess that you're choosing the right quality carbohydrates, higher fiber. And what I always mentioned to my patients is making sure that there's always a source of carbohydrate or healthy fat when the carbohydrates consumed also to help prevent that blood sugar spike or to help make sure that the increase of blood sugars isn't as fast. So quality, quantity, timing of day, and the hearing of it with a source of protein in conjunction with the medication. And in general, I don't usually just put someone on it for me if they're trying to get pregnant and nothing else, but it's often a good thing to add into the mix that's there, there really is a lot to think about. I think, you know, we sort of touched on, it really is individual. There's no sort of black and white treatment for PCOS and each person is different. It's really important to speak with your healthcare provider and figure out what's the best case management present management for you and cancer, such a ride. A definition of PCs includes such a large group of women that there are almost different subtypes. It seems like a PCLs within the diagnosis. And so yeah, in certain sense it does need to be tailored and based on an individual what's wonderful. Well, we got a lot of information from you today. We really appreciate that. I feel a lot more confident now with the subject as I'm sure Rina has as well. How we like to end our sessions is to discuss gratitude, but we're grateful for today. So dr. Horton, what are you grateful for right at this moment? I would say at this moment in time, I am very grateful for health and would say in the middle of the pandemic at something that I've been healthy and my family's been healthy and just grateful for the little bit of warmer weather today is a little extreme, warm and nice summer weather. It's been a little nice. I'm just grateful to talk about PCLs, it's something that I've known that I've had for quite some time, but it's always great to be reminded about what we can do. And as much as I wish I had known all this information way back when it's great to keep on top of it, keep abreast with all the information so we can better help the people that we come across in our clinic. What about you? I agree. I think one of those things of gratitude sort of from this pandemic is almost as like family time, you know, the past events been filling up with a lot of extra time to do research, to figure out how to better serve my patients and those around me. And I've really uncovered a lot of data and information about PCs. That's been really helpful to me individually and then sort of ripple effect to my patients in terms of CCOs or stress management, everything like that. So grateful for the research. So thank you so much. This is definitely something, you know, we can do part one part two part three, it's a really big subject and you know, a lot more to discuss. There's a lot of information out there, but make sure you, you know, you trust your doctor, you go to them for advice because there's certainly a lot on the internet and you want to make sure that you're really understanding what's best for you individually. And also if there's any questions about PCLs, you can always find us on Instagram at fertility forward and DMS with any of those questions, which can be very helpful to part two with dr. Thorton. Hopefully that's going to say I can do that. So just talking about what to eat with PCs, it's one of the most common questions I get. I know that's your up your alley for sure. Well, thanks for being on today and for giving us time out of your busy schedule. Thank you so much. Thank you so much for today and always remember practice gratitude, give a little love to someone else and yourself and remember you are not alone. Find us on Instagram at fertility underscore forward. And if you're looking for more support, visit us@wwwdotrmaandy.com and tune in next week for more fertility forward,
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