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Speaker 2Hey guys, this is Dr. Abby . Evelyn was another episode of fertility docs censored . I'm here with my friends, Dr. Carrie BDN of the fertility center of Las Vegas and Dr. Susan Hudson of Texas fertility center. Hey guys, how are you doing ? Doing good? Well, we are really excited because we have been in a hotel room in Las Vegas for the last two days, filming several episodes of fertility docs, uncensored. And so this is our very last one that we're going to film right now. And so Dr. Hudson and I , Susan and I were talking about what we should do on our very last night out in Las Vegas. So we need to ask our resident expert . So is going to give us some recommendations, I think, well,
Speaker 3I mean, you two seem like the wild child, and so I'm pretty sure you should start your night at, at one of the lovely local bars and restaurants. You can always go down to the strip, which is nothing. If not entertaining. Um, my , um, my family at this point only goes down there when we have out-of-town visitors. However, it is full of any place you could ever want to eat. And the people watching is truly phenomenal. And so, cause you will see people from all walks of life, doing everything that they want. And then I think you guys should go to a nightclub there's haka song . There's a dozen other places. I'm a nerd. So
Speaker 2I say nightclub, what does that mean? Exactly? I mean
Speaker 3Like the full on nightclub where you put on a cute little outfit and shoes that are sky high and
Speaker 2Deep in my closet for those ,
Speaker 3And then you just go dance and you shake what your mama gave you. And then I'm pretty sure being the wild children that you are, that you should go see the thunder down under or the
Speaker 2So, okay. So give me, you know, I've never been to one of those kinds of shows I'm thinking you have. So tell me what those are like.
Speaker 3So I actually have not been, because I am, I moved to Las Vegas five years ago and at that point I was already
Speaker 2In tonight then. Huh? Uh, I
Speaker 3Don't think they allow children there and I'm pretty sure I have to babysit tonight. Um, but there is, I mean, there's really a lot of wonderful things. If you go down to the Bellagio fountains and just see the, I'm going to say this wrong, because I always do the , uh, Julie, Julie, Julie , um , glass flowers, and the Bellagio is wonderful. I have to say that's one of
Speaker 2The things I miss about the Mayo clinic. [inaudible]
Speaker 3All of the class, just the beer . I mean, it's really beautiful. Um, I really like the Cirque de Solei shows there's oh , which is the water show there's call , which tells us it's the only Cirque show to show a story with it. They've got a new mobster show. There's some of the music shows there's the impersonators. I mean, there's, there's a ton to do here and any fancy restaurant or food or even unfancied . I mean, the beautiful thing about Vegas is everybody has an extension of their restaurant here. So my husband and I love Chicago deep dish pizza, and there's a Giordano's down on the strip and you can get New York style pizza. You can get a Southern barbecue, you can get all sorts of things here. So Garrett's popcorn, which is a Chicago based popcorn. They've got a , uh , uh,
Speaker 2So if I wanted to gamble, where would you recommend that? I go to gamble ,
Speaker 3Uh, casino. So in the five years that I've been here, I, and before then I have never spent a nickel gambling. So there's a ton of places. Depends what you like to play. There's poker, there's blackjack. There's, rillette, there's all that .
Speaker 4It's a little odd when you come to Vegas and like the restaurant we went to last night, like there's this little side room, that's just a little miniature casino and that you can be gambling when you go to the pharmacy. And it's, it's amazing.
Speaker 3There are machines, whether those are slot machines or video poker in pretty much every place you go, whether it's the gas station or the grocery store. But at this point we never see them. I mean, my, my kids and I, when we're walking through grocery store or wherever it may be, it doesn't even register.
Speaker 2Well, I think one of the funny things, one of our earlier guests today mentioned that when people go to church, some churches even accept chips, chips from the casinos for offering ,
Speaker 3Hey, and it works. It totally, I mean, that's the, this city is in many respects , um, driven by the strip and the tourist injury in industry. Now there's a lot of other business and , um, and endeavors here as well. But, but that is a large part of what drives this town. And so even though the strip is a tiny little, three mile, three mile street in the entirety of Vegas. So most of Vegas has absolutely nothing to do with it, but many livelihoods do depend on that. And so, you know, poker chips are a way of life. Although I don't think anybody's ever coming to the office trying to pay their copay with blue chip,
Speaker 2Which brings us to our topic today. Our topic today is we're going to talk about irregular periods that we see that a lot in our practice. Um , I think probably a patient, at least in my practice that comes in, it's a common, common complaint, probably one of the most common. What do you guys think?
Speaker 4I'd say probably about half of my patients have had a history of irregular periods and part of what our job is, is dying to figure out what's causing those periods to be irregular.
Speaker 2So what are the kinds of things that you do to evaluate that for
Speaker 3History? It's always top of the line because you want to find out, have they always been a regular? Is that a new thing? You want to know what else is going along with it? Do they have,
Speaker 2So let me stop you there. Why is it important if it's a new thing?
Speaker 3Well, the first reason for a regular periods are particularly missed period. And this sounds goofy when you're talking about a patient, a patient population that is trying to get pregnant, struggling, but the first thing we always go to is, are you pregnant? Because sometimes women have been through so many false starts of, oh, I think I'm pregnant. They're not even checking the pregnancy tests anymore. And so they come in to see us and we find out, Hey, your parents are regular. We're going to check a pregnancy test and make sure that you really need us at all. Because if you don't, we're not offended.
Speaker 2So I have a funny story that I just thought of, as you said, that I had a patient who came to see me and she had been on a fertility medicine because she'd had irregular cycles. She was on Clomid. And for some reason she was really frustrated because the Clomid had just stopped working or cycles have gotten really erratic. And she was just so frustrated. And so we , we talked a little bit and then we went and do her to do our ultrasound. And we went in to do the ultrasound. We realized not only was she pregnant, but she was in the second trimester of her pregnancy and didn't know it.
Speaker 4I had a patient one time who came in for a new patient appointment. And she was probably between 32 to 34 weeks
Speaker 2Pregnant. Okay. Well that tops my story.
Speaker 4I put in the ultrasound and all I could see was the top of the baby's head. And it was like, oh, well, let's take a look with the abdominal ultrasound and see what we see. And, and sure enough, she was, you know, about a month away from delivering.
Speaker 2And I think sometimes we, as physicians have to remind ourselves to do simple things like that. Sometimes the answers right there, you just have to look for it .
Speaker 3One of my good friends in residency, she was like, oh, my periods are really weird. And I don't, I don't know. And I, and I immediately started going through that, well, we need to check these labs and we need to do this. And we knew that and you need an ultrasound and dah, dah, dah. Yeah. She was pregnant.
Speaker 2And she's like, could I be pregnant? And you're like, oh yeah, you probably could be pregnant. Yeah .
Speaker 4Um , so some, sometimes patients are pregnant and then sometimes there, there are other issues. So I think what we see most often is a condition called polycystic ovarian syndrome or PCOS, which I personally think is a terribly named
Speaker 2Condition. Why do you think that?
Speaker 4Well, to me, a cyst is something that's over two centimeters and shouldn't be there at the beginning of the cycle. Well, when we look at ladies ovaries with PCO S they actually have lots of little bitty, tiny follicles, so it should be poly follicular, ovarian syndrome. So whenever we're good , we want to have, actually, we would much rather have too many follicles, but not enough. That's a whole lot easier a battle for us to
Speaker 3Fight the
Speaker 4Alternative . And on that other end, sometimes people who are having those irregular periods may have diminished ovarian reserve or ovaries that are acting older.
Speaker 3Sometimes it is caused by a, a breakdown in communication between the hormones being produced by the brain that typically communicate with you ovaries and those hormones just aren't being produced. And that can be from either a malfunction of those particular organs, you know, product of a hemorrhage or infection, things like that. Sometimes it's a very low birth weight, or excuse me, a very low regular weight, not birth weight. And I was thinking you are for that one , um, very low weight. All of those things can, can make a difference.
Speaker 4I've even had a patient who was actually born with a little defect in her brain that, that suffered that connection. And so that's the reason why her periods weren't happening regularly.
Speaker 2I feel challenged sometimes to explain kind of that in detail to patients. And so the way I kind of put it, and maybe this is simplistic, so I can understand and explain it better. But I sort of say that, you know, with PCLs you have most women have lots of eggs. In fact, sometimes they have more eggs than the average person and eggs are like seeds in the soil and they're there, but they just don't have the water and sunshine to make them grow. And so the water and the sunshine comes from the hormones in the brain and it helps us seeds grow. And so really what we do, I think in our practice to try and get those eggs, to develop and mature and grow and bloom, if you will, is we have to figure out what medicines we have to give the patient to make that happen. So I feel really optimistic when I see patients that have PCOS because you know, it's to me for most patients and you guys correct me if I'm wrong, but for a lot of patients, it's a fairly easy fix.
Speaker 4One tricky thing about PCOS though, is, is it can be a little , um , laborious for us to actually diagnose it. Cause it's not just one simple thing. How, how do you diagnose PCs?
Speaker 3So go by the Rotterdam criteria goal is to make sure that they, number one is some of the clinical criteria. Do you have a regular periods, a regular periods. So outside of the window of 21, every 21 to 34 days or so
Speaker 2Too short, shorter than 21 days and cycles that are longer than 34 days. Exactly . So irregular periods is one criteria,
Speaker 3And then you need to also meet, I kind of feel like I'm on my board example .
Speaker 2Yeah . Sorry about that. We can, we can chime in , you have to have a certain number of microfossils or antral follicles to gather 12, 12, or more kind of puts you in that piece .
Speaker 3And then last is hyper Angenette hyper , um, or essentially male hormone levels that are too high in that can be a laboratory diagnosis that we make, or that can just be by symptoms . So a lot of women with PCOS come in and they have more hair growth on their upper lip, their chin, their chest, their back. And I'm not talking about the few random stray hairs that everybody is entitled to. I'm talking about a more complete development of those follicles into the terminal hairs that are the black really coarse hair. It's not the really fine hairs that everybody has on their , their face and their body, but the thick, darker hairs that, that once they're there, they don't go away.
Speaker 4The , the things also we can all, so look at someone who has severe acne. And when we were talking about those laboratory criteria, looking for actual hormone levels, like testosterone, D H GA , as in other things that may be elevated, that could be contributing to this.
Speaker 2And about 50% of the cases to patients tend to be overweight. And it's really hard to know if it's a cause or an effect, but we see at least that correlation of obesity. And it's kind of like diabetes. If, you know, if you know somebody that's gotten diabetes later in life, you can sort of get PCLs and then you can kind of lose it. So if you lose weight hormonally, you change. And a lot of times, or some women will start to ovulate then and have regular cycles. Whereas if you gain even as little as five or 10 pounds, it can put you in that range where you can develop PCOS. Again,
Speaker 4I, I often think of PCs as a spectrum. Not all Pecos women are going to look the same. There are some that are going to be a little easier to treat some that are going to be a little harder to treat. If I have a woman with PCLs that has 12 follicles on each ovary, that's going to be a whole lot easier situation than somebody who has 40 follicles on each ovary.
Speaker 3And also looking at, at the impact of weight, because many of the medications we give the weight of the woman involved makes an impact of how much we have to give and how well they respond. And so even just exercise as they're going through can make them more responsive and their hormonal system reacts better to what we're giving them to develop the follicle or egg that's otherwise not developing.
Speaker 4So kind of leading into that, it's thinking about what if somebody has PCOS , what are some things that they can do that will make either whether medications or lifestyle changes that will make them more responsive to some of the fertility medicines we give
Speaker 3Exercise is always first on the list of things that I recommend, because even if you're not seeing weight loss from the exercise, just the sheer exercise alone can start sensitizing. Some of those cells, particularly to insulin, which is tied into the system, we don't know the exact biochemistry and physiology of how S works, but we do know some of the things can mitigate it. And exercise is a big
Speaker 2One. And I think symptoms too, if women have higher insulin levels, it just simplistic way to understand is it just throws off your male hormones. You tend to have more male hormones. If you have higher insulin levels, exercise, burns , sugar, and it, and therefore you have less insulin. So it's really tied very closely together.
Speaker 4And so sometimes using medicines like Metformin can make a woman ovaries more sensitive to the medications. Um , that foreman by itself is actually pretty lousy at , at helping people get pregnant. Um, it may help you get a little bit more regular periods, but if you're wanting to get pregnant using fertility medications with the Metformin is really going to be a better combination than it by itself,
Speaker 280% of people actually opulate on oral fertility medicine. Um , we try and get the person's body to produce those hormones from the brain that are necessary to mature the ag . If that doesn't work, though, we can always just give that medicine, but it's in the form of an injection and it's a little bit more complex to do it a little bit more expensive and a little bit more risky to do that
Speaker 4Higher risk of getting too many babies. Exactly
Speaker 3The goal is for people to leave, leave our office and go back to their OB with one happy, healthy baby, no litters of children, which is actually more of a risk in PCLs when you're absolutely leave some of these advanced treatments with the injectable medications and insemination, or just timed intercourse. You have to be very careful that all of a sudden you don't go from zero eggs being produced to five or six X produced because I tell my patients, I don't want you to be on the cover of time, time magazine with six kids, and I don't want to be there with you. Okay .
Speaker 4That's what I tell my patients as well. Let's talk a little bit about what medicines we can use.
Speaker 2So Metformin, as you mentioned before, clomiphene citrate is a medicine that will help produce those particular hormones in the brain.
Speaker 3Letrozole is , is typically first-line for anybody who has PCOS , where we're trying to do oblation induction or getting an egg to be produced where it's not otherwise,
Speaker 4It's a little bit of a change in practice that we've seen happen over just the last few years used to clomiphene citrate was the, the main stay . But I think recent data is showing us that we're having higher chances of pregnancy and fewer side effects and less risk of multiples with the Letrozole.
Speaker 2So to kind of sum it up, I guess you can say about PCOS , generally, patients with PCOS have a really good number of eggs. It's just their brain. Doesn't really produce the hormones at the right time to kind of mature those eggs. And so that's in contrast to another dilemma that women have when they have irregular cycles. And that is diminished ovarian reserve that you've talked about before Susan.
Speaker 4So when ladies don't have many eggs left, the brain's having to work really hard to send those signals, to make the ovary produce a healthy follicle that month. And so sometimes as we are kind of leading into the end of our reproductive lives, those periods become more irregular. So it's important for us to, to figure out, you know, do we have too much or not enough because one of them, we have a little bit more time than the other. We need to be working on this yesterday
Speaker 3And diminished ovarian reserve. We typically diagnose that by doing an ultrasound and seeing very few antral follicles where those many potential eggs growing, or when the hormones coming from the brain have to be way overactive in order to get even something close to the normal response. So instead of levels being low of those hormones, we're actually looking at them and finding them to be very high because the brain is essentially yelling at the ovaries. Hey guys, do your job, grow me some eggs, and they're just not. So how
Speaker 2Do you figure it out if somebody got diminished, ovarian reserve,
Speaker 4Combination of ultrasound and blood tests? Um, I think none of our ovarian reserve testing is perfect, but when we put kind of the , the different tests together, I think we get a very good idea. Do we have a quality and or quantity issue or both or both? Absolutely. Absolutely. And then we have a very small segment of our population who have something that we call hypothalamic, amenorrhea, fancy word for saying the brain isn't sending the message to make us have periods.
Speaker 3And the nice thing about hypothalamic amenorrhea is that
Speaker 2There's a nice thing about upper limits .
Speaker 3I mean, it, it kind of goes up there with PCOS and that these women have eggs. They're just not being produced because as much as it has to , uh , as much as it stinks to have to give somebody medication in order to get them pregnant, oh , I'd much rather give them medication to get them pregnant with their own genetic material, if possible, because that typically makes them much.
Speaker 2So what you're saying about diminished ovarian reserve is there's really not a lot you can do about that. If you're a patient, is there anything you can take or anything you can do to enhance your eggs or increase the number of your eggs or
Speaker 3Most of the data on that is really not very strong. So you will see lots of information out there on various supplements and other things that you can do, you know, stopping smoking is a big one, cutting down alcohol. All of those things are going to help, but there's nothing that's going to truly recover the amount. So if you have two antral follicles, you're not all of a sudden going to go up to 12 .
Speaker 2So back to what you said before with PCLs , you have a lot of eggs, the good news about hops and then became gonorrhea is you have a lot of eggs, but unfortunately with diminished ovarian reserve, you just don't have a lot of eggs and there's not a whole lot you can do about it. So you might want to move to more aggressive treatment, maybe more quickly with that condition.
Speaker 4Correct. And with the hypothalamic game NRA, generally speaking, this is the one time that we probably lean towards the injectable medications and younger patients as compared to what , what we would do for somebody with PCLs . If we gave injectable medications to our PCLs patients, they would very likely way overstimulate and lead to that higher order, multiple situation. Um, but the hypothalamic amenorrhea patients really need a combination of hormones to make their ovaries respond correctly.
Speaker 2And just so our listeners will kind of get an idea of what a person looks like with hypothalamic amenorrhea. You guys would probably agree like somebody who's a marathon runner is a good example of at least the top is not that every runner has episodic amenorrhea, but , but it's patients that tend to exercise a whole lot. They tend to be on the thinner side of things. It's almost like the body saying that, you know, now it's just not a great time for you to be pregnant. Cause you're , you're, there's too much physical or psychological stress in your life.
Speaker 3Yeah . I mean, if you think about it on an evolutionary basis, the body wants to protect itself and you don't want to have to think about supporting a second life
Speaker 2When the calories, when you
Speaker 4Have physical stress.
Speaker 3Exactly. So if you are , you know, running a marathon each day or an ultra marathon, and you're extremely more meticulous about what you eat, then you are running a higher risk of having that. And again, it certainly doesn't apply to every athlete, but it is more likely to occur to them just because calories in it tends to be lower than calories out. And the body sees itself as in that deficit. And doesn't want to put itself where they're at risk by getting pregnant.
Speaker 2So Susan, if somebody asked you if a patient said, okay, yeah, maybe I exercise a little bit too much. And they said, what do you, what would be a normal exercise pattern over the course of a week?
Speaker 4My, what I encourage patients to do is life and moderation and
Speaker 2Moderation .
Speaker 4I mean , everything in moderation. So exercise is great for you when you're trying to get pregnant. Exercise is great for you when you're, when you're actually pregnant. Um, but it is not the time to start training for a marathon. It is not time for pretty much any type of exercise that has the word extreme in front of it. We want you to be safe and we want you to be healthy. And, and just like Carrie mentioned, you know, you're, you're essentially wanting to , to grow this little being within you and your body needs to know that you have enough reserve to support both you and that baby,
Speaker 2You know, in Nashville in April, we have something called the country music marathon. So my antenna goes up about January, February when somebody shows up in my practice and says, you know, my periods are really gotten crazy. And, you know, then I start talking to them more and they're like, yeah, you know, I'm training for the country music marathon. You know, sometimes it's just something like that. You think you're being healthy and you are, but your body just sees it as a stressor. And it just kind of shuts down your ovulation for a time period.
Speaker 4Absolutely. And I'd like to say that, you know, we don't tell you to stop absolutely exercising, you know, cause we know that people who do tend to like to run and marathons and things like that, that that's a huge stress reliever for those individuals. And so, but bringing it down a notch , um, can often help improve that fertility outcomes
Speaker 2And tell to patients too , you know, it's hard to know what the actual prescription is for each individual person, but I agree , you know, maybe exercising five days a week rather than seven days a week. And you know, I'm a runner, but I'm not, I don't run really fast. So somebody tells me that, oh, I run a seven minute miles to me that's pretty intense. So I say, you know, maybe 11 or 12 minute mile might be better than a seven minute mile. So it's the intensity of exercise. Um, there's data to show that there's the types of exercise are different. So if you're a runner versus maybe a swimmer, you know, you may have a different set point for the top of exercise and the amount that you can do. I'm in the foods that you eat too . And Carrie , what are your thoughts about that on the different types of foods?
Speaker 3I think it really depends on, on what you're looking at, whether you're talking about more of a PCFS picture or more of a hypothalamic amenorrhea picture for PCFS because it's so associated with insulin abnormalities. Oftentimes we want people to be more mindful of the simple carbohydrates that they're taking in and carbohydrates by themselves are , are wonderful. That's the immediate fuel for our brain and we need them. So you never want to cut them off completely, but making sure that you're getting them in a more complex form rather than I would rather see somebody eating a piece of legit whole wheat bread rather than plain white rice or a plain piece of wonder bread. Um, in comparison, your hypothalamic amenorrhea patients tend to not be eating enough in sheer volume. And they tend to be very restrictive with everything, particularly fats. And so they need to make sure that they are getting enough. Now, again, there is not a clear
Speaker 2Prescription
Speaker 3Prescription for if you eat X number of calories a day of which so many grams are carbohydrates versus fats versus proteins, that that will work so many times. I send those patients to a nutritionist to start gradually bulking things up because they're oftentimes very set in their patterns and they've been living this way for a long time. And it's, it's healthy in many respects, but it's maybe just not quite enough to support some of those higher level functions with them ,
Speaker 2The body , you know, and just as a side note in our neck of the woods, we have Kroger's and I don't, I'm not trying to play Kroger's here, but they have the little clinic and they actually have nutritionists in the clinics and Kroger's, and patients can sign up to see a nutritionist. And that's really cool through the grocery store. And you know, if you eat cereal, the nutritionist can tell you what, what type of cereal you should be eating. I think Hy-Vee in the Midwest also has a similar program like that too. So, you know, our listeners may want to check in their area because minute clinics have really branched out. It's not necessarily just treating saunas, saunas, sinusitis, and ear infections. They've branched out to treat, you know, nutritional difficulties. And I think a great resource for any of us. It's a great resource. So , um,
Speaker 3Cool things about particularly the nutrition is that oftentimes when a patient resets that in their life, they don't
Speaker 2Need us at all. Things fall into place. After
Speaker 3That, I had a patient who she had PCLs she really needed to lose weight before we could attempt any major type of treatment. And in the process of losing weight, she got pregnant on her own. Yeah. And that's the
Speaker 2Best that's happened more than once.
Speaker 3Yeah.
Speaker 2That's phenomenal. So ladies, it was great to talk to you about these different causes of irregular periods. I know it's helped a lot of our listeners and , um, I've enjoyed being with you guys in Vegas during the last few days. Any last words of wisdom,
Speaker 3It's a pleasure to have you both here, come back tomorrow.
Speaker 2That'll be, we'll be signing off for fertility docs, uncensored. Great to have you faith in next time.
Speaker 5[inaudible] .