Episode #364: Polycystic Ovarian Syndrome (PCOS)

26:33And while an individual's time is valuable, hers and mine, if we say that up front, I think that it helps to decrease a lot of the angst and the distrust and the frustration that a lot of patients tend to feel. Because I can be up front and say, this matters to your health and you matter to me and I want to help take care of you. It's going to take time if we're going to do a good job of this and also understand that if PCOS is the conclusion that we come to in this case, it is a chronic condition. It is not something that we're going to establish treatment plan for and that we're going to fix, quote unquote, not to say that you are broken, but we're going to have to address your goals and priorities and also identify risks and continually think about how we're going to mitigate those risks lifelong.

27:28Dr. Jordan Feigenbaum:It also is nice in that, you know, we don't want people to like have to spend their entire life in the doctor's office and, you know, go to the ends of the earth to access healthcare. But if there's a silver lining to all of this, you have more opportunities to interface with the patient. And when it comes to mitigating long-term risks and improving long-term quality of life, having more opportunities to get your foot in the door and, you know, come up with a shared plan. It does seem like that's much better than like, I'm going to see you once, I'm going to give you a prescription and then be gone, go on, go forth and prosper.

28:02And unfortunately, I tend to see a lot of that secondarily when a patient then represents later on, or maybe they moved and now they're establishing care again. And I just hear tales of, you know, patients being told that they had to do this particular treatment plan and that was it. And they didn't understand why, and they're scared of that treatment plan, or they don't fully understand it. So they don't like it. So they don't want to do that. And, and so it really sets the stage for a little bit of an uphill conversation, but, um, but that person in front of me deserves to understand what's going on with them.

28:38And, um, and if they will confide in me and give a little bit more time. I do appreciate the opportunity to do that over several visits.

28:48Dr. Jordan Feigenbaum:Yeah. Yeah. It seems like that has the opportunity, at least the potential to work better. Although as the amount of appointments increases, there's some level of attrition that happens. And so I could see that being a double-edged sword. When we talk about PCOS, invariably people are going to ask, well, what causes it? What's the path of physiology? What really is the root cause again? And unfortunately, we don't have a great answer for you. And we could write it off as simple as that and say, yeah, sorry, but we don't understand this completely. But I think we can get at a potential better understanding when we talk about this increased production of androgens by the ovaries and its subsequent disruption in the normal feedback loop that traditionally goes on between the hypothalamus, the pituitary, and the ovarian glands.

29:38Dr. Jordan Feigenbaum:I mean, that's happening on some level. And as you alluded to earlier, you know, normally females are born with like, what, one to two million follicles. And then by the time they hit puberty, it's 400 to 500 ,000. Hundreds of thousands. And then it gets less and less. And, you know, what is the difference in normal physiology during a menstrual cycle compared to somebody with PCOS? Because I think if we can identify like, look, traditionally we have these hormone changes, that's what normally happens. And then an individual with PCOS, these are the hormone changes that we're seeing. And this is kind of why that cycle starts and it's almost like a positive feedback loop that continues to progress unchecked.

30:18Sure. So it's a bit tricky to describe with words alone and is often best supplemented with a diagram or a graph.

30:27Dr. Jordan Feigenbaum:We need that one picture. Yes, with all the little peaks and troughs and all the roller coasters that tends to show us the relationship between estrogen, progesterone, luteinizing hormone and follicle stimulating hormone throughout a normal, quote unquote, 28 day menstrual cycle. that demonstrates essentially a lower estrogen state in the first half of the cycle. And as the follicles are being stimulated, you see increases in follicle-stimulating hormone. And then about halfway through this cycle, there are triggers that lead to a surge or a spike in the luteinizing hormone. That spike is associated with the ovulation event.

31:17And after which time there is an increase in estrogen production and all of these milieu of hormones are interacting with each other and causing a variety of different actions, reactions there in this feedback loops. And so if we take it back to kind of one of the fundamental elements of PCOS is this oligo or an ovulation, then what we take from that is that you don't have a normal low LH until it's time to spike. You don't have a period where there's lower estrogen than higher estrogen or lower progesterone and then higher progesterone. And there's a bit more of a static state where it is more of an estrogen predominant state more persistently without having that interaction to fluctuate and to kind of switch places with progesterone as a progesterone dominant state in that part of the menstrual cycle.

32:26And so, um, and that leads to, to one of the risk factors that we'll, we'll talk about here in a moment. But, um, additionally, the, the LH itself, um, is kind of at a steady state too. So it's not, it's, it's not peaking when it should. So it's not triggering that follicle to ovulate. And that was preceded by follicle stimulating hormone, not behaving normally to encourage that cohort to progress and so on and so forth. Um, and so you do find these periods of, of more static hormonal, um, statuses, which also speaks to the lack of utility of kind of measuring these things, um, in at, at any point in the workup, because none of those levels are going to be diagnostic or really helpful.

33:14Um, what's helpful is listening to a person's story, like what they're actually experiencing. If they're telling you they're bleeding, you can tease out more to determine whether it sounds like they are ovulating or not. And just as a plug to kind of get that out of some folks' mind that we don't need to be measuring every single hormone at play here. Just recognize that they are not interacting normally, and therefore the downstream effects are something that you experience and that you can glean through an interview with the patient.

33:47Dr. Jordan Feigenbaum:Yeah. I think when people are trying to wrap their head around this, again, and before we went on air, I was like, man, just trying to figure out this pathophysiology. If I could just understand it better, then I could understand the condition better. And you're like, eh, not really. I'm like, I know, but I just want to. Just to summarize for folks, there is this complex interplay between FSH, LH, estrogen, progesterone, inhibition. There's a bunch of other players there too, and they cycle in this very complex orchestrated month-long journey to ultimately produce a viable follicle. And then look, if that doesn't get fertilized, well, you got some changes on the back end of that too.

34:24Dr. Jordan Feigenbaum:That's the, quote, normal physiology. But instead of having this cyclical cascade of multiple things happening, it's pretty much static the whole way through. And if you had to take home one thing, it's like, well, LH is way too high. And FSH is well too – is way too low. And because LH is high, you get a bunch of weird things that happen. Testosterone levels are higher. Androstenedione, these are precursor pro-hormone to more testosterone-like hormones that those end up being higher. And so the outcomes from a hyperandrogenism standpoint, almost predictable. You're like, well, shoot, if my testosterone, my androstenedione is higher, all these things are higher.

35:06Dr. Jordan Feigenbaum:and FSH never gets as high as it should be. I don't get this ovulation event. Well, shoot, I'm going to have all these dormant follicles. I'm going to have all this excess testosterone. And oh, shoot, dang, that's kind of, that's PCOS. Now, I don't want to reduce PCOS to just that because it's much more complex. But I think if you wanted to wrap your head around it, like maybe you could do worse. You could do worse than that. Do you agree with that? I think you did pretty well. Yeah, that's a great summary. I spent a lot of time on OB. With respect to risk factors, here's where it starts to get a little weird in my mind because there are significant risk factors that are like independent of PCOS, the condition itself.

35:46Dr. Jordan Feigenbaum:And then there are ones that not only contribute to PCOS, like having it, but also like contribute to the severity of the condition. And so just to give an example, like genetics, certainly genetic targets, mostly having to do with like sex, steroid, hormone signaling, ovarian follicle maturation, insulin production and activity. Those sort of things, there's a lot of genetic targets here that when combined, it's not a single gene. One weird gene is contributing, but it's polygenic. That doesn't – it influences the likelihood of somebody developing PCOS and their course. But that's static. It doesn't really change over time, whereas something like obesity, you have a higher risk of not only experiencing PCOS, but the worse the obesity is also tends to make it more severe too.

36:32Dr. Jordan Feigenbaum:So it's kind of like works in both ways. When you think about risk factors and you're in a patient environment where you're explaining this to them, do you bring up risk factors at all? Or is it more like it's in the back of your head trying to say like, oh, this makes more sense why this person is experiencing this? Sure. So the main risk categories that my counseling will cover includes endometrial risks. We talk about metabolic health. We talk about psychological propensity towards stress, depression, anxiety. essentially tie those into, like you said, it can be linked to or tied into the diagnosis of PCOS.

37:16In other words, we're going to talk about mitigating risk and also addressing some of their symptoms that are part of their diagnosis or independent of their symptoms, say you have PCOS and therefore going forward, you do have an increased risk with regard to your metabolic health and your, and your, um, uh, health outcomes. Um, and so we talk about, um, healthy, you know, establishing what their, what their baseline for like physical activity is and healthy weight, um, and, uh, some strategies to achieve that as well as in terms of the endometrial health, we talk about, um, how we can try to prevent basically an excess of endometrial stimulation.

38:07So what do I mean by that? I mentioned that in PCOS, it tends to be a higher estrogen state. And especially if you are not having a period on a regular basis, that means that the uterine lining or the endometrium is not shedding regularly and therefore has the opportunity to overgrow essentially in what we would call hyperplasia. And hyperplasia exists on a continuum, which can lead to basically like a precancerous condition and ultimately endometrial cancer. And so this is not to say that anyone with a PCOS diagnosis will have or might have endometrial cancer. It totally depends on what their menstrual patterns are, how often they are having withdrawal bleeds and whatnot.

39:00But we talk about strategies for either regulating or just suppressing endometrial growth. And then to address the psychological risks, I think it's important to just take a step back and to identify the individual as just a whole person that is there to see me for this one thing, but it's really not just one thing. And depending on what their goals are or what their concerns are, what their insecurities are, what their hopes and prospects for whatever the future may hold, whether it includes fertility goals or not, whatever the case may be, it's important to just recognize that they are a whole person and to encourage just behavioral health resources to just have the opportunity to talk through these things.

39:50Because I just mentioned that it's a chronic disease as well, or a chronic syndrome, I should say. And so those are kind of the big categories for risk identification and mitigation. Circling back to the healthy weight part, I did want to mention that in patients who are overweight and obese, who do have some weight loss, that it is quite common to see improvement in symptoms, specifically symptoms of abnormal bleeding. So it is quite common to experience normalization of menses with, um, five to 10 % weight loss of, um, uh, adipose as well as improving fertility outcomes as well. Because if I, if I regulate your menses, um, well not me directly, but if your menses regulate because, uh, you had some weight loss, then that is telling me that you are probably ovulating on a more regular basis.

40:57And the more often you are ovulating and if you are engaging in unprotected intercourse, then the more likely that pregnancy can happen if that's what you desire.

41:07Dr. Jordan Feigenbaum:And the store comes. That's what you're saying. That's exactly what I'm saying. Yeah. I actually – this is a good segue because I didn't want to belabor the point too much on weight management, body fat management, body composition, or even obesity, generally speaking, mainly because in my, you know, coming up with this outline and working on this and relearning a lot of stuff that I had selectively blocked from my medical training, I became acutely aware that as far as obesity stigma goes or which weight stigma in general goes, PCOS may be like one of the most affected medical conditions by that.

41:47Dr. Jordan Feigenbaum:And I don't mean that just from like a general populist standpoint, but even amongst medical professionals, they see an individual with PCOS and the person may be overweight or have obesity, for example, and they're like, oh, well, just lose weight. Just lose weight, you know, and it's like, well, that may in some cases, yeah, lead to a big improvement in their the symptoms and help them reach their goals, whether it's fertility or otherwise, but the actual effect of obesity on this condition is far more complicated than that. And, you know, there's been a lot of research into this. Are the appetite-promoting hormones significantly higher in individuals with PCOS?

42:25Dr. Jordan Feigenbaum:Are the satiety or fullness hormones that people experience as they eat and when they finish eating a meal, are those lower, right? Is that what's tripping off this propensity to gain weight at a faster rate than individuals without PCOS or have more difficulties with weight management? Yeah, not really. There's been a lot of investigation here. But my point on saying all this is that we haven't had great treatments for obesity, you know, previously. It's mostly like, hey, have you considered exercise or eating differently? And it's like, yeah, dude, my whole life I've been trying this. And we've been limited with opportunities to intervene otherwise.

43:01And having gone to medical school together, Dr. Fagenbaum and I, we're speaking from the same era and literally from the same learning environment. But we now, me, as a board certified OBGYN, we don't come into this specialty and are armed with extra knowledge or information on how to effectively handle this particular topic. And it is something that I think that each of us need to take upon ourselves to stay in the know and to stay up to date with any other ways that we can approach this topic without coming off like in a paternalistic way or an overly reductionist tone to the patient too. because it's not her fault that she has PCOS.

43:53And while some weight loss can help with the symptoms, any weight gain that she's experienced is not the result of her in, you know, inactivity or sloth or decision to gain weight, whatever the case may be. And honestly, we just need to get smarter on how to address this in a multidisciplinary way and a multifactorial and really like in a biopsychosocial way. I mean, obviously I know that it's been discussed on this podcast and a lot just on the interwebs in general, but obviously with various weight loss medications that are becoming more and more popular. I did want to mention just that with GLP, one medication specifically that like with a lot of things in reproductive health or pregnancy in general, it's important to recognize that the side effect of some weight loss in a person who has had fertility issues can be increased fertility because of like a downstream effect, ultimately leading to ovulation, leading to that opportunity for the stork to come.

45:05And so, and at this point in time, we don't have any safety data really. We're in the information gathering phase for that. You may have heard of some ozempic babies and the like. There are registries for these things. So it's one of those things that I think that as time goes on, there will be more and more and we'll be in a position to try to speak on the safety and efficacy of that in the preconception timeframe. But for now, if someone's trying to conceive and you're on a GLP-1, it's advised to come off of it for a couple of months. And then the other thing I wanted to mention is just when it comes to weight loss surgery.

45:42Um, that's another thing that is not really, um, heavily, uh, anchored in our curriculum, um, just in medical school in general, and certainly not like an OBGYN training, but, um, but I am a surgeon and I have patients that can absolutely benefit from at least having a discussion with a bariatric surgeon to talk about some of the benefits of, um, of potential weight loss surgery and, uh, and just the myriad of, uh, health considerations that we can positively impact through that.

46:16Dr. Jordan Feigenbaum:Yeah. Yeah. And it's a great segue into our break. When we come back after this, we'll talk about more about PCOS and how to treat it. This podcast is brought to you by butcher box. One thing I try to stay consistent with is keeping enough protein in the house. So I don't end up ordering takeout a few times a week. That sounds simple, but between work and everything else, the grocery store trip is usually the first thing that gets cut. ButcherBox fixed that for me. They deliver grass-fed beef, organic chicken, wild-caught seafood, and more, all sourced to the standards they are transparent about.

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52:44Dr. Jordan Feigenbaum:Again, we're talking about PCOS and now how to treat it. So we're going to start with lifestyle stuff here. And when it comes to lifestyle-based treatments for PCOS, weight management is a big component for nearly all published guidelines. Now, most of these guidelines acknowledge that the rate of weight gain and the prevalence of obesity are higher in those with PCOS compared to those without. And in addition, excess body weight and body fat appear to increase the risk of not only developing PCOS and PCOS-related symptoms, but also increasing the severity of those symptoms. So the question to you, Dr.

53:17Dr. Jordan Feigenbaum:Baraki, is when it comes to lifestyle-based treatments for both PCOS and weight management in general, exercise is at the top of the list. Now, recent studies show that individuals with PCOS tend to engage in similar levels of physical activity and exercise as those who don't have it. But the problem with that is most people are not meeting the current physical activity guidelines. Most people are not exercising. So when it comes to counseling individuals with PCOS on exercise, how do you start this conversation? I would argue that it doesn't differ too much from anyone. That's a perfect response.

53:54Yeah, that is my answer is just that there's not a special treatment or a special approach or a special program that applies to patients who have been diagnosed with PCOS and that general health guidelines and general physical activity guidelines apply to this population as it does to anyone else. With the understanding that the prevalence of insulin resistance is quite a bit higher in this population and goes back to the conversation of expectation management and just acknowledging some things up front, including the fact that achieving your weight loss goals can and usually are a bit more difficult.

54:40And our timelines probably need to stretch out a bit more. But it's important to be encouraging and to not take those factoids as deterrence to getting started or to even moving in that direction.

54:55Dr. Jordan Feigenbaum:Yeah. Yeah. This actually brings up a bigger, maybe we'll call it a barbell medicine point if I can be so bold. Well, because, you know, people invariably will say, look, I have this medical condition. What specific exercise prescription, you know, do I need to undertake? And in the majority, but not all, certainly not all of cases, medical conditions, there's not really a unique secret sauce here when it comes to exercise prescription. It's generally the same as somebody who did not have that particular condition. And PCOS is exactly like that. There's not a particular, look, they need a particular split, particular amount of exercise or anything like that.

55:30Dr. Jordan Feigenbaum:We want people to first achieve this sort of minimum amount of exercise that's consistent with the current physical activity guidelines. And generally speaking, more would be better. We effectively want people to be as active as humanly possible, where the limitations are really logistics and then their physiological tolerance to exercise. The limit does not exist. The upper limit does not exist. But the if there's anything that's unique about this particular situation with PCOS, to my mind, it's mostly that we can use some of these long-term risks that are associated with PCOS as leverage during motivational interviewing.

56:06Dr. Jordan Feigenbaum:And that also tends to bolster people's understanding of the condition. So for example, you mentioned insulin resistance and you're like, look, insulin resistance is associated with the condition that you have. It can lead to type 2 diabetes. It can lead to increase rates of heart disease. It can lead all these other things. Exercise is a very potent tool that we can use to limit that, attenuate that, or even in some cases, reduce it back to what would be considered like baseline. Baseline. Same thing, body image improvement, if that's a big issue with a particular patient, their mental health.

56:37Dr. Jordan Feigenbaum:There's just so many levers that you can pull. And again, these aren't really unique to PCOS because this would otherwise be true of anybody, but because it is pertinent to this condition, you could use that theoretically in this motivational interviewing process. But there's not a specific, I'm not going to release a, you know, PCOS template. Like, look, here's the training that you need to do. It would more, if I did do something like that, if we collaborated and did something like that, it would look a lot like the rest of our exercise programs. We would just have more information about PCOS and how like, you know, this would benefit you.

57:10Dr. Jordan Feigenbaum:And so that would be the template. But the template wouldn't look really any different than a general template for strength conditioning that we'd release to the public. Absolutely. So buyer beware for that. That's just for you. Yeah. If somebody is putting out stuff that's like, look, this is you got to do this exercise, a PCOS patient like that's. Yeah, that's the red flag. If it's to lure people into this, like get more physically active thing, then maybe I don't know. I don't know that you need to use misinformation to get there. It seems a little sketch. I still don't feel good about that.

57:45Dr. Jordan Feigenbaum:It doesn't make me feel good. No warm and fuzzies from that. But maybe more important to this population with respect to exercise. Now, there's little data available on exercise counseling and prescription practices delivered to individual PCOS. But if you go to other medical conditions, whether it's heart disease, whether it's individuals with obesity, whether it's diabetes, unfortunately, you see the exact opposite of what you would want to see from like a public health perspective. If anything, you'd want folks with these chronic medical conditions and risks to be counseled more frequently on exercise than folks who are otherwise healthy.

58:18Dr. Jordan Feigenbaum:Of course, you'd want everybody to be counseled. But if you had to choose, you would want folks who stand to benefit the most, the most vulnerable populations. So the question to you, Dr. Baraki, is do you think that exercise is being discussed with the majority of patients with PCOS? I do not. I absolutely do not. Why do you think that is? Do you think it's because this syndrome is so complex? And to your point earlier, multiple sort of appointments and multiple like a pretty extensive workup and there's a lot of comorbidities going on. Is it because the complexity or is it because doctors look, we just don't know anything about exercise.

58:53Dr. Jordan Feigenbaum:And so we don't know what to do. I think it is twofold. I think that the thing one would be that there is so much to cover and there is so much on the interviewing and the exam side of the house that is going to take up time so that you can find yourself in a diagnostically appropriate place to then recommend a way forward for working this patient up. And then there is all the different interpretations and how do we apply meaning to these things? What does this mean to you? That by the time we get to treatments or interventions, we can be very well past a normal appointment time at that point.

59:35And the plate is very clinically full. It's not a great excuse, but I suspect that it is a very common cause for that to be nixed. And the other thing is that we tend to avoid the things that we don't feel super confident in just as humans. And that applies to physicians and health care providers as well. So that's thing, too, is just that if if we are not trained or don't feel super savvy in what to tell a patient that is meaningful or actionable, don't feel super confident in that, then we're typically going to skip over those things or leave them out. or at the very most, maybe provide a handout or a resource or something like that.

1:00:18That's not individualized or tailored to the patient. So I think it is both of those things synergizing to lead to that.

1:00:25Dr. Jordan Feigenbaum:So if you're a fitness professional listening to this and you have a client with PCOS, standard exercise prescription techniques apply. What amount of exercise are they willing to do or can they do based on their previous or current fitness level and resources? What types of exercise do they want to do? And you come up with a shared sort of plan for how that all shakes out. And ideally, that at least meets the current physical activity guidelines of twice weekly resistance training for all major muscle groups. And you're doing at least 150 minutes of moderate to vigorous physical activity. That's cardio.

1:01:00Dr. Jordan Feigenbaum:It only counts as cardio. And that's where you start. And ideally, you'd get them to do more and you'd monitor the results. Ideally, you'd like a program that makes them stronger. Ideally, you'd like them to be doing a program that makes them more fit from a cardiorespiratory standpoint. And you go from there. But there's no specific PCOS-related concerns to, ooh, don't have them do back squats because or don't have them do supersets because or something like that. There's nothing really there. So you can feel confident in your exercise prescription techniques provided that you're actually doing it.

1:01:32Dr. Jordan Feigenbaum:And that message is to our healthcare professionals. Make sure that if you don't feel comfortable doing it, no hate comms, peace and love, but a referral would be appropriate in that case. I did want to bring up something interesting, and I don't know that you're going to have expertise here, but I don't want to like box you in. But I thought this was interesting. It's about PCOS in sport. All right. So the proportion of women who engage in sports at all levels is at an all-time high. It's increased dramatically over the past 50 years, and this is reflected in the proportion of female Olympic athletes.

1:02:09Dr. Jordan Feigenbaum:This is probably one of the cohorts we have the most data in. So, for example, in the Summer Olympics in Munich in 1972, only 15 percent of all participants were women. In 2012, the London Summer Games, that increased to 44 percent. But it wasn't until this past Olympics, 2024, Paris Games, that we finally reached the 50-50 thing where half of all competitors were women. Hey, finally. Feels good. Yeah. Also, by the way, if you're keeping score at home, London 2012 was the first Olympic Games where women competed in all disciplines that men competed in. So just if you're keeping score at home about opportunities to participate in sport and how that may affect participation rates, well, there you go.

1:02:53Dr. Jordan Feigenbaum:Here's where it gets interesting. Amenorrhea and hyperandrogenism are far more common in female athletes than in non-athletic female populations. And in addition to that, ultrasound evidence of polycystic ovaries are again far more prevalent, about 37 percent of female athletes compared to the prevalence in the general population, which is about 20 percent. And so at the time of this recording, there's limited evidence comparing the true rate of PCOS in female athletes, but it does seem a bit higher. So in your opinion, Dr. Baraki, is there – is it possible that there's an athletic advantage to having PCOS?

1:03:32Dr. Jordan Feigenbaum:Is it the hyperandrogenism, for example, that may be advantageous or something else? Any insight there? I will acknowledge to your point that you're right. I am not an expert in this very specific question, not being boxed in. But I think that it's a very interesting finding. It is certainly hypothesis generating. And it takes us back to questioning or just looking at the diagnostic criteria, looking at the Rotterdam criteria to evaluate whether any of these individual components can be clinically reasonably explained by some other physiology or pathophysiology. physiology. And also kind of highlights the place that we find ourselves in that we have found ourselves in for decades now is basically like a chicken or the egg situation where is the insulin resistance leading to increased levels of LH, which is leading to ovulatory dysfunction and also just circling back to more insulin resistance and increased adipose and higher weight and obesity and cardiometabolic outcomes.

1:04:50Is that the cycle that we're in or are there offshoots of this equation, um, that are operating with a completely different rule book? Um, which I have, I have to believe that it may be more the latter, but there, it's certainly, um, interesting query and, and, uh, worth further investigation to know, are we talking, Are we on the same continuum or are we so far down in a different branch entirely that we're just seeing similar findings, but how we got there is quite different?

1:05:22Dr. Jordan Feigenbaum:Yeah. So I'm going to present two hypotheses. Oh, okay. And you get to pick one. Okay. Sounds great. With the full understanding that both could be wrong. To your point, I agree. More research needs to be done. And ultimately, this is a twud. It's a time wasted on useless detail, but like, you know, could be used. Maybe, maybe not. Look, it could be used as leverage during the motivational interviewing process for activity. Like, look, you got PCOS. You could be a world beater if only. Going to the very top. So here are the two hypotheses, right? Hypotheses number one, this is a teleological or evolutionary-based argument for PCOS.

1:05:58Dr. Jordan Feigenbaum:Like, hey, why does this thing persist in populations? Why? What the heck's going on? So is it the relatively high testosterone had conferred some sort of survival advantage to women in ancestral environments because they had increased strength, reduced fracture risk, and maybe the insulin resistance was actually adaptive to ameliorate some of the signs of low energy availability, for example, because that can happen. And so maybe this is like, look, it just persists. And now our ancestral environment, the closest thing we can get to is sport. And so women who are selected into sport, you know, they just they thrive.

1:06:37Dr. Jordan Feigenbaum:So that's hypothesis one. Sure. Just to like add a little bit more to hypothesis one, I have heard a semblance of that. And there's also like a layer of like war and famine and, you know, this mortal threat and also tying that into fertility or relative infertility and basically being a manifestation of basically genetics, getting it right and saying this is not a great time to reproduce. To reproduce. Yeah, yeah. To reproduce. Exactly. All right. So that's hypothesis one. We'll call it the evolutionary hypothesis. And then the second hypothesis is the artifact hypothesis. So, for example, amenorrhea being common is not surprising in sport due to the high volumes of intense training, perhaps with insufficient fueling, right, and the types of people that end up selecting themselves in the sport.

1:07:27Dr. Jordan Feigenbaum:And same thing for hyperandrogenism. People with – particularly women with high volumes of exercise and sport tend to have higher testosterone levels mainly in comparison to their levels of estrogen, which tend to be lower, right? And so proportionally, there's this hyper androgenic type state. And so maybe these are just artifacts of participating in sport for a long period of time at a high level with high levels of training and not sufficiently fueling because various body types, body compositions are selected for in sport. And so you have to maintain that. So that's hypothesis to this artifact thing.

1:08:03Dr. Jordan Feigenbaum:It's like we're seeing similar signs and maybe biochemical findings to PCOS, but they're more reflective of the person's general practices, in this case in sport. But it's not PCOS. Sure. Of the two, I certainly do find hypothesis number two to be more likely just based off of that energy equation imbalance, if you want to call it that, and how that affects the hypothalamus and how that's affecting downstream signaling to your ovaries and so on and so forth and how that manifests in not having a period, for example. as well as looking at individuals who, for one reason or other, typically a genetic predisposition to adapt very well to high levels of intense physical activity in this sport or that sport, also tend to express more in the realm of a higher circulating androgens.

1:09:04And so it's just kind of happenstance, exactly. And then we see it or catch it, so to speak, because they're highly visible because they are performing at such a high level, at such an elite level. And so therefore presenting these artifacts that you mentioned.

1:09:21Dr. Jordan Feigenbaum:Yeah. Well, look, if you're listening to this, you made it this far in the podcast and you got a hot take or even if it's a tepid take, let us know. Weigh in, comment, you know, helps the algorithm anyway. But we want to know. Tepid takes only. Is it evolution or is it artifact? Correct. Maybe or option C, neither and you're a bunch of idiots and move on. Fair, fair. Wow. All right. That's unkind, but OK. So that's the exercise. That's a story on exercise. We want everybody who is able to exercise to exercise. And that certainly includes individual individuals with PCOS trying to get them to not only meet the physical activity guidelines, but to more than that, if possible.

1:09:58Dr. Jordan Feigenbaum:and no specific exercise considerations other than starting and maintaining that. Those are the real considerations here. Now, moving on to dietary interventions. So similar to exercise and its effects on PCOS-related health risks, dietary interventions are also heavily promoted in nearly all PCOS guidelines. Now, despite individuals with PCOS having a higher prevalence of obesity, most evidence shows that women with PCOS have comparable total energy and macronutrient intakes as individuals without PCOS. Now, despite that, it is unfortunate that there's a widespread misinformation campaign and promotion of specific dietary compositions that are designed to treat PCOS, particularly on social media, most of these lacking evidence.

1:10:44Dr. Jordan Feigenbaum:And in fact, if you go to the evidence, you'll see that there's a wide range of macronutrient compositions and dietary patterns that can be used to improve health and quality of life in individuals with PCOS. Yes. So the question to you, Dr. Baraki, is how do you discuss changing nutrition with your PCOS patients? And is there any difference in how you would approach that conversation with any other type of patient? Yeah, this answer does mirror the exercise answer a lot. Um, but just like with exercise, if we're starting out with nothing, then we want to trend towards something and ultimately get to a place where we are, uh, meeting and ultimately exceeding, um, the movement guidelines and, um, recommendations.

1:11:29So when it comes to diet, um, like you said, there isn't a single PCOS diet. It has been queried time and time again. It's been looked at and folks certainly want to promote and usually sell some kind of diet that they've slapped PCOS onto. But the reality is, is that at this time, we don't have compelling evidence that that tells me that there is a unique composition like macronutrient composition or micronutrient composition in the diet of someone who has PCOS that will be more effective at um, healthy weight loss or, um, optimizing anything else under the hood, so to speak, that's going to impact their symptoms.

1:12:15Um, there are some investigations and some recommendations based off of, um, not great data of some supplements talking about things like chromium and Ossetol, things like that, which, um, and particularly in Ossetol, the thought being that it can help to improve sensitivity, insulin sensitivity specifically. There are a few things like that that pose a very low potential for harm and might demonstrate a marginal response. So far, there's not an overwhelmingly compelling response that tells me that anyone that has PCOS needs to be supplementing with X, Y, or Z at this time. And so essentially my discussion with someone with PCOS is the same discussion as someone without PCOS that's in my office for something else, but also has obesity.

1:13:17And we're talking about some strategies to increase fiber intake, to identify and ultimately decrease saturated fats in their diets and increase monounsaturated fats and just look at the overall balance between their macronutrients, but not to say that there is like a perfect recipe for PCOS specifically.

1:13:37Dr. Jordan Feigenbaum:Yeah, a large variety of dietary interventions are going to work here and they've been studied almost to the nth degree. You know, well, there's very low calorie diet, low calorie diet, very low carb, ketogenic, high carb, it's all there. It's all been studied and yeah, there's no one diet to rule them all. Mainly, you would want to involve the patient, whatever their preferences are for a dietary pattern, what they have access to, and it focused on minimally processed foods, lean proteins, fruits, vegetables, whole grains, high fiber, limiting foods with added sugars, especially sugar-sweetened beverages, the standard dietary pattern recommendations to the extent somebody can do that, modifying the food environment, eating environments, and we've discussed at length on this podcast.

1:14:15Dr. Jordan Feigenbaum:However, I'm going to push back just a little bit on what both of us have said, so talking out of both sides of my mouth. There are, to my mind, three maybe unique concerns with respect to the diet for a person with PCOS. The first one being that there are, generally speaking, higher rates of disordered eating amongst individuals with PCOS. And so that may deserve its own particular not only workup, but subsequent management by a specialist, a registered dietitian who has expertise in this. And you may not pick that up initially, especially if you're not listening to the patient. So ideally, you're listening to women.

1:14:54Dr. Jordan Feigenbaum:Yeah, again. The second thing I would bring up is that there does tend to be a lower baseline dietary quality in those with PCOS. Now, this doesn't really affect management because when we talk about dietary quality and how it's measured, these are just standard indices. Healthy eating index, for example, is one of them. And so your recommendations don't really change. It's just a maybe a bigger gap to go from your average PCOS patient compared to somebody without. But again, it doesn't really change what you prescribe or what you recommend, but more so like how much effort it may take to get there.

1:15:28Dr. Jordan Feigenbaum:And there are multiple contributors to that, you know, why that is in the first place. And the third thing, and perhaps the most actionable thing here with respect to dietary interventions for PCOS, to my mind, is this idea around chrononutrition. But this isn't PCOS specific. It's more like insulin resistance specific. And so individuals with insulin resistance, whether it's, you know, the run of the, I hate to call it run of the mill, but it kind of is like type 2 diabetes, something like that, metabolic syndrome, or in this case PCOS, there does seem to be a benefit to time -restricted feeding, but not what most people think about when I say those words.

1:16:05Dr. Jordan Feigenbaum:When I say time-restricted feeding, people jump to intermittent fasting. And then the way most people think about intermittent fasting is that, oh, you skip breakfast and then you have a big lunch. You're eating windows like 1 p.m. to 9 p.m., right? You just eat throughout the rest of the day and that's how you do it. And there's been a bunch of weird mechanisms that people propose. Look, you're fasting autophagy at the beginning of the day. And ultimately the way that works as far to the extent that it does is that it gives people less opportunity to eat if they follow it. And so calorie restriction.

1:16:34Dr. Jordan Feigenbaum:But in this particular case, time-restricted feeding is flipped the incomplete other way where most of the calories are consumed earlier in the day, less later in the day. And it seems like there's some circadian rhythm, some biorhythm-related processes that this helps regulate a little bit better in individuals with metabolic syndrome or insulin resistance. And so if you were trying to like ratchet things up to the nth degree, person's already eating a health-promoting dietary pattern. They're exercising like crazy and they're like, what else can I do lifestyle-wise? You could suggest, hey, look, if dinner is your biggest meal of the day, right, perhaps if you flip that on its head where breakfast is a bigger meal, lunch is a bigger meal, and dinner is a little bit less, that may work a little bit better in this particular setting.

1:17:21Dr. Jordan Feigenbaum:Right. Caveats to that include if somebody is working out at night, that's all off the table. Like just does it doesn't seem to matter. And the effect of doing this is not like crazy big where it's going to completely change somebody's life. But if somebody was looking to pull every possible lever, that is maybe a unique consideration for an individual with PCOS. Sure. Cool. All right. No disagreement. I love that. Let's do it. Yeah. Well, anything we can add to the old toolbox. Yeah, there you go. Yeah, you have more arrows in your quiver. Yeah, we went Renaissance Fair on that. The last thing I wanted to talk about here were actual treatments for PCOS with respect to medical management and perhaps even surgical interventions.

1:18:03Dr. Jordan Feigenbaum:And so if you go look online and you have access to some of the professional materials, you'll see different groups or categories of medications. So everything from contraception, androgen blockers, certain metabolic care-type medications like metformin, for example, things relating to pregnancy and fertility. And so just briefly, can you give us a general lay of the land when you have a patient that you have diagnosed with PCOS? You've gone through the whole workup. When you start thinking about our medical management, where do you start and what are some common things that you end up using in these patients?

1:18:42Yeah. So before I invariably end up with my foot in my mouth and start talking about a particular treatment strategy or path, if you will, I always, always, always try to remember to get their goals written down upfront. front because I can counsel and counsel and counsel until I'm blue in the face. And, and whatever I've counseled them on is just not consistent or not compatible with what their goal is. And we just wasted a lot of time. And so, so super important to not only ask the individual, what are the things that concern you the most and what are your goals? And so particularly, if they're not sure what kind of goals I'm referring to, I will then specify, do you want to become pregnant in the near term?

1:19:36Or would you say that your primary goal is to regulate your menstrual bleeding? If that is one of their presenting concerns is irregular bleeding or absent menses for long periods of time. Because that's going to take us down two very different pathways because if I'm talking about regulating menstrual cycles, it will involve some form of a recommendation for a hormonal contraceptive. It's going to be mainstay being oral birth control pills. It doesn't have to be that. And I can explain some of the differences there. But obviously, if we are addressing your bleeding, It's going to be with something that prevents pregnancy usually.

1:20:22And if your goal is to become pregnant, then we need to go in a different direction entirely. With regard to hormonal birth control, I mentioned the oral form specifically, and that's going to be the mainstay for that individual that has clinical signs and features of hyperandrogenism that have the acne, oily skin, perhaps hirsutism, as well as irregular bleeding patterns from that ovulatory dysfunction. The thought being that if you take the pill that has a synthetic estrogen, in this case, ethinyl estradiol combined with a progestin, then we are seeking to have that pill be processed like at the level of your liver.

1:21:12And once it is absorbed and processed there, then you're ultimately going to produce more sex binding, sex hormone binding globulin. You can think of that as something that is produced by the liver that circulates in your blood and that will grab up any free testosterone circulating androgens and it will bind to them. And when those things are bound, then they don't have the opportunity to bounce around the rest of your body and to have some of those outward effects that you see, such as the acne, the oily skin, the hirsutism and whatnot. And so if you go with a birth control option that is not ingested, then you are not necessarily going to get that benefit, but you do have other approaches to trying to control, um, the disordered bleeding patterns.

1:22:06And so that could be with a vaginal ring that can be with a patch. Um, if there is a reason that an individual can't or shouldn't have, um, estrogen, there are progesterone only, um, options as well. That would include a pill. It could include, um, an intrauterine, um, system such as a Mirena IUD, um, as well as an implant in your arm. And then finally, the option for an injection, which is the Depo-Provera.

1:22:36Dr. Jordan Feigenbaum:Yeah. And so you move to like androgen blockers afterwards, most common androgen-related features of PCOS being like hirsutism, acne, female pattern, androgen-related pattern hair loss. And so like spironolactone or aldactone is like one of the mainstays here. It inhibits ovarian and adrenal stereogenesis, just making the sex steroids and other various pathways are like a ton of different mechanism of action. And that's a standby. There's also flutamide, I think, but I don't know how widely used that is. The only thing to add about spironolactone, I'll let you talk about it some more if there's other concerns, but this is a banned substance in tested sports.

1:23:14Dr. Jordan Feigenbaum:And so you need a therapeutic use exemption. And so each organization that follows WADA or USADA in the United States has a TUE, a therapeutic use exemption form that you would need your physician to help you fill out and submit. So that way, you know, you wouldn't want somebody who was diagnosed with something, started on treatment to go to a competition, right? Recreational powerlifting meet. They get drug tests and, oh, you're banned because you're taking spironolactone. It can be a, it's a diuretic, not great one, but. What a bummer. Yeah. And a masking agent. So they're like, look, it's banned.

1:23:49Dr. Jordan Feigenbaum:So you need this TUE. But yeah, that's what I think about androgen blockers and PCOS. I think about spironolactone and then I start thinking about other medications for maybe hair loss like finasteride, for example. How often are those being prescribed in practice? The finasteride, not very much. The spironolactone, I would say that gynecologists are much more comfortable and more commonly prescribing that. And that would be usually in series. So first step would be to try the oral birth control pill. and typically after about three to six months wanting to reassess symptoms. And if there hasn't been really any movement or improvement in symptoms, specifically hirsutism, then you can consider adding on spironolactone at that time to use both of those agents to address those symptoms.

1:24:42And then further down this pathway is the option to consult with dermatology as well to talk about other management options for excess hair growth for those patients that do suffer with hirsutism.

1:24:55Dr. Jordan Feigenbaum:Yeah. And then you move along, there's like some metabolic concerns. So metformin is commonly prescribed in PCOS. Is that something you guys are still doing or is that you're getting a little standoffish when it comes to metformin? Oh, well, it's not standoffish due to any specific harm, I would say, other than pretty common GI side effects. But the fact is that we've had some pretty reasonable theories and hypotheses over time. They've been studied. At this time, there is not compelling evidence that would indicate that the addition of metformin to your treatment strategy or metformin alone is particularly effective for regulating ovulatory dysfunction for improving fertility outcomes or for reducing some of these hyperandrogenic symptoms.

1:25:53And so it has mostly fallen out of favor. You'll see that folks of our generation and then slightly older will just knee-jerk, like reflexively still be tacking this on to the treatment plan for anyone with PCOS.

1:26:11Dr. Jordan Feigenbaum:Metformin contraception. Let's go. Yeah, exactly. That's the combo. But individuals who are staying a little bit closer to the evidence and really scrutinizing and over time saying, is this actually doing anything for us? At most for all of those different dimensions that I mentioned may have a very, very, very modest impact, but should not be considered a mainstay really these days. Yeah, that's the same thing like when I was doing my reading on inositol. Inositol being – it's a sugar alcohol. It plays a role in insulin signaling. You do make it and you obviously can ingest it and can supplement it.

1:26:52Dr. Jordan Feigenbaum:There's some thought that it improves insulin sensitivity and some other glucose uptake by the cells and a bunch of other stuff. And there is some – I don't want to call it defectiveness, but there's a change in the inositol pathway in individual PCOS. And so look, hey, it's a supplement. You can take it. It may help. Problem is it's expensive, thing one. Thing two, supplements, generally speaking, are poorly regulated. And then three, the effects are relatively modest. And so like my interpretation of this as a non-OBGYN is that it's like, look, if this was a slam dunk, this thing works and does a great job at it.

1:27:30Dr. Jordan Feigenbaum:You guys would be like, take an acetol. And oh, by the way, like maybe there's a pharmaceutical grade one. Similar to like fish oil. Well, there's Lavazza. There are other options that are prescription grade, but that's not really the case. And so my interpretation, tell me if you agree, is that, look, if somebody wants to take an Ocetol, they have PCOS, they want to take it, they had a discussion with their physician, they're all behind it. Find a brand that is third-party tested. It's going to be on the label. Is GMP accredited? You can either search it or it should be on the label. And, you know, again, setting the expectation that it's not going to set the world on fire, but maybe a potential benefit.

1:28:05Dr. Jordan Feigenbaum:Is that how you kind of see this? On this, Dr. Fangenbaum, I agree. We concur. All right. Fair enough. Yes, doctor. We concur. The other two components I was thinking about with metabolic care had to do with anti-obesity medications. And unfortunately, you alluded to this earlier, there's not really great data on the newer agents, semaglutide, for example, terzepatide, and there are going to be other ones coming down the pike. Most of the data is on exenatide, a very old drug, loraglutide, a very old drug, and fentramine, topiramate. That data does exist. And it's mostly for treating obesity that can be associated with PCOS and individuals with PCOS who also have obesity.

1:28:46Dr. Jordan Feigenbaum:So it's more like a weight management thing versus like, let's look at the PCOS-specific outcomes, fertility, anovulation, whatever. Now, weight loss, 5%, 10%, which is very consistent with these drugs. And sometimes they do much more than that, you would predict that that would be helpful. But unfortunately, we don't really have good evidence on that. And in particular around like conception and fertility, like that's even more. I think it's a matter of time, though, with how the tides are have turned recently and just the direction that we're going. I think it's a matter of time if it is a big if if research dollars are allocated to find it an important enough query to fund and to ultimately study.

1:29:30Dr. Jordan Feigenbaum:Yeah. But I think that it's a matter of time. Okay. That's the same thing. I mean, metabolic bariatric surgery is also like it's not that it's new, right? But in this field, it's relatively under research. There are some studies on individuals with PCOS undergoing metabolic bariatric surgery. And effectively, all of the we'll call it excess adiposity related concerns of the condition tend to get better. So cardiovascular risk because blood pressure tends to normalize. Insulin resistance tends to get much, much better. Hercetism tends to improve. Sure. But this doesn't appear to be like a mainstay in treatment.

1:30:04Dr. Jordan Feigenbaum:And I don't know if there's just like a disconnect between like obesity management and PCOS management, or if there's more of this concern related to women where it's like, well, I don't know, these are reproductive age females. Mostly we don't want to surgerize them prior to conceiving. I don't know. What's your take on that? I don't know that, well, there's lots of hot takes and opinions as to why there is not better integrated considerations for conditions that only affect women and greater health questions and concerns. Different podcast. I won't get into it. Different podcast. But I will say, like, on the ground, I don't feel that necessarily, like, within myself and my colleagues and the spaces that I practice.

1:30:50I don't think that there is a concern for precluding these treatment strategies for women because of their reproductive potential. I don't see that at all, and certainly not the way that I practice. And so it comes back to what their goals are and whether or not that includes fertility and what that timeline looks like and how we optimize things from here to there.

1:31:12Dr. Jordan Feigenbaum:Yeah, I was unable to find any evidence on this, for example, how many individuals with PCOS are being – their obesity is being managed using current evidence, which would include either pharmaceutical interventions and or metabolic bariatric surgery, early sort of like referral for a surgeon's opinion on the – are you a good candidate for this or not? I couldn't find any evidence on that, but my suspicion is that it's really low. I mean, it's low in general, like it's just underutilized. People talk about metabolic bariatric surgery like, oh, too many people are getting surgerized. They're getting this, you know, the lap band just to make your stomach smaller, make your gut smaller.

1:31:53Dr. Jordan Feigenbaum:I'm like, well, that's not really how it works. We talked about that in our podcast on metabolic and bariatric surgery. But overall, it's underutilized right now. I assume it's even more underutilized in patients with PCOS. Yes, I would agree. And just to kind of add that onto that clinical plate we were referring to earlier and then thinking about the clinician's prowess and their bandwidth, essentially, to navigate all these different topics is exactly the reason why this particular problem set or these particular symptoms and this particular syndrome is something that I capture in a very comprehensive template that I use in the clinic in my documentation.

1:32:36It serves as a great reminder to help cue me to cover all this variety of risk identification and counseling topics and as reminders to say, hey, don't leave this out. Don't leave out that physical activity, motivational discussion with the patient. And don't forget to acknowledge whether this is someone who would be a candidate for weight loss medications or metabolic bariatric surgery. So you protocolize it for yourself, you put it in a checklist, and it can cue you to make it a part of the regular conversation that you're having. And the more and more we have these conversations too, hopefully that leads to continuing to reduce stigma around this topic as well.

1:33:26And ultimately, just in the name of trying to do what's right for the patient and really set them up for success.

1:33:33Dr. Jordan Feigenbaum:The old checklist manifesto. Love to, yeah, shout out to one. Love to hear it. Yeah. Last thing I wanted to get you to talk about before wrap this up is about fertility related treatments. So you have a person who you've diagnosed with PCOS, you're managing all of these other constellation of potential risk factors and long-term health sequelae, and they desire pregnancy. And there is a laundry list of different agents and interventions that can be used, whether it's clomiphene, letrozole, gonadotropins, et cetera. Can you just give us like a two or three minute summary of like how your brain is operating in that space and like how you communicate that to the patient?

1:34:10Sure. So before getting even to the treatment part, I always want to remember, remind myself that someone who's been identified as having PCOS is not someone who needs to reach a 12 month of actively trying to conceive without a pregnancy criteria for that infertility criteria before you're moving forward with a general fertility evaluation and starting to counsel them on some treatment strategies. So this is going to be someone that we are moving forward with those things probably more like at the six month mark because you can have someone with PCOS wait 12 months, but the reality is the rate of pregnancy is going to be lower, especially if they have that oligo or an ovulation.

1:35:01If there's not an opportunity for, um, that egg to have that handshake with the stork, then we're going to find ourselves in the same place, but just like kicking the can down the road, essentially. So just keeping that in mind, um, to, uh, to go down this path a little bit sooner. And after completing a workup for female and male infertility, then we are at this point looking at offering letrozole and aromatase inhibitor. You mentioned clomiphene and that is an old and very widely used medication. It's been looked at head to head in a variety of studies. And where we are now with the body of research is just that patients with PCOS, the preferred agent is letrozole.

1:35:52They can receive this from a general gynecologist, not necessarily from an infertility specialist. And they can take this medication during specific days in their menstrual cycle that would typically be within the first half. It's going to be for five days that they take it, usually like starting on day two or day three. And if they are someone who does not have regular cycles, say they are an ambulatory, they can do something that's called like a quick start. So they just take it anytime, regardless of where they may be. Because the truth is we're not sure where they are because they haven't had a period, which means has ovulation happened?

1:36:37When was the last time it happened? Not sure. But this romatase inhibitor is intended to induce ovulation. So the strategy is called ovulation induction. And there's a variety of ways to also test if they take that medication at the first part of that cycle or a quick start approximately 10 to 14 days later, depending on whether or not they're cycling normally, when an LH surge would potentially lead to an ovulation event and the opportunity to become pregnant. You can do ultrasounds that can verify whether someone has ovulated. You can test a progesterone in what should be like the midluteal phase of the cycle, or you can just wait and see.

1:37:28Because if they go on to have a period, if they bleed, if pregnancy does not occur, then at least we know, okay, that did induce ovulation. Because the period is something that we also call like a withdrawal bleed. Because ovulation happened, a pregnancy did not occur, and then we're kind of wiping slate starting over. Um, and so, um, that is just like a very rough summary of what this medication is, how it works when you take it and what should happen afterwards. Um, this is something that can be prescribed for three to six cycles consecutively. Um, and if pregnancy does not occur, um, then, uh, referral to a fertility specialist is absolutely, um, an option at that point.

1:38:16Dr. Jordan Feigenbaum:Yeah, no good summary. Well, I appreciate your time on this. We've talked, I would argue, not long enough about PCOS, but I also understand the attention span in the podcast universe. You know, perhaps if we normally had four-hour podcasts, we could keep it going. But I think just to summarize briefly, you know, PCOS is a complex medical syndrome. The diagnostic workup is complex. The patient care, it's all complex. and you would really be best served by having an individual like Dr. Baraki in your corner who is coordinating all of these moving parts here. It's not just one thing and there's no weird trick that I can sell you or she can sell you or anyone can sell you.

1:39:01Dr. Jordan Feigenbaum:And so I've listed a ton of resources in the show notes for you. And also Dr. Baraki is going to be doing some work here with Barbell Medicine with respect to women-specific consultations and such. So if you're an individual with PCOS and you want some more hands-on care, you can contact us, support at barbellmedicine.com. Dr. Baraki, is there anything you want to leave the audience with? I know I've taken up too much of your time, but if there was a parting shot here, here's your chance. No, Jordan, I'll echo what you said. Yes, complex is complex. Yes, it's complex, but it's not insurmountable.

1:39:32And it's not impossible to overcome and to optimize and to reach a healthful place in your life if this is something that affects you.

1:39:43Dr. Jordan Feigenbaum:I like that. Well, that is a wrap here on the Barbell Medicine PCOS podcast. Now, before you guys go anywhere, please leave us a five-star rating and a review. It really helps drive traffic to our podcast so we can keep bringing you on the latest nuance in health and fitness. A special shout out to Dr. Lorraine Baraki, the most handsome doctor in North America, for joining us here. And we'll catch you next week and every week right here on the Barbell Medicine podcast.

1:40:12We'll be right back.