Why your PCOS Got WORSE after 30 and How to FIX it | Dr. Fiona McCulloch

27:33But then there's another thing where we're looking at perfectly metabolically healthy people who are wearing a glucometer. And now the goal seems to be to never have a glucose spike, you know, and then now is that an eating disorder? That's my question, you know, because this person doesn't have any underlying, you know, overall insulin resistance, and they're controlling their glucose. Is that healthy for your mood and your brain? Because now you're always thinking about this, right? Like A certain amount of your brain's activity is now going towards, how much is my glucose going up? How much of this can I eat?

28:12How much of that can I eat? And that's a kind of anxiety or it's certainly not healthy for our mental health to put that energy into that when it's not really necessary. Of course, it can be very valuable though. I find for certain people with diabetes, there might be specific foods that are a huge issue for them. Or we might see that when they have a huge spike, their entire next day is really off and they need to like balance this out. Or maybe it's at night when they're sleeping, we're learning these. But they have an underlying condition that we can actually see. In the past, we never had glucometers.

28:48So if people were metabolically healthy, is there any negative that's proven to having a glucose spike from, you know, eating dessert with your meal and enjoying your life? I don't think so. So we're sort of pathologizing things that aren't even pathology just because we have all the options of measuring everything now. Yeah. And as you were saying, this is a normal physiological response and we are pathologizing things that are normal physiological responses. And this tends to happen in women's health. It feels like it's very isolated to women's health, but something that is part of our normal experience becomes something that you must now divert your energy to fixing, to always focusing on.

29:30And I think, you know, with continuous glucose monitors, like for people listening, I think in pregnancy, they can be great because if we can start detecting that there are issues before you drink that nasty sugary beverage that we've all done and do your glucose challenge, right? Because by the time we're doing that glucose challenge, you may have already had all of these issues and baby was being exposed to high levels of glucose, like we may have already had those problems. I certainly think in perimenopausal women, especially those who have a family history of diabetes, that having a continuous glucose monitor as a way of understanding how you're interacting with food, but honestly, not doing it for more than three months unless there's something more going on.

30:15I think there are certain cases that it can be used, and I think it's wise to work with a professional when you're doing that, whether that is a physician, you know, a doctor of, you know, any kind or, you know, a registered dietitian, a nutrition specialist of some kind, somebody to help guide you. Because just getting a continuous glucose monitor and following social media influencers who are telling you all glucose spikes are bad, all insulin spikes are bad, especially when it's like, you know, they have like a bachelor's education in science. I'm always blown away by that. I'm like, that's helpful, but that's not doctorate level education of actual human body and disease.

31:00And so sometimes the things they're telling you, it's like, that's an extrapolation of the data that we have. And it's not actually the way it plays out in human bodies. Yeah. Like a single variable like that, like your glucose is one thing, but it's like, they're not considering the whole entire system of the body because there's no background of understanding medical conditions and how like diseases develop and what normal looks like. And, you know, the risks of actually doing things and seeing those play out in humans. Like we see people developing eating disorders are getting like hyper fixated on these things.

31:37So yeah, it's like, we see that with PCOS, a lot of these patients are told when they're like 16 years old to lose weight and they're not even overweight, you know, and that's how eating disorders start. So it's like very similar with all of this like cycle syncing and, you know, with your exercise and not eating anything to ever spike anything and being, it's just controlling, keeping us focusing on all kinds of things to keep us busy. That's what I think. yeah oh and i do just i just think like as a medical profession like we all have to own the fact that doctors really are um they're the ones that actually induce eating disorders in much of the pcos patients because of the myth that weight gain causes pcos and so they tell patients if you want to cure your pcos i've literally seen this in chart notes of like you just need to lose weight and you look at this person and you take their measurements and you're like, I don't, I don't under, I mean, I remember having a patient and she had done a BIA and she was 18 % body fat and her doctor's recommendation for PCOS was to lose weight.

32:46And I'm like, that ain't it. You did not cause your PCOS by gaining weight. Your PCOS caused metabolic dysfunction that caused you to gain weight. 100%. Yeah. eczema is unpredictable but you can flare less with epglyss a once monthly treatment for moderate to severe eczema after an initial four month or longer dosing phase about four in ten people taking epglyss achieved itch relief and clear or almost clear skin at 16 weeks and most of those people maintain skin that's still more clear at one year with monthly dosing epglyss lebrikizumab lbkz a 250 milligram per two milliliter injection is a prescription medicine used to treat adults and children 12 years of age and older who weigh at least 88 pounds or 40 kilograms with moderate to severe eczema.

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33:57And for the patients who actually don't have insulin resistance, this is really a problem because they continuously try to eat less and less and it doesn't help them at all. Actually, it does almost nothing for them. In fact, it just makes them worse. And then they feel bad about themselves. They're like, am I not eating little enough? Do I need to eat even less than this? and then by the time they come in, I see them and I'm like, they're like, I'm going as low carb as possible. You know, I'm only eating protein and vegetables. Like they're not even enjoying their life, you know? And then this has not made any difference for their PCOS.

34:32It's just the same. So it's a huge disservice, all of this. So there needs to be more understanding overall. Yeah, I definitely agree with that. I want to go back to talking about in utero, it's come up a few times, but you had said before about how stress hormones can be affecting a PCOS woman in utero. So for everybody listening, this is when you were a little tiny fetus, you were developing. What does the research say about the impact of mom's health in terms of how it shapes a PCOS woman's experience for her lifetime? Yeah. So, I mean, I would say there's quite a bit of evidence on that because they have researched PCOS and found that it's really epigenetic.

35:15So you have to have certain genes and then the environment will turn them on. And a lot of those genes actually are turned on in utero. So there's two things that seem to be the main ones. One is having higher testosterone in utero. That seems to have effects on the brain development in PCOS, has androgenic effects, which means the baby develops testosterone-like kind of traits in their brain as an embryo. And then that, you know, is turned on in adolescence when the hormones start up. So that seems to be one of the major ones. The other one seems to be insulin resistance. If there's that happening in utero, that will influence the PCOS outcome.

35:59And then finally, there's also the stress that has a little bit less information, but there should be more in my opinion, but that does seem to influence the outcome as well. And then there's also like environmental toxins seem to influence it in utero as well, because any endocrine disruption can make it worse. And we do know, we don't have studies specifically on the stress component for what I'm going to talk about as it relates to PCOS, but we do know from looking at Holocaust survivors, people who've gone through famines. We do know that moms who are under tremendous stress, it programs that baby and subsequently when it becomes an adult to have a more reactive nervous system.

36:46So it may have more cortisol receptors. It may just have a heightened response when stress hormones come into play. And often as people hear all of this, they often think like, oh, so this bad thing happened and it made bad things happen in this human. But what happened is there were environmental inputs that said you need to survive, therefore we need to adapt to you. So if in utero you're under high stress, the body says, okay, we must survive when we're born. So the adaptation is about survival. We see the same thing when you don't have enough food or you have too much food, too much of the wrong food causing insulin issues, that then the metabolic system of that human in utero, once they're born, is changed and it's primed for an environment that may no longer be the environment that they're living in.

37:39So these are very, very great mechanisms to have in play. The problem is that we live in such an artificial environment in terms of like our evolution and our adaptation and what our body is capable of doing. Yeah, I agree with you so much on that. And the other part that even, you know, just goes like along with that with PCOS is the genes for PCOS are thought to be genes that help us survive a famine in particular, because it can help us store energy better. So people with PCOS have been thought to be the ones who could survive these big famines. And it also gives you more muscle mass, which also helps you survive famines.

38:22And then the other thing is it affects reproduction in a specific way where you have babies further apart and later in life. That allows a different kind of survival as well. So then when we add our current environment to those survival genes, we could see maybe why that sensitivity is there to, you know, cortisols because those are turned on in famines. Our cortisol goes up to allow us to seek food and store energy. So that part is very important in PCOS. And I think that that's part, they haven't researched well enough in my opinion, but it's very much involved, I would say. Do we, do you know, I don't know if these studies exist.

39:04Like are there, is there more PCOS like among Irish people, for example, since they did have the potato famine, which was like a complete bottleneck of genetics. There's only been a few times in history, right, that we've completely bottlenecked people and that's one of them. I'm just curious. I'm honestly not that sure, but it would be really interesting to know because I would imagine that that's true. Yeah. But I don't know. Yeah. Yeah. I would just be really curious. It's just a thought that I had that I was like, huh, that was one of the very significant famines that we saw in history. So I'm like, oh, I really want to go look that up.

39:41What I also am curious about is that you spoke about neurodivergence and the connection with PCOS. And we know that mom's hormones in utero can influence neurodivergent development. Again, you have the genes, you are inherently neurodivergent, and then the hormones switch these things on. Can you speak a little bit about that? Yeah, definitely. So there's definitely a higher risk of ADHD in PCOS. So we do that for sure. I think it's something like 5 % to 20 % of women with PCOS might have ADHD. But it's very interesting. It's also been shown that the type of ADHD is a little different in that it's more impulsivity and hyperactivity compared to other women.

40:31So it's more the testosterone might be involved there. You know, personally, I'm happy to reveal I have ADHD and I've always been very hyperactive, like physically, mentally, and in every single way. They believe that the prenatal testosterone actually is associated to this, the development of ADHD. And this environment, again, seems to turn on those genes. But there is such a high rate of ADHD and PCOS that I wonder too, you know, it's just, we don't really fully even understand what the type of ADHD is in PCOS. Maybe it's specific, but it's definitely neurodivergence. Yeah. And the interesting thing, there was a study showing that the impulsivity and hyperactivity in women who have ADHD tends to be at its worst, like around ovulation, which we know testosterone can be higher at that time of the cycle or not being completely challenged by everybody in terms of, you know, having that hormonal balance of the reproductive hormones.

41:40The other thing that's interesting is I was reading a study of women who had hyperandrogenism, so not necessarily diagnosed with PCOS, although PCOS people were included in the study because of course, right? But looking at hirsutism, acne, so looking at the symptoms of PCOS, and they found that those women tended to have offspring that had higher levels of anxiety, so higher rates of anxiety. And I thought that was really interesting as well because we see anxiety as a co-occurring condition with PCOS women. And often, you know, the mental health conditions of PCOS get attributed to like how you're perceived in life for being overweight or for having acne or for having your hair loss and how you feel about yourself.

42:25And then, you know, there's other aspects where it talks about like the inflammatory aspect of it, the insulin dysregulation of it. But to understand that in utero, the exposure to androgens, given your genetics, may actually flip a switch that leads to higher rates of anxiety. Yeah, exactly. And there's other differences in cognition too, like they've found, like different ways of like, you know, possibly cognition, like understanding things, memory differences. So it seems to me like it's a type of neurodiversity. But yeah, all of those switches can be flipped. And then different people might experience that in a different way, depending on their environment.

43:06Like for some people, they might become very driven or someone else might become very anxious. So obviously your family and all sorts of things might influence that. And also your environment, of course, that you're in at the time could really like flip that switch again and turn a gene on or off. Yeah. Getting accommodations, I think, so, well, let me back that up because to get to accommodations, you're going to have to be diagnosed. So if you are someone with PCOS, odds are you're going to have a child with PCOS. If you are somebody who's neurodivergent, odds are you're going to have a child that's neurodivergent.

43:41So if you have PCOS and ADHD, it's really important to get your children evaluated because we understand that if they get diagnosed and they get appropriate accommodations in school and they get appropriate treatment, which is not always stimulant medication. I want people to understand that. That is one option and it can work really well for some people, but not for everybody. So it's one option. But if they're getting that treatment, they have lower risk of suicide, of mental health disorders, of substance abuse, and they're more likely to be successful in life, but often that success doesn't look like the neurotypical success.

44:20That success doesn't look like the recipe book that society has told us of like, go to college, get married, have kids, this is how you be successful. It may look different. And if you can understand that about yourself or about your child, making those accommodations and really working with that individual can have tremendous beneficial outcomes. I think that often neurodivergence gets viewed as something really negative. And, you know, like all disabilities, there are negative aspects to it. However, there's also a lot of positive. Like we know that ADHD individuals tend to be incredibly creative, whether that is in the arts or logically problem-solving things that other people can't even see.

45:04And so it just takes fostering and supporting them. But we, I will say, if we leave the hormone conversation out of this for women, we are missing the mark completely in how to support them holistically. Like it's impossible, in my opinion, to have a, you know, somebody feel like whole and complete and well, if you just forget about these hormones altogether, because they can act as neurotransmitters in the brain. Oh yeah. And we see like obvious huge changes in our brains function at hormonal events. I like to say, you know, just like menopause, having a baby, PMS, like these are obviously from hormones.

45:45Like we can just isolate that, but that's from hormones. So we know that hormones affect the brain. We've just always, it's just been underplayed in research. Like it's always been not important to look at, but they're very important. And you know, the hormones themselves can, when they're corrected, can fix a lot of the kind of more problematic mood changes. But yeah, it's really interesting how, you know, at postpartum, you see a huge, huge, obvious mood shift in most people. So that is really, it's really obvious, and we really need to take that seriously. Yeah. And I think that, you know, I've spoken about this on other podcast episodes, but there's an entire generation before us of practitioners who spit this rhetoric that women are no different from men, our hormones don't have any effect on us, and also you should just take the pill, flatline your hormones, then you can be just like your male counterpart, and then you can work just like them.

46:47And I think that their intention was that they felt like if our hormones were weaponized against us, that would do a disservice, and that would keep us from advancing forward in society. And yet I don't think they recognize the unintended consequences of what they were doing in that it actually did keep us from advancing forward in society. And it left us, I mean, it honestly left so many women feeling like they're crazy and something's wrong with them because, you know, there's these, you know, there's some gynecologists even still who are like very prominent on social media who, despite all the science, are like hormones do not affect women's moods.

47:28They don't affect women's brains. And I'm like, you can't just like call yourself evidence-based while you look the other way on science that doesn't fit your narrative while you also tell every woman like you should just be on the pill because the way nature made you is completely broken and wrong. Yeah, I know, right? It's so common and it's sort of still viewed because of the evidence, but we have to look at why is there no, like just because there is no evidence or not enough evidence, maybe that's the problem. They're not researching this area well enough for us. They're just utilizing these simple things that they view as solutions, which are actually not really helping.

48:07And it's a complex area. Hormones is complex. It takes more time to understand it. It takes more time. You have to talk to people and look into detail as to what's going on. So it's not really wanted in medicine because it's more work. It's one of those areas that it's more complicated. So I just think that we need to change that because it's obviously a huge area for women. And women are, we're all, part of us is change. Our entire body, our whole lifespan, it's all about change. And it's natural for us to change. And we are change in many ways. Good sleep is everything. That's why Oli's Science Bag Support is made with a blend of melatonin and L-theanine for both kiddos and grownups.

48:55So when your mind won't switch off, you've got something that can help. Erasing thoughts and restless nights won't stand a chance. Find Oli Sleep Solutions for the whole family at Oli.com. That's O-L-L-Y dot com. So suppressing that is really suppressing who we are. And if we can work with it somehow and let that be included in society, just like neurodivergence, we look at it as a pathology. Meanwhile, it's the type of human that is, you know, people with neurodiversity are very good at many things. And it's just our society has determined that that's, there's something wrong here, but our society is structured in a certain way.

49:37Is it that that's the issue? That's not including everybody who's in our society as valuable, really. Yeah. I'm going to link to a few studies in the episode notes for everybody. It'll be at drbrighton.com. There was a study that It just came out on, it was a review of all the research we have about hormones and ADHD women. And even the review was like, yes, when it comes to menopause, there's nothing. We've just like, we just forgot that these women exist and we haven't researched this. But it did validate a lot of things that women have been saying, like ADHD medications don't work before their period, how PCOS women actually show up and how they sometimes look more like the male archetype of ADHD.

50:23If you're not watching me on YouTube, I'm doing air quotes because really there's this whole like there's male ADHD and female ADHD. And I'm like, anybody can present either of these ways and also hormones matter. And depending on where you're at in your cycle or what your hormones are looking like, you may present differently, which is also why it makes it kind of complicated to get a diagnosis. And then there was another study that actually just fell out of my head here for a second, but there's another study I'm going to link to about behavior in women and their hormones and how that does influence us.

51:01And we also know Dr. Lisa Moscone, she has done great research on just how estrogen changes the brain, like doing brain scans and seeing how estrogen changes areas of our brain, how they function, how they're metabolically active they are. And for everybody listening with PCOS, it's really important to know that, so as we talk about PCOS and ADHD, ADHD is a state of dysregulation. We have a dysregulated nervous system. We have dysregulated immune system. We've dysregulated, you name it, it's dysregulated. Our metabolic system is dysregulated as well in the brain. then you couple that with PCOS, DCOS has dysregulation of insulin, of androgens.

51:44And so all of that can impact how your brain is functioning as well and just energy metabolism. And so I just think it's really important that people, oh, this is the study that I was actually going to talk about before is there was a study showing that women with ADHD are at higher risk of adverse mood outcomes when they're given hormonal birth control. So it's always been a question mark, you know, since I wrote Beyond the Pill. Why do some women take birth control and now their mood is stable? They feel awesome. And other women take birth control and they're losing their mind and they change different formulations and they're still like, I don't feel like myself.

52:25Well, as it turns out, we need more research, of course, but some research is starting to point towards being neurodivergent means you're more hormonally sensitive and you likely have paradoxal effects to medications across the board, hormonal medications being no exception. So if you are someone with PCOS, your doctor offers you birth control as the first line of treatment, please, please, please chart your mood symptoms. Then you start that medication and continue to track that. And if you have adverse mood symptoms, you need to see a provider right away because the risk of suicide can be really high among these patients.

53:02And I just don't think we talk enough about that. And, you know, often it's because doctors are like, well, if you say something, they'll be scared not to take it. Okay. So why do you get to withhold information for women? Like, like you get to be the boss of them. That's not how that works. Like we need to inform them and we need to tell them what to look out for just in case they are that person who has the adverse effects. Then we can intervene. We can do something different. Yeah, exactly. Like so much is not disclosed. And I've even seen patients who were, you know, had, for example, endometriosis offered the depo shot, which is going to shut your hormones off, you know, for a long time.

53:39And it's linked to suicide and all kinds of serious conditions, not informed of any of this, just like try this hormone injection. It's going to, you know, put your endometriosis sleep for several months. And as if it's a very casual thing, you know, and shutting all of your hormones off or even altering all your hormones really can have a strong effect in many people, but especially if you have anything else happening. And most people who are taking these medications, it's because they have something else happening. They have a condition, PCOS or something like this. And they are utilizing it sort of as like a treatment per se, even though it's not really treating the condition.

54:21And then it's going into the system where that condition is present without any warning or support for those other areas. So yeah, it's really looking for control. A lot of the research is on, you know, it's just so wide that it doesn't differentiate these different scenarios very well. Well, and it's in the interest of the pharmaceutical companies who have developed these medications to fund research that has positive outcomes and show positive effects. And as much as people are like to roll their eyes and say it's a conspiracy theory. Friend, if you just understand capitalism and that if a business is going to invest in something, there needs to be an ROI on it.

55:01It makes sense. And I don't get mad about it because I'm like, this is just a system that we live in and we need to recognize that. And so how do we deal with that? We ask what's true for you. And that's all I care about. I don't care if a research study says that your experience can't be possible or isn't real. You're experiencing it. So that's real. Like, you know your body better than anyone else. And that's, I think, a big misstep in medicine, especially with PCOS, is how often doctors are like, we don't have the data, therefore you're lying. Like, no, we don't have the data, therefore you know who can teach you best?

55:37That person sitting in front of you and their lived experience. Yeah, exactly. And there's so much information on, like, these topics are just not published in major journals. They're rejected over and over and put into smaller journals, or there's just a huge difficulty, there's not as much interest in publishing these topics. That doesn't mean that it's not real. So whenever I'm looking something up, I'm always like, is it because there's a lack of evidence? Because whenever you're in this realm, there, this is a major thing to consider is that there's a lack of evidence. And so if you're experiencing something, that's real.

56:12And it doesn't matter, you know, any doctor that dismisses that is not a good doctor for you. So find another doctor who doesn't dismiss what you're saying because what you're saying is real. And not everybody is, these studies don't even exist most of the time. And secondly, not everybody, there may not be someone like you in that study. So we just don't have enough information to make generalizations. Absolutely. I want to shift gears a bit and I want to ask you, what do we know currently about PCOS showing up in men? Oh yeah, that's interesting. So we do see the genes for PCOS in men as well.

56:51And so with men, obviously, because men have a lot of testosterone compared to women, you can't see it. We've just not known if they've had this, right? And so we were able to look at genetic testing. So basically with men though, what they've seen is that there's more insulin resistance. So type two diabetes, gaining weight around the midsection, fatty liver disease, high cholesterol, all the same things that we'll see in insulin resistant women with PCOS. And sometimes you'll also see hair loss in men who have these genes with PCOS. So there might be higher levels of DHT, dihydrotestosterone.

57:29So that's another thing. But yeah, we definitely see this genetic link is in men as well as women. How many men roughly are anticipated to have male PCOS? Yeah. And of course, horrible name. Horrible name. They don't have ovaries. Yeah. I don't know, honestly, because I don't know that they've ever looked at that. But it would be interesting because you can see in families, there are traits of it. You know, if you look, I treat a lot of families in my practice. So I'll definitely see the same traits, you know, those kinds of diabetic traits. in the boys. So my guess is it kind of passes just the same, but I don't really know.

58:11And I think it would be interesting to find out. Yeah. I wonder if we would get more research if men had a PCOS. Yeah. They'd have to change the name and then yeah, all the research will just, you know, start up and that'll be great. But yeah, I think with, with everything with AI and everything going quickly on this front, I think we will get more info on that soon. Mm-hmm. What can women do who are listening to this right now? Maybe we freaked out some women who are like, well, I want to get pregnant in the future, but I don't want to have these imbalances going on that are going to influence my baby in a negative way.

58:47I want to ask you that question. I also want to caveat with that men matter too. The sperm donor matters greatly. We don't even understand. We are at the tip of the iceberg of understanding their contributions to like how awful our pregnancy can be. That's one thing, morning sickness coming from the sperm. So I say this because I want women to understand that we tend to research and blame moms. That's what research does. It's like, hey, we've got these outcomes we don't like. What did the mom do wrong? Let's go all in on that. But I want women who are listening to understand that 50 % of the genetic donor, which is sperm, matters too.

59:26So it's not all on you, But because we are talking about PCOS women, we did talk about the in utero conditions that can lead to adverse outcomes. I do want to focus on that here. So I agree with you. The sperm is so important. And then, but with the in utero environment, the first thing I'll say is it's very easy. I hear a lot of people who are fearful of it. You know, like if I get pregnant, I'm going to have, you know, cause this actually. But if we think of it this way, PCOS is genetic diversity and it's survival genes. And those genes are passing on because they are good genes that give us benefits.

1:00:06And it's not a disease, even though it has those, it can turn into problems and it can turn into diseases. It's not in its most basic state necessarily a huge problem. So if we have the awareness of it and we know that because we have PCOS, we probably have higher than average androgens. We cannot change that fact while we're pregnant. Now we can always do everything we can to be healthy, but you know, there's PCOS is genetic and it's been there for a very long time. It's in all the old medical textbooks. And you know, they realize, you know, it just helps you survive. So knowing that we want to just take away any worry on that front, because there's benefits of it.

1:00:49The other factor is the environment. We cannot control that to any degree either. We are all in this environment. Of course, we all want to work towards making our environment better and stopping things like plastics, microplastics from entering our environment. That's very important. But in our individual system, we can't always control all of those things. And we don't want to increase our stress, which is something that, you know, you can do some things about that, you know, in pregnancy, you know, maybe not looking up too much of this stuff, the anxiety provoking, because, you know, the things that we can manage or have as helpful areas in our life, we can like going for a walk outside, you know, doing all those nice things, making ourself a beautiful meal that we really enjoy, focusing on all the positive things that we can do.

1:01:37And knowing that if we have a baby with PCOS, we're there to help guide them. We're there to help them make the most of their genes rather than look at it as like a negative. Um, the people with PCOS can do, I've seen so many women just do so many amazing things with their lives. Um, so there's a lot of good things about that. And if you have that knowledge, like you can do so much. So yeah, I always focus on that area because this is definitely the top thing I hear is that it's a scary thing. Um. No, but it doesn't have to be. Yeah. Well, I appreciate that. I also want to ask you about prolactin because when a woman's period goes missing, this is one of the tests that we will run, checking prolactin because for everybody listening, there's something called a prolactinoma, which can secrete a lot of prolactin, which is supposed to make you make milk.

1:02:31But in this instance, it's going to shut down ovulation. But why would lowering this in women with PCOS potentially be an issue? That's a really good question. So prolactin, we see a lot in PCOS that patients have higher prolactin. And it's not super high, but it'll go up and down just a little bit above and below the range. And then I'll see people go get the scan to see if they have a prolactinoma. And then, you know, sometimes people are put on bromocryptine or medications to lower prolactin. Um, but this actually, there's been some research to show this can actually have some negative consequences to the metabolism because the prolactin can be compensation to help your metabolism in PCOS.

1:03:19So I always say, you know, do we want to try to force prolactin down? That's not necessarily a smart idea. Prolactin when it's super high can block ovulation, but it's not the underlying cause in PCOS. The prolactin is more responding to the situation and it's not high enough to block ovulation. In cases where a prolactinoma has been ruled out, but there are significant elevations in prolactin, do you ever see Chase, Treeberry, or Vitex being helpful? It's definitely the most helpful herb for hyperlactin. And it's a hormone balancer. It works in the brain. It works with dopamine. So it does more than just prolactin.

1:04:01But yeah, it tends to work well when there's those like elevations that are possibly involved, you know, in hormone imbalance without shutting it right off. It brings it to a more normal level. There's a myth that women with PCOS can never use chase tree berry. Can you explain why that's not true? Yeah. So this myth is based on that chase tree berry might raise a LH hormone. This is based on a very old animal study. And this animal study showed that Chase Treeberry could raise LH. Now, LH is raised right before we ovulate. So in these studies in particular, they were showing that it could help with ovulation.

1:04:40So again, we have to look at the system that we're placing this into. If someone is not ovulating and the Chase Treeberry raises LH to cause ovulation. That's not the same thing as it is in a patient with PCOS who has high LH all the time. It won't just raise their LH. So that's not something that we actually ever see when we use Chase Treeberry in clinical practice. I have not seen that to happen. Study and play. Come together on a Windows 11 PC. And for a limited time, college students get the best of both worlds. Get the Unreal College Deal. Everything you need to study and play with select Windows 11 PCs.

1:05:22Eligible students get a year of Microsoft 365 Premium and a year of Xbox Game Pass Ultimate with a custom color Xbox wireless controller. Learn more at windows.com slash student offer. While supplies last, ends June 30th. Terms at aka.ms slash college PC. um and another factor is that you know if it's used in the luteal phase you're going to be working on you know it outside of any of that timing so if you have any concern with that you can have it just in the luteal phase but one thing with chase tree berries when you first start it it can definitely make your cycles a little bit irregular like it can cause a reboot of the system almost so if you take it in the second phase it can avoid that that's not necessarily a problem though.

1:06:06Like we can use taste tree berry full cycle for many situations. So again, I always look at it as individual. It's certainly not something that you can't take in PCOS. It may or may not be the right choice or the best option depending on your overall hormones. But yeah, I do use it in PCOS in very specific ways. Well, I appreciate you saying it's a harmonizer as well, because that's how I use it as well. And, you know, I had with patients, there are times where I definitely use it like post-ovulation only. So for people to understand, luteinizing hormone continues to pulse post-ovulation to keep your progesterone around.

1:06:43But I found exactly what you said, that using it throughout the cycle can be really beneficial because it's also supporting estrogen and it's working in ways that we don't even fully understand yet in the research. And as you said, I have absolutely seen Chase Treeberry do that reboot. Actually, there's some women that take our Balanced Women's Hormone Support Formula and they'll say like, oh, like my first cycle got thrown off and things were weird. And like, maybe it came like five days late. And then my next cycle was amazing. Like, that's the best I ever felt. And it's exactly, I've never used reboot before, but that word of you saying, oh yeah, it gives your system or reboot, very much what it's like because after that first wonky cycle, things do tend to get a lot better.

1:07:32I want to shift gears again and I want to talk about gut health because I know that you are definitely on the cutting edge of a lot of the research with PCOS and this has been a really interesting area that's starting to expand more. I specifically wanted to ask about the emerging research that suggests that fungal organisms in the gut may play a role in PCOS by driving inflammation. so i'm curious what do we know about that connection the gut in is very important in pcos and we've known that for a long time and um we know the microbiome is very altered in pcos and in patients who have insulin resistance and diabetes we know generally that they have much more likelihood of having fungal organisms anywhere in their body really vaginal yeast infection, skin, dandruff, and then in the gut as well.

1:08:23And fungal organisms, like our immune system sees these. Our immune system resides underneath the gut. About 70 to 90 % of it is just right under the gut, like developing. And if there's fungal organisms there, our immune system will see those and start inflammatory reactions to them that can get into the bloodstream. So it depends on how much there is, but we definitely see the microbiome is really different in patients with PCOS, especially if they have insulin resistance. It's quite different. And when you don't have enough of the good bacteria, these opportunistic organisms like fungi will start growing in there.

1:08:59Are there interventions that you find can be helpful when you see this dysbiosis or imbalance in PCOS women's guts? Yeah, there's so many things that you can do. So if you're looking at supplements, one of the best ones is berberine because berberine is great for insulin resistance and it is antifungal. It helps with the microbiome. It's been shown to actually alter the microbiome in a positive way in PCOS. So it's a really good option. Of course, probiotics can really be great at crowding out and creating competition, but also creating anti-inflammatory signals moving through the gut itself. And then fiber, soluble fibers.

1:09:41So having those in your diet or as a supplement, fiber is the food for the microbiome. So a lot of the time, you know, we minimize how important fiber is, but it's what grows our microbiome. It gives us that good diversity. So having lots of soluble fibers is great. How close do you think we are to integrating a gut health approach in the treatment of PCOS? Unfortunately, not very close, but I

1:10:09I kind of knew the answer, but man. You know, in the last guidelines, they actually did include a lot of lifestyle and nutritional information in there, which is new. And even the supplement inositol was actually included, which is one of the first times, you know, it's had a vitamin D, which that's great progress, I think. Which is wild because, yeah, I mean, we've had inositol research. So my inositol, D-chironositol, these are the inositols we're talking. about, we've had this research for a long time with PCOS. It's like, you know, everyone's like, creatine is the best research supplement.

1:10:44And then I'm like, here comes my inositol into the PCOS conversation. It's been around for so long. It's very safe. It has a lot of data. So yeah, this recent guideline 2023, they actually finally included inositol in there. So that's great. I'm considering that to be progress. But yeah, maybe the gut will be in the next series. Yeah, they also included information about the weight bias that happens, which we alluded to earlier on. But can you talk about how the new PCOS guidelines had specific information for clinicians about weight bias? It's amazing. I was really happy to see that. But there's a lot of stigma around having PCOS, and especially in the medical system, patients with PCOS are often looked at as eating too much or not exercising too much.

1:11:34and then dismissed based on that. And they're not looking and understanding that PCOS is the cause of the weight gain in the first place. If they didn't have PCOS, they would not gain this weight. And this was addressed in the guidelines. So they were saying that weight stigma is actually very common in PCOS. It's very important to understand that, to understand that PCOS causes weight gain and that clinicians really need to, you know, serve patients with PCOS, understanding that they may have not had very good care throughout their whole journey. So I also want to ask, because we're talking about the new guidelines, the new guidelines address the role of diversity, including genetics, cultural, ethnic variations.

1:12:19Can you explain to people just what the guidelines said and why this is so important? Yeah, because with PCOS, it's very common and it may present differently with different ethnic backgrounds. And this was actually included in the guidelines. And, you know, for example, in patients who are of Asian descent, there's a different metric for hirsutism. So it's categorized differently. And Black women, for example, have different risks for heart disease and diabetes. And this needs to be looked at earlier in a very specific way. So they were looking at how PCOS affects different ethnic backgrounds differently and really how to identify that and also what factors to focus on more in different ethnic backgrounds.

1:13:13I think that's so important. I mean, even when you look at medical textbooks for how certain rashes can show up, it's usually on a white body. And we know it doesn't show up the same way based on how much melanin you have. And in the case of diabetes, there are darkening patches of skin that may show up that if a clinician isn't culturally competent, they may not actually recognize. I think the other thing that's really important that we need to see medicine go a step further is that often within the United States, everything is viewed through the lens of like everybody eats a standard American diet.

1:13:54And then if they don't, they adhere to these foods and not recognizing the cultural differences in how people eat and why they eat that, you know, in the U S there's very much this mindset of like food is fuel, Or maybe it might be pleasure, but not understanding that, you know, for certain cultures, there's community, that there are times where they're fast. There are times where they're eating specific things. And I think that especially for providers who are going to be counseling women on diet to have that understanding. Like if, you know, I, for instance, have had patients come to me and they're vegan because of their religion and they've left doctors who were like, yeah, but you have to eat protein.

1:14:40Like you need to eat protein. It needs to be animal protein. That's best. And it's like, okay, certainly you cannot beat and rival like the amino acid profile of a steak. It absolutely, I mean, an egg, gold standard. But if somebody is telling you that culturally, this is important to me religiously, spiritually, this is my belief, then you have to meet them where they're at. And I think that so much of what the guidelines did this time is they said, you need to stop acting like every single PCOS patient is exactly the same. And you need to actually understand who they are as a person and what their genetic makeup is.

1:15:17Like you need to understand more about them than just this label of PCOS. Yeah, it was so much more comprehensive. So I was involved in the diagnostic, the peer review and the diagnostic guidelines. So it was really interesting. Like they really included a lot of different factors that, that they did not ever include in any previous guidelines, things like eating disorders, mental health, um, and yeah, ethnic, different ethnic backgrounds, because I work with a lot of patients. I'm in Toronto and I work with patients from so many different backgrounds. And I try to learn as much as I can about every different culture that I work with, because if you are going to, you're not going to change your favorite foods because for the rest of your entire life because you have a health condition.

1:16:04You need to adjust your favorite foods to suit your health condition. But it's important that if we want to help people get better in a way that's more than just birth control and telling someone to lose weight and sending them on their way, then we really need to be sensitive that this is a lifelong thing where we can't just put everybody into a box. And those guidelines really were great and that they started to show that type of leaning, which has never been done before. What research is up and coming or maybe new research that's been published have you been most excited about? I would say some of the interesting research would be, I find the GLP-1 research is super interesting overall.

1:16:50Ooh, talk to us about GLP-1s and PCOS. So these medications are very interesting in PCOS. So I have many patients with very, very severe insulin resistance, you know, and people underestimate this, I believe. Like a lot of the time, you know, these patients are just, you know, just go to the gym, do these things. You know, I see these patients doing these things day after day. They're doing every single thing that other people are not even doing and nothing is budging for them because insulin resistance is a brain condition. it affects the brain, it affects the gut, and our entire body changes because of it being there when it's very severe.

1:17:31There's a lot of inflammation and then we start making cortisol out of our fat cells. So this causes a lot of really big changes in the body and it's not the same as somebody else trying to lose some weight if they're not insulin resistant. This is a kind of beast of a condition when it's really severe. So the GLP ones are very interesting in that they can chip away at severe insulin resistance. And a lot of this is happening through the brain. It used to be thought it was primarily appetite regulation, but now we're seeing a lot of information on inflammation and these effects. And we see our patients, I know it's very new, and we don't have enough research on PCOS specifically, but I can see my patients on this.

1:18:17There's sort of a long-term slow effect where things, the inflammatory problems seem to decrease gradually over time because it takes a long time to treat insulin resistance because everything in your brain, your cells has to change. So I find the research on inflammation and the brain, really interesting. There's also a recent study that came out showing on PCOS patients showing that the taste centers in the brain really profoundly changed with GLP-1s. So basically all of those sensitivities to taste became more normalized after using GLP-1. Yeah. And they could actually track this in the brain specifically.

1:19:05That's so interesting. So tell us more, like, what should women with PCOS know about insulin resistance and its effect on their brain? So when your brain has a lot of insulin resistance, there's a lot of different changes that are going to happen there. So we see a lot of changes with the energy metabolism in the brain. So the way our brain will use energy isn't as efficient in many ways. There can be ups and downs in glucose. So, you know, sometimes you'll see issues with brain fog, cognition, and memory. And we see a lot of that, you know, in diabetics as well. And in diabetics, we can see changes in the brain.

1:19:42So the insulin resistance really does impact it. It influences our taste, our appetite centers of our brain as well. And obviously our mood, it can definitely influence that too. Mm-hmm. And have you seen, are you using GLP-1s or do you have patients who are on them? Yeah, I do have patients on them. I cannot prescribe them myself, but I have quite a few patients on them in my practice who I'm following. Yeah. Well, Canada has just very interesting rules. So, you know, because I have prescriptive rights for GLP-1s and I do use those in my practice. And for everybody listening, I will put in the show notes, It's McCall McPherson's interview that we did because her and I use them similarly with autoimmune patients with doing low dose to help with bringing down their inflammation.

1:20:33She does a lot more weight loss. I'm less about the weight loss. I'm more about like the brain metabolism, what is happening with inflammation. So I use them in autoimmune patients, endometriosis patients. I really am trying to work with a group right now to get a study going around that because I've seen tremendous impact on endometriosis patients with it as well. And then certainly those with ADHD, seeing that their brain, they feel their brain works better. And I think it is because of exactly what you're talking about with the insulin, the inflammation, they can better utilize the energy that's happening in their brain.

1:21:09With the dosages of PCOS, we know that mainstream they are dosing, they typically start at the 0.25 milligrams, then they jump people up 2.5 and their goal is to get everybody to 2.5. I do not share that goal because usually I find people are sick. They're not happy. Like when they're passing two, they're like, my gut's not happy. Like I just do not feel good. My energy is getting low. And I'm like, if we can go slow, use it low and achieve what we need to achieve, then why not do that? So, you know, for people eliciting that 2.5 is like the goal for those who are obese, but a lot of prescribers are just using that as the standard of what they're trying to reach towards.

1:21:55What are you seeing specifically is working with GLP-1s in the PCOS population? Yeah. So yeah, I also agree that there's differences between weight loss as a goal and, you know, PCOS. And I also find with PCOS, We have a lot of fatty liver, a lot of biliary issues already in these patients, a lot of hormone imbalance. So the aggravations from GLP-1 sometimes can be worse. But one of the things I notice in the patients is that it takes a long time. Like if I'm tracking somebody's CRP, that person could be on that same dose for a very long time. And I'm seeing like improvements gradually in time with these inflammatory markers.

1:22:40because if it's weight loss is not the goal, then we can observe and see what's happening because it takes time for our brain to change quite a bit of time as well. It takes time for our liver to burn fat and to change and for all of our hormones to change. And we'll see a lot of patients starting to get more regular cycles, but without even necessarily raising their dose, without necessarily losing further amounts of weight. so it's this exposure over a long time to less insulin to less inflammation our tissues start to change their receptors so yeah using lower doses for longer times observing there's lots of different strategies um you know i always recommend to build muscle also because muscle's anti-inflammatory and has effects on the brain so when you do those things together for a long time don't necessarily always need to be amping the dose up all the way and get making yourself sick because many people just start getting sick when they go up high.

1:23:40You can still benefit by using it in different ways. So it's an interesting medication overall, I would say. Yeah, I appreciate that you talked about how you need to build muscle mass. And I think when you're on a GLP-1, especially if your appetite starts going down, you have to be even more focused on your protein intake and definitely strength training. I will tell anyone listening, I don't trust anyone prescribing GLPs who are not also talking about how you retain your muscle mass and about strength training as well. And we're just seeing that in a lot of weight loss clinics where they're just a mill.

1:24:16They're just like pump. They're just like have people in a conveyor belt of like, click, click, click, give your injection, just go. And I think that is where we see the problems with GLPs. I also think there's a lot of stigma and pushback from people who are not, they're not in the medical community. I've never seen anybody with a medical license say this, but I see a lot of keyboard warriors out there who are on PCOS women's accounts saying, how dare you use the GLP-1? How dare you use any of these medications? You're taking this away from someone with diabetes. And I'm always like, okay, firstly, this is a peptide.

1:24:52And we got a lot of peptides out there and we're using them in a lot of different ways. Secondly, tell me you don't know anything about PCOS without telling me because the fact that you would criticize a woman with PCOS, like you might look at her and you might think, oh, she looks fit. She can't have diabetes. But in reality, she does already have insulin resistance. And as you were talking about, we're testing fasting insulin. What most people are waiting for, and I think this is the absolute most idiotic thing of medicine is waiting until your hemoglobin A1C is through the roof. waiting until there is a frank diagnosis of diabetes and then saying, we should do something about that because you already have kidney damage.

1:25:37You already have damage to your eyes. You've already damaged your organs by the time we catch that diagnosis. If we test fasting insulin and we do something about it, and for people listening, sometimes in patients, it's like your fasting insulin is up. We're gonna do diet and we're gonna do lifestyle. You're gonna get working on that and that's gonna take a while. So we're gonna do a GLP, for several months to help you along in that journey and then continue to support you. Because the fitness bros out there will tell everybody, if you stop GLP-1s, oh, the weight will just come back. Not if you are working with somebody who supports you in your nutrition and lifestyle endeavors, working with your individual biochemistry, and then tapers you off the medication and you continue that on.

1:26:24we actually don't see that weight comes back, but also we see lasting benefits. So it's also the kind of thing too that like sometimes you're going to use metformin where you work on nutrition and lifestyle and then you're going to pull a person off of metformin. Sometimes, you know, you're going to use a medication for a period of time because we know that the natural stuff, that can take months if not a year before your body has really adapted to that and that your lifestyle has adapted and be able to be successful with that. So I'm just about give people all the tools and let them choose what is appropriate and right for them and have that dialogue with them.

1:27:04And sometimes it is going to be GLP ones. Yeah, exactly. Like as doctors, we recognize that these are just tools that can be used by us for certain scenarios, for certain people at certain times, we can take them away. But when you see things on social media, it's very much like a tunnel focus on that one thing, you know, and really just a single example of a single person's experience without that perspective of seeing these severe insulin resistant people going through maybe a year of using a lower dose of that while really working on their metabolism, making sure their thyroid's good, building muscle, and then like weaning them off of that.

1:27:44That is an individual approach to medicine based on understanding people's health overall. This like, you know, what we see on social media, judging people, it just shows a lack of understanding very certain, certain people's insulin resistance is so severe that it is slowly making them sicker and sicker. And these tools can break into that and help them get better. And there's no judgment around that because we can all get sick. All of us can. And we all will at some point in our life. Yeah. I especially think about in the context of people who already have insulin dysregulation, they have brain energy metabolism issues.

1:28:22Like we see TCOs, ADHD, then they go into late stage perimenopause and then menopause and they don't have enough estrogen. I think about the dementia risk. I think about the Alzheimer's risk with that. And that is something that has been interesting as well with ADHD medication. People with ADHD have a much higher risk of dementia. And we see that when they use ADHD medication, that risk drops significantly. And that's all about brain energy metabolism. And so for people listening, I think it's just really important to consider what your risk factors are and then use the tool that's best for you.

1:29:00Even if it comes with stigma, even if it comes to judgment, here's the thing. It's nobody's business and you don't have to tell anybody anything about your health and they're not entitled to it. And for people listening, especially people who have, I find this so ridiculous. I don't know if this happens in Canada, but in the United States, if somebody has a large social media following or they're a celebrity, suddenly people feel that they are entitled to know everything about their life and that they're owed an explanation about everything. And I always find that so bizarre because the person following demanding that will also turn around and say, I don't owe you anything, but you owe me everything because you played in this movie one time.

1:29:42Yeah, exactly. Like it's, it's something that because there's judgment and stigma out there, we have to protect ourselves. Like, so if you have a condition and you're at some party and someone's going to be like, have an opinion about that, you don't have to tell anybody anything about what you're doing. If you lost weight and you look great and people are making comments, did you use, you don't have to tell anybody that's none of their business, especially some people, when you tell them things, that's not going to go well for you. So it's just a self protection. And a lot of things are like this when they first come out, you know, there's a stigma and then it's accepted, um, once more is understood.

1:30:19So it's something where you just have to do what's best for yourself and try and not care what anybody says, especially on social media because a lot of them are really lacking the experience understanding these things. Yeah. And what's funny is that a lot of people are like, these are brand new drugs. They're actually not. We've had them for a very, very long time. The biggest thing that happened is that insurance started changing how things were covered. And so people started getting access to them. But people have been using these for a very long time. They're not new and we have a lot of data on them.

1:30:53I think that we are only now with people being more interested, starting to get more data about how they can specifically benefit us outside of just weight loss. And so I think that's just really important for your people to understand is that when a drug goes to market, it's all about who can we market this to, to get, we get the FDA to approve it. Like we've got the trials for that. And then we can sell it. We use drugs off-label all the time. You got PCOS, spironolactone, ring a bell? Yeah, it's an off-label use. Like that drug is not intended to treat the excess androgens causing hair growth, hirsutism, where you don't want it, and, you know, causing oily skin and acne.

1:31:35That's not what it was FDA approved for. That's off-label use, but it's generally accepted. Testosterone prescribing in, you know, menopausal women, off-label use unless you have issues with your sexual desire, which I just find so ridiculous because they're like, I always laugh when people are like, oh, there's no evidence that testosterone can help someone's mood or it has any effect on women's moods. And I'm like, do you ever hear about being in the mood? Do you know why it's called that? Like, libido is a mood. Yeah, obviously, right? Like, I don't understand. It's like the lack, They're like, the fact that the studies aren't done means it's not effective.

1:32:15That's not the case. You know, research takes time and there's not enough interest in doing this research in the first place unless money can be made. So yeah, obviously all the hormones affect our mood. We can all feel that in our own bodies. Well, thank you so much for taking the time and having this conversation. For everyone listening, leave me a comment. We will have Dr. Fiona McCullough back. She is definitely like the go-to PCOS expert. So if you have more that you want to hear from her, leave us a comment. And then I will certainly link to you everywhere in the show notes so people can learn more about you, follow you, get in on all of your information.

1:32:50But thank you again for taking the time. Thank you so much for having me. It's been awesome. Your call has been forwarded to voicemail. Hi, this is Zoe Deutsch. And Nick Robinson. Our brand new movie, Voicemails for Isabel, is all about those little moments that feel like the universe is looking out. Feeling homesick, then your sister calls. Hearing that perfect song exactly when you need it.

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