Female Hormone Health, PCOS, Endometriosis, Fertility & Breast Cancer | Dr. Thaïs Aliabadi

Every single opthalmologist knows about cataract. Yes. Most common form of of blindness. So it would be rare for you to go to an opthalmologist with cataract and not get diagnosed. Correct. Correct. So why is it that the leading cause of infertility on this planet? 90% of women are not diagnosed. Women's health is very different than other fields of medicine. It's very it's a different monster. It's that cataract patient that goes to 20 opthalmologist and she keeps saying, "I can't see." And the opthalmologist says, "You're crazy. There's nothing wrong with you." Welcome to the Hubberman Lab podcast, where we discuss science and science-based tools for everyday life. I'm Andrew Huberman and I'm a professor of neurobiology and opthalmology at Stanford School of Medicine. My guest today is Dr. Tais Aliyabati, an obstitrician, gynecologist, and surgeon and one of the most sought-after experts and trusted voices in women's health. Today we discuss crucial topics in women's reproductive and general health, including PCOS, endometriosis, breast cancer, pmenopause, and menopause. Dr. Dr. Aliabati explains why so many cases of PCOS and endometriosis go undiagnosed and how many physicians unfortunately write off things like pain, hair thinning, mood changes, and other symptoms as normal when in fact they reflect larger underlying issues that can impair fertility and lead to bodywide health complications. And she explains the key things to do to diagnose and treat PCOS and endometriosis. Everything from how to adjust insulin sensitivity to hormone replacement, over-the-counter, and prescription-based protocols. As you'll soon hear, Dr. Aliabati is incredibly passionate about women's health and has developed various zerocost online tools that women of any age can use to assess their risk for things like breast cancer, PCOS, and endometriosis. I should also emphasize that today's discussion is relevant to women of all ages. Many of the conditions we discuss are starting to show up in women even in their mid- teens and 20s and can carry serious health risks. Dr. Aliabati makes very clear that often these issues can be resolved, but that it requires knowing the telltale signs and taking the appropriate steps. She explains that alas, many doctors and even OBGYNS are unaware of those telltale markers. So, what you're about to hear is an extremely eye-opening conversation that thanks to Dr. Dr. Aliabati's passion for and expertise in women's health could very well save someone's mental and physical health, their fertility, and in the case of breast cancer screening, even their life. Before we begin, I'd like to emphasize that this podcast is separate from my teaching and research roles at Stanford. It is however part of my desire and effort to bring zerocost to consumer information about science and science related tools to the general public. In keeping with that theme, today's episode does include sponsors. And now for my discussion with Dr. Tais Aliabati. Dr. Tais Aliabati. Welcome. Thank you for having me. Super excited to talk about today's topics and there are a lot of them because I think these days we hear a tremendous amount about how fertility rates are dropping. We hear that sperm counts are dropping. We hear that things like PCOS, which he'll explain to us, are on the rise. I'm curious if they're on the rise or they're just being detected or not detected as much. Let's start off quite simply and just bracket for people what the sort of standard trajectory of fertility looks like for the quote unquote average woman. I realize there's no such thing as an average woman, but I think we hear so much these days about people are waiting to have kids, some people are freezing eggs early, all this. If we were to just march through and say, you know, um what fraction of healthy women are fertile in their say 20 to 25, 25 to 30 and march that forward just to give people a sense of what the data and your experience really tell us. First of all, before I go there, I want to tell you something. I want to tell you how excited I am to be here today. And I'll tell you why. Because I've been in women's health for 30 years. And one thing I learned is that women's symptoms get dismissed, minimized, or completely ignored, right? It's normalized. These women, every time they complain, they say, "It's in your head. You're anxious. You're stressed. Um, you know, it's it's normal. It's part of being a woman." And behind these dismissals are millions and millions of women suffering undiagnosed PCOS, endometriosis, chronic pelvic pain, infertility, which we're going to cover right now, and so many other issues because no one takes the time to listen to them. And um the reason I'm so excited to be on this podcast is I want to shed light on these topics, especially endometriosis and PCOS, because they're the top leading causes of infertility on this planet. Majority of these patients are never diagnosed. Majority. And that's why I'm so excited to be here and I love talking about fertility because the reason these women end up in a fertility clinic in the first place Majority of them have undiagnosed PCOS and endometriosis. So we are born with certain number of eggs, millions of them. And we don't make more eggs after we're born. And as we go through life, we start losing these eggs until at about menopause, we have about a thousand of them left. So as we get older, the number goes down, but the quality also declines. The issue is PCOS and endometriosis affect your egg count and your egg quality. So because 90% of these patients are never diagnosed. What happens is they start losing their eggs. Let's say take an endometriosis patients which we're going to get into it. But they start losing these eggs. The quality starts shooting down. Some of them by age 30 they have zero eggs left. And these are patients who bounce from doctor to doctor and their symptoms are dismissed. They're being told that their painful period is normal, that their painful sex is in their head, that they're exaggerating their pain, and meanwhile their ovarian reserve is completely depleting, and no one is addressing that. Andrew, I've always said this, and I really mean it. If every 20-year-old in this country would go through my office once at age 20, I would shut down these fertility clinics. Because where do these patients end up? In fertility clinics. That's why these doctors are so busy. And that's why these patients go bankrupt, selling their homes, selling everything they have to pay for an IVF cycle that could have been completely blocked had they been diagnosed correctly and treated at a very young age. And I'm talking sometimes I treat 13y olds with endometriosis. I have right now in my practice a girl at 14 with endometriosis whose egg count is the egg count of a 40year-old. That's why you can't I can't sit here and generalize that if you're in your 20s you're going to be fine. It's not true. You need to know at a very young age, every girl on this planet needs to be screened for endometriosis, for PCOS, and they need to know their egg count. Egg count, AMH, antimmalarian hormone, is a simple blood test. It's covered by most insuranceances. It needs to be offered if you don't want to offer it to your young patients because, you know, teenagers are tricky because they have so many eggs. But if they're complaining of severe pain, if they're missing school, if you're have if you as a parent, you have to go pick them up from school, the nurse is calling you, they don't want to take their test because they're rolled up in bed from pain. That patient, even at 14, deserves an egg count check because for these patients, sometimes by age 16, I freeze their eggs. Incredible. So I'm going to reframe my question on the basis of what you just said um and ask is the typical plot that we see of you know this x number of uh or x percentage of of women of a given age bracket are of this fertile or not fertile meaning how many trials or times it would take in order to successfully um get pregnant carry a baby to turn. Should we either discard or think differently about the data that we see plotted out? Like if I were to go into one of the AI platforms and ask, I'm sure it would generate a plot for me. What I'm hearing from you is that because PCOS and endometriosis are not taken into account. The textbook picture is a false picture of fertility as a function of age. Correct. And that's why I have a patient who came to me, she was 24, severe pain. She said, I listened to your podcast. I went to my doctor and I asked her, my gynecologist, and I said, "I have really bad painful periods and I think I have endometriosis. Can you check my egg count?" You know what the doctor told her? Her gynecologist, "You're too young. It would be malpractice for me to check your egg count because at 24, you should not have any issues and you have no problems getting pregnant." I operate on stage 4 endometriosis patients at age 18. That's why I'm here. That's why I want to grab this mic. And that's why I want to just focus first on PCOS and then focus on endometriosis. Cuz these two conditions, you don't need a doctor to diagnose you. If you listen to this podcast, by the time you and I are done, whoever is listening, if it's a parent, if it's your sister, if it's yourself, if it's your daughter, you're going to be able to diagnose these conditions, the leading causes of infertility on this planet. It can be diagnosed by the time we're done. You're going to walk on the street and you're going to say, "I think that woman has PCOS." I'm serious. That my patients are so smart. They literally send their friends. They're like, "I'm sending you my cousin because she has endometriosis." Patients are diagnosing when doctors are not. Incredible. That's why I'm looking forward to these robotic doctors. I read that China has this robotic hospital. I'm like, "Praise the Lord. These robots are not going to dismiss women. If you tell a robot, sex hurts, I stay in bed, I end up in the emergency room every time I have my period," the robot will not call you crazy. The robot will say, "You probably have endometriosis." 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But again, nothing sticks to it, so it's really easy to clean, and it's even dishwasher safe. I love it, and I use it constantly. Our Place now has a full line of titanium Pro cookwware that uses the firstofits-kind titanium non-stick technology. So, if you're looking for non-toxic, long-lasting pots and pans, go to fromourplace.com/huberman and use the code hubman. Right now, HourPlace is having their biggest sale of the year. You can get up to 35% off all products now through January 12th, 2026. With a 100-day risk-free trial, free shipping, and free returns, you can try HourPlace with zero risk, and you can see why more than 1 million people have made the switch to ourplace kitchen wear. Again, that's from hourplace.com/huberman to get up to 35% off. Well, clearly you're on an important mission and clearly it's good that we reframe the question that I initially asked and start with PCOS and then endometriosis. But before I do that, I just want to um just give a reflection which is u one of the takeaways from what you just said and just one there are many but one of them is that most young women learn about the menstrual cycle. I think they also make an attempt to teach boys about the menstrual cycle when we were in high school. They they try to teach everybody. Whether or not it sinks in to to the males brains is is a question of debate, but most every woman learns at some point about the menstrual cycle. It sounds to me like female health education should also include education about PCOS and endometriosis at a very young age. Mandatory. It should be mandatory. And currently I it's not. In fact, many um female listeners of this podcast, I believe, um either suffer from or know somebody who suffers from PCOS or endometriosis. I know this cuz I get asked a lot uh to cover these topics, which is one of the reasons you're here. And the other thing is that I'm I'm certain that many do not that many do not because they came up through an education system where that just didn't happen. So, we can start this important initiative now. Um what is PCOS? Very good question. So PCOS is the most common hormone disorder in women in the reproductive age. The most common. So we're not talking about some rare diagnosis. Number one, it affects 15% of women in this country. If you go to Middle Eastern countries, that number can go north of 20%. Studies show that 70% of these patients are never diagnosed. I tell you today that that number is over 90%. diagnosed or even when they're diagnosed, they're not being treated correctly. I listen to podcasts on PCOS where doctors come and uh you know, whoever's interviewing them ask them, "So, what do we do for PCOS?" And the answer is we give birth control. That's not true. Birth control is just one tiny little aspect of the entire treatment plan and that's why patients get frustrated. So when it comes to diagnosing PCOS, right, you need to meet two out of three criteria. The first one being symptoms of high testosterone or high androgens. What are those? Facial hair, body hair, the most common acne, oily skin or male pattern hair thinning which a lot of women complain of. Number two is basically uh ovulation dysfunction. These are women with irregular periods. They get their periods um over like you know 35 days. It's not regular 28 days or they get about eight periods per year. These are patients who usually come to the doctor and when you ask them how your periods are, they can't really tell. They tell you it's irregular. I can't quite pinpoint when I'm going to get my period. And number three is PCOS looking ovaries on ultrasound. Polycystic ovary syndrome does not mean cyst. That's a bad name. It's a very specific finding on ultrasound. When you see almost like 20 plus follicles in the ovary and these are follicles. They look like string of pearl. It's very specific to PCOS. The issue is doctors don't recognize it. they dismiss it and they look at the ovary and they like they say, "Oh, you have so many eggs you have no issues with fertility." So PCOS looking ovaries on ultrasound does not mean cyst. To this day, doctors tell patients, "I don't see a cyst on your ovary, so you don't have PCOS." So PCOS is an ultrasound finding. However, in 2023, they added another criteria to this third um criteria, which is elevated egg count or elevated AMH. So, women who have very high AMH, that is a telltale sign for PCOS. And that's what we were talking about before this podcast. Yeah. Because so many women who are interested in and concerned about their fertility will go in and get their AMH measured. And so many just have in mind to that you just want the higher numbers. Higher is better, right? The higher is better. But in case of PCOS, higher does not mean good quality eggs. I see. We're going to talk about that. So you need to meet two of these three criteria. Only two of the three. You don't need all three. No. So if you have irregular periods, right, and you have uh PCOS looking ovaries on ultrasound, you meet the criteria. If you have uh irregular periods and you have symptoms of high testosterone, you qualify. Now, let me tell you, you do not need to have a high testosterone in the blood to get the diagnosis of PCOS. If you do, great. Then you qualify for that high testosterone symptom or in blood. But you do not need to have a high testosterone in your blood. And that's why a lot of doctors tell their patients, well, I checked your hormones and your testosterone is normal. That's not one of the diagnostic criteria. So if you're sitting at home, if you have irregular period, if you have a daughter who gets laser of, you know, constantly is lasering her face, she has acne, she's on spirolactone, she takes Accutane, these are criteria. She meets the criteria of PCOS. PCOS patients have mood disorder. If you listen to them, they struggle from with anxiety, depression. They're moody people. Uh 75% of them gain weight. 25% of them are very lean. I see a lot of eating disorder or disordered eating in my PCOS patients. I would literally tell you that 60 70% of my PCOS patients have disordered eating. You want to find PCOS patients, go knock on the doors of these eating disorder centers. They're sitting behind those doors, undiagnosed, and it's the leading cause of infertility. So this is the big picture of PCOS. So imagine these women who are walking around, they're gaining weight, they can't lose it, they're anxious, they can't get pregnant, they have acne, hair loss, facial hair, body hair, their periods are irregular. They go to the doctor and what do they hear? There's nothing wrong with you. Eat less. You probably need to exercise more. That's all they hear. What do they do? They put them in eating disorder centers when they're a teenager and they feed them pizza and they say, "If you don't eat this pizza, that means your eating disorder is not better." I did a podcast with a patient of mine, Phoebe. She said in this eating disorder center, every day they would put pizza in front of her. And she would say, "I I I eat this pizza, but when I eat it, I get sick. I can't I feel awful when I have this pizza." You know what they would tell her? See, you have an eating disorder. you're not ready to go. No, she had PCOS. But at least if you diagnose and validate them, you can start helping them better. I have several questions. Um you mentioned irregular periods and um I think to most people that means that whatever cycle length they are accustomed to 28 days or 30 days or even you know 22 days that it's regular um and that if it changes by you know plus or minus 5 days or so for you know more than 2 or 3 months out of the year then you would call that irregular. Okay. But if a given how young you're seeing PCOS in your clinic and given that women start menrating at let's say in the in their in their mid- teens early teens I mean I know the age is getting pushed back and but it's going to vary but I could imagine I I've only lived as a male so I'm I'm really uh truly imagining here but I could only imagine that for a lot of women cycle regularity is something that they're still figuring out at the stage when they could already have PCO. OS, maybe not full-blown PCOS, but more milder forms of PCOS. And so this notion of regular periods versus irregular periods, it could be quite confusing for someone to figure out. Um, if it's happening on a backdrop of PCOS, uh, and then that of course leaves aside all the, you know, stress and food induced regulation of of menstrual cycle length etc. So it seems like a very difficult thing to identify. So that's actually you brought up a very good point and I want to make that very clear for teenagers you have to be very careful very cautious diagnosing them with PCOS. Why? As you said when you first start having your periods your periods are irregular and if you do an ultrasound these young ovaries have tons of follicles. So actually the PCOS um uh PCOS morphology does is not used for teenagers. For teenagers to get the diagnosis of PCOS they need to have criteria one which is the irregular period and criteria two which is the high androgen symptoms. You do not use the AMH or PCOS morphology on ultrasound as a diagnostic criteria. Number one. Number two, you want to be very careful diagnosing these patients because you don't want to label them at a very young age. So what I do with these patients, I do a hormone panel and these are patients who usually at a very young age they end up on Accutane for their acne. You give them spirolactone and it's not working. They complain of hair loss. They're gaining weight. They're showing signs of an eating disorder. They're anxious. They're not feeling well. they have really bad I see a lot of PMDD with my PCOS patients. So you look at the big picture and I tend to not label them but I will treat them. And uh you know in uh um 2014 I started using GLP1s on my patients for weight loss for PCOS. 2014 11 years ago. I think most people don't realize that these peptides were out there. They weren't as commonly discussed. they were sort of considered a little bit niche, a little bit, you know, was certainly cutting edge. Incredible. Okay. A question that I just um have to ask is because PCOS is diagnosed, if it's diagnosed properly, by this kind of amalgam of different features and and you mentioned by ultrasound, this kind of characteristic lining up of of the follicles. I have to ask what might sound like a politically incorrect question, but I'm going to ask it anyway. Do you think that male OBGYNS more often make this mistake than female OBGYNS or is this an equally distributed problem in the OBGYn community? Equal. 90% of these patients, let me tell you, are never diagnosed. A a lot of gynecologists don't do a pelvic ultrasound, which I want to change that in this country. It needs to be part of a wellwoman exam. They don't do a pelvic ultrasound. No. Is there I I'm I'm baffled. what what is the reason for not doing it? They're not trained to do it or they have to hire a ultrasound tech to their office to do it. Uh or they but for me in my office, if you come to my office and you say you can't do an ultrasound, it's just like me grabbing your glasses right now and say read how can I how can I diagnose you? Pelvic ultrasound should be mandatory. That's another topic I want to cover with the what wellwoman exam should look like versus what women get when they go to their doctor's office. So one of the issues is because women don't get a pelvic ultrasound. No one knows. One, two, a lot of doctors don't even know what a PCOS looking ovary looks like. They think polycystic ovary syndrome means cysts on the ovary. The naming is really a problem. And this is true in science and very clearly true in medicine as well. the what things are named can be it can be very useful but it can also really limit understanding. Yeah. Uh if anything um today's discussion hopefully will maybe even remove or put an asterisk next to the C and in and PCOS. you know, they want to change the name, but I personally am against it because I've spent 25 years saying PCOS, PCOS, PCOS, PCOS. And I feel like just in the past few years, more and more people, you know, like people didn't talk about menopause. Now, everyone's talking about uh menopause. I feel like PCOS is the next topic hopefully. And if you go and change the name, then I feel like I have to start all over again. No, but you make a very good point. We don't want that to have to happen. And I agree. But they're trying to do it. There's this there's a a strange thing in public health where there needs to be a ton of hydraulic pressure over time. Like, you know, I guess today's my day to be only slightly politically incorrect. You know, 5 years ago, if you said the word obese or you said, you know, this person has health issues because they're obese. It was considered I mean, people were losing jobs for for making statements like that. Now, we understand obesity to be a serious risk to brain and body health. It's a medical condition. I think the GLPs have kind of helped shift the view now because there's a medical treatment, but it was always true that obesity was dangerous for people, but now you can say it. So, I do think that there need to be a lot of hydraulic pressure behind that. And now, um, you're doing the same for PCOS. So, uh, I have a couple questions about the thinning of of hair, acne, and so forth. I could imagine that a number of women listening to this are thinking, well, you know, I've got a little bit of acne. My hair is thinner than it was 5 years ago, but, you know, is this mild PCOS? Is this indicative of PCOS? I mean, everyone knows that hopefully knows their body best, but how bad does the acne or the hair thinning have to be? How rapid before you might say, you know, it it's maybe just, you know, the the hairs seemingly thinner. Um there's a little bit more acne. It's back acne, but and is it throughout the cycle? Yes, it's throughout the cycle. And these are patients who usually come to the office asking for help. They say, "I can't get rid of my acne." I always say, if you're twer than 25 and you're struggling with acne and you come to my office and you're asking for sperolactone and Accutane, something's not right. Right. If you have hair thinning, like you brush your hair and you lose tons of hair. I mean, these are patients you look at, you could look at their scalp and you know they're losing hair. I'm not talking about the hair loss that you get postpartum. Do you know what that's transitional and it recovers in like 9 to 12 months. These are symptoms that persist and as they get these patients get older, it becomes more and more and more significant. But the reason I give that big picture is I always look at other factors. Are they having a hard time losing weight? Do they have mood disorder? Do they have any history of eating disorder? Have they been on Accutane? Do they go and laser their hair like twice a year because they can't get rid of it. It's a pattern that you will know. It's not a little bit of this and a these are patients. Patients who are listening right now to me, they're going to say, "Yes, I have this. I have every symptom." And I put a check in front of it. The problem with PCOS is there are four different phenotypes of PCOS. That's why it's so confusing for doctors to diagnose PCOS. The most common classic phenotype is a patient that has all three PCOS looking ovaries on ultrasound. Elevated testosterone symptoms or high testosterone or androgens in the blood or and irregular period and irregular period. The second type B patients have the high androgen symptoms. They do have um dysfunctional ovulation with irregular periods. But these patients have normal ovaries on ultrasound. So you can't in this group of patients you can't do an ultrasound and say your ovaries are not PCOS looking so you don't have it. Then the third phenotype is the ovulatory PCOS. It gets very confusing. this group of uh PCOS patients actually ovulate at least sometimes because you know 70 to 80% of PCOS patients don't ovulate 70 to 80% do not ovulate even when they have regular cycles. So of the 20 30% who ovulate you need to ovulate to get pregnant this se phenotype these patients are ovulating sometimes with regular cycles. So these are PCOS patients who go to the doctor, they have PCOS looking ovaries on ultrasound, they have acne, hair loss, facial hair, body hair, mood, all of that, but their periods are regular. Even these patients a lot of times are not ovulating. That regular cycle that you're seeing is estrogen withdrawal. It's not from the progesterone of ovulation. And we're going to get into all that if you want to. And the fourth category, these are patients who um basically don't have any uh elevated testosterone or androgen symptoms. They don't have acne, hair loss, facial hair, body hair. They just don't ovulate regularly and they have PCOS looking ovaries on ultrasound. So imagine these four phenotypes, right? And imagine all the insulin resistance and all these other underlying conditions. It makes the big picture, the image of these patients so different. They all present differently to the office. That's why doctors scratch their heads. That's why doctors don't want to diagnose PCOS because they really don't understand all these phenotypes. They don't understand that you can be completely thin and have PCOS. That not all PCOS patients need to have weight issues. That you don't have to have acne, hair loss, facial hair, body hair. That in some phenotypes you don't need to have a PCOS looking ovaries. there's some that have regular cycles. So that's why it gets so confusing. It is uh confusing and yet I think when one hears that there there are different um indicators obviously and it sounds like a a skilled practitioner like yourself can can see the contour of which ones fit together. I it's pattern pattern recognition clinical pattern recognition which is very difficult to do from an AI search or from it's impossible really. I mean I think um I have a couple of questions. Uh one is just leap to mind as it relates to the mood disorders. Um I could imagine that some of these disorders are treated or they attempt to treat them through uh anti-depressants, SSRIs and things of that sort. Is there any indication that the drug treatments for these mood disorders interact with the hormones that we're talking about in a way that exacerbates the PCOS? I mean we know that serotonin and dopamine all these things have feedback and interaction with these hormones or do you think that um that's se a separate thing entirely? In order to answer that I think it's better for me to tell you the underlying drivers of the symptoms of PCOS and how those can affect the mood. And by treating the underlying conditions, sometimes you can address mood changes without having to give them a zoloft or alexapore. You might have to, right? But there's no evidence from what I understand that those drugs are actually causing PCOS. Okay. I just want to essentially rule that out. Right. Okay. Good. I'm relieved to hear that because those drugs are not to my knowledge. I've never experienced that. My my, you know, not so cursory uh web search on this uh said no, but I I want to verify with you. So, um so what is the cause of the mood disorders? You're talking slightly elevated testosterone. So, all the all the males listening are like, "Oo, sounds great." And of course, um supplementing with testosterone um in women in menopause has now become kind of a trendy thing. And you can absolutely do that with PCOS patients. We can get to that. But I is it okay if I discuss the underlying pillars because it's very important and I think that's what people don't understand and I think that's what I've observed in my practice at least over the past 25 years and it's so important to understand it because if you don't understand it then you don't know how to treat PCOS then you don't just throw birth control pill at it and that's why these patients don't feel better so they're underlying pillars that drive the symptoms of PCOS us the number one issue is the brain pituitary ovary access which I'm sure you know it by heart but as you know our hypothalamus releases a hormone called G&R that stimulates in a uh it fires in a pulsatile fashion and basically it stimulates the pituitary gland to release this hormone called FSH which stimulates the follicles in the ovaries as the follicles one follicle per month. As the follicle gets stimulated and starts growing, it starts releasing estrogen. When the estrogen peaks really high for 48 hours, it stimulates that same pituitary gland to release a hormone called LH. And LH is responsible for ovulation. It comes, it basically weakens the wall of the follicle. It causes inflammation. It causes vascular changes, all of that. So the egg gets released. Once the egg gets released, whatever's left of that follicle is the corpus ludial cyst which starts releasing progesterone to basically uh support implantation. This is what's supposed to happen and that's how people get pregnant. It's such a beautiful mechanism, right? Very cells that are stimulated by FSH produce a hormone which feeds back to shut down the production of FSH and bring in the LH. I mean it's it's a I mean it's a beautiful molecular set of gears basically. It's beautiful. I mean not to make it too reductionist but it's it's truly incredible when one thinks about it. And as you mentioned that it spans from the brain all the way to the ovary. It's to the uterus. It's it's a it's a spectacular set of of interactions really. And you know that estrogen that the follicle is uh stimulating gets the lining of the uterus nice and juicy ready for pregnancy. And then when the egg ovulates and now the progesterone comes, the progesterone stabilizes that lining so the embryo can go and implant and turn into a beautiful baby. And usually that cyst, the corpus ludial cyst during the first 12 weeks of pregnancy is helping release the progesterone to help the pregnancy really stick to that wall of the uterus. In simple terms, nothing wasted. Nothing. But women are incredible, aren't we? Incredible. It's amazing. I mean, it's it it indeed indeed they are. It's it's like nothing's wasted. The the portion of the follicle that that would otherwise be quote unquote discarded is actually a source of critical hormones. It's incredible. It's incredible. But let me tell you what happens in a poor PCOS patient. That's the problem. The G&RH, remember that secretes from the hypothalamus, it starts pulsating super fast. By doing that, it shifts the FSH LH balance. So FSH goes down and LH goes up. LH stimulates these cells in the ovary. I don't know if you remember the thea cells in the ovary and they start pumping androgens out, right? And it when you have a lot of androgens in the ovaries, the androgens block the growth of that beautiful follicle that's growing to ovulate. So it freezes the follicle and it prevents it from ovulating. The follicle is still secretreting the estrogen, but it never gets to that peak high, right? And it's still stimulating the lining of the uterus, but the ovulation doesn't happen. So when the ovulation doesn't happen, polycystic ovary syndrome, you start seeing these follicles in the ovary. So is it um lack of sufficient LH? It's too much LH in PCOS. the LH FSH ratio flips. So the LH is twice as much as the FSH. So you have this constant secretion of LH that stimulates these cells to just pump androgens out, right? So the follicle freezes, doesn't ovulate, the follicle stays in the ovary. And one thing that they've noticed with PCOS patients, for whatever reason, their ovary is super sensitive to the LH. It's like adding fuel to the fire. It's like a positive feedback. The reason I asked if it's if it's um how LH is adjusted is the the LH surge is what triggers ovulation normally. Correct. But there is no LH surge. What I'm getting a kind of mental visual of is that um the strong pull of the levers is is it's just a bunch of smaller levers being pulled repeatedly. But but there's still shedding of the uterine lining, right? There's still menses. So it can be. So that's why it's probably very misleading for people who don't have extreme symptoms of PCOS because they think, well, if they're menrating, then they assume that they're And 20 to 30% of them actually ovulate, right? But they don't always ovulate. That's the problem. And of the ones who ovulate, it gets worse. of the ones who let's say you know this uh brain pituitary ovary access is just partially disrupted of the ones who ovulate 40% of them the embryo does either doesn't form because the quality of the egg is bad but also the environment is not ready for it so the progesterone the uterine lining is not ready for it that's why these patients don't get that what is thought to disrupt the hypothalamic uh G&RH neurons it could be everything it could it comes to all the other pillars yes but but is there any evidence um I mean we don't want to attribute everything to psychological stress but the more I learn about the brain and body and their interactions over the years the more I'm convinced that psychological state does impact hormones and brain function anyone listening will say of course it does but 10 years ago there was this notion of psychossematic illness people would say oh they would say it's all in your head we now know that um that stress is a is a powerful modulator of hypothalamic function it actually comes from the hypothalamus in part so I is there evidence that this is you know preceded by stress or trauma things of that sort it just comes absolutely it yes it's genetic and that's why I want to talk about it this is just the first pillar you saw like just the first driving force is this brain main pituitary ovary pathway that's completely disrupted that some most patients 70 to 80% don't even ovulate and of the ones who ovulate the environment is not really good for the embryo so that's just the first pillar but at its core PCOS has insulin resistance and I'm sure you know all about insulin resistance but I want to explain it please remind our audience because you know we we have newcomers to the conversation and I don't think we could hear enough about insulin resistance resistance as a gynecologist, I'll explain insulin resistance. So, I'm sure you've had, you know, physicians uh who probably explain it better, but I'm going to simplify it because it's one of the biggest drivers of PCOS symptom and it's extremely common. Even lean PCOS patients can have insulin resistance. So, what is insulin resistance? The simple way of explaining it is when we eat carbohydrates and our body breaks it down into glucose, glucose stimulates our pancreas to release a hormone called insulin. The job of insulin is it goes to the cells in our muscle in our liver and it opens up the channels on these cells and pushes sugar into the cell where it can turn into energy. So basically insulin takes the sugar from the blood, pushes into the cell and turns it into energy. PCOS patients, 80% of them have insulin resistance. It's not their fault. They're born that way. What does insulin resistant do? When they eat carbohydrate and their body breaks it down into glucose, glucose stimulates their pancreas to release insulin, but their cells are resistant. And I'll tell you why. Remember that androgen that I was talking to you about that gets secreted from their ovaries because of the first pillar makes women more insulin resistant. So, their cells don't respond well. I know it's like, let me get there. It's do the the question I was going to ask was going to be a facicious one. I was going to say, do androgens do anything good? No, of course they do. But do women. No, they do. Well, women need androgens, but they don't need this many androgens coming from the theal cells. Right. Right. So, when their cells can't uptake this glucose, glucose bounces in the blood. Well, you can't have blood stay I mean, glucose stay in your blood. You have to clear it. So as glucose goes up, it pushes our insulin to go up. What does insulin do to PCOS patients? Number one, when insulin goes up, insulin stimulates our ovaries to push more androgens out. How about that? And it blocks the ovulation. It freezes that follicle, right? And it causes acne, hair loss, facial hair, body hair, irregular periods, all of that. The other thing insulin does, it blocks the liver from secretreting sex hormone binding globbulin. If you do a blood test on a PCOS patient, a lot of them the sex hormone binding globbulin is low. Sex hormone binding globulin is a protein in the blood that grabs free testosterone from our blood. Right? When the levels go down because of high insulin, our free androgens and testosterone go up. So more acne, hair loss, facial hair, body hair, all those symptoms. High insulin does one more thing. It basically tells your body, take this sugar, get rid of it from the blood and store it as fat. How does it do that? It pushes our liver to turn it into triglyceride. The triglycerides can a go into our blood as a form of VLDL and go and attach themselves to the heart. And that's why PCOS patients, you have to screen them their lipid panel because of their cholesterol, risk of cardiovascular disease, risk of diabetes, all of that. But what it does, it sends these triglycerides to our visceral organs. So these patients start having visceral fat. Visceral fat is very different than the fat that you have under your skin. Visceral fat actually c releases cytoines inflammatory factors that increases the inflammation. Inflammation makes our insulin resistance worse and inflammation which is the next pillar stimulates our ovaries to secrete more androgens. So it's a vicious feedback cycle. And I think maybe if we just double click on uh visceral fat a little bit. We've never talked about it on this podcast really. And I'm not a visceral fat expert. No. Well, nor do I expect you to be, but I think it's it it's worth um people just hearing twice that visceral fat is not subcutaneous fat. This is why some PCOS patients can be lean. Um indeed, many people, male or female, can be lean and have too much visceral fat. It's important to correct. You can now detect visceral fat and I believe MRI will do it. Not everyone of course has access to MRI. fatty liver they call it. You know what I'm saying? But it gets dismissed. But it's a very dangerous form of fat because of that inflammation. We've known for a long time that there are things that we can do to improve our sleep. And that includes things that we can take things like magnesium thrienate, theine, chamomile extract, and glycine along with lesserk known things like saffron and valyan root. These are all clinically supported ingredients that can help you fall asleep, stay asleep, and wake up feeling more refreshed. 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What sets THW lights apart and why they're my preferred red light therapy device is that they use clinically proven wavelengths, meaning specific wavelengths of red light and near infrared light in combination to trigger the optimal cellar adaptations. Personally, I use the JWV whole body panel about three to four times a week, and I use the JWV handheld light both at home and when I travel. Right now, JW is having their biggest sale of the year. From now through December 1st, 2025, you can save up to $1,000 on select JWV devices during their Black Friday sale. Just go to jv.com/huberman. That's jovv.com/huberman. Some exclusions apply. So the next pillar is chronic inflammation. That's why PCOS patients have this chronic inflammation that they complain about. And this chronic inflammation basically stimulates their ovaries to release more androgens. This chronic inflammation makes their insulin resistance worse. This chronic inflammation can affect their gut. That's why PCOS patients come and say, "I don't feel good. I have food sensitivities. I feel bloated." Because these hormonal shifts and these inflammations do affect our gut. Then we go to the next pillar which is genetics. If you look in PCOS families, there's someone who's either diabetic, pre-diabetic, had gestational diabetes, is overweight, there's some form of insulin resistance. A lot of times you see these patients and their dad is diabetic. So you don't have to look in your mom's side of the family. This is a very important point both sides. A lot of people just do the direct one to one and they assume, well, if my mother had no fertility issues and she wasn't overweight and wasn't diabetic, didn't seem to have type 2 diabetes, then it's not an issue, but yeah, dad's genetics are critical as well. And then the last uh pillar is epigenetics, which I know you talk a lot about it, but it's our stress. How much are we sleeping? What kind of food are we eating? Right? Someone said this to me, and I love this saying. They said, "Your genes load the gun. Your environment pulls the trigger." And I love that because even if you're loaded with insulin resistance, all of that, you can suppress these symptoms, but if you start eating unhealthy, if you're stressed out, if you're not sleeping, if you're just not exercising right, you're pulling that trigger. And that's why, Andrew, all these pillars work together. And that's why these patients present so many different ways, right? And when you were talking about mood, why does someone feel bad? Why does a PCOS first of all the androgens do affect disrupt the dopamine and serotonin in their brain? That's a fact. But put yourself in the shoes of a PCOS young girl who lives at home with a thin, beautiful mom or a thin, beautiful older sister. She's overweight. She doesn't eat anything. She's exercising every day. She's already a little anxious. She has acne. Her mom takes her and they put her on Accutane. She's constantly lasering her hair. Her periods are completely unpredictable. She's starting to have an eating disorder because nothing she does is working for her, right? And then you take this patient with everything I told you with all these underlying pillars not working in her. You take her to the doctor and she gets dismissed. That's why I'm here to speak for them. I feel like over the past 25 years their trauma has become my trauma. I literally can cry right now. It's clear how much you care about your patients and the ones that are not even your patients. just the women out there that are suffering in this way. I uh perhaps um could we explore the possibility of a different if I say phenotype it may make it sounds so clinical uh but but a different person who um perhaps is only experiencing a subset of those symptoms that you just described um and and on that note I'm struck by the fact that you know what we know from male pattern baldness and female pattern baldness is that when androgens get too high it miniaturizes the hair follicle. It's kind of interesting that when androgens get too high in the ovary, they miniaturaturize the follicle there, too. It seems like that basically excessive androgens are bad for follicle development. It Yeah. So, two parallel pathways operating in the exact same way. Um, it sounds like we're trying to make high testosterone the issue, but in some sense, unless we think back to the the G&R neurons firing too much, the elevated androgens really seem to be the the kind of tip of the spear in this whole thing. not what initially sets off the cascade, but in terms of of tractable things that good medications and good practices might be able to take hold of. Correct. Is that right? And and certainly insulin sensitivity as well. But um so I'm imagining, you know, a bunch of different uh patient profiles here, but I can imagine women in their 20s, in their 30s who have been told by society, okay, you're still fertile, you're good. You're going to be fine. These are the women that are showing up in clinics in their late 30s and 40s and saying, you know, why is it that, you know, my egg count is so low or why is it that I can't conceive? So PCOS patients, their egg count is falsely high because of that, you know, these tiny follicles that are frozen in the ovaries that never got to ovulate, they do secrete AMH. So these patients that's why in 2023 they changed that second criteria the PCOS ovaries to elevated or elevated AMH. How high for for AMH? I mean sometimes I like a norm let's say what's a typical value for someone in their 20s and 30s? So I would say up to six is normal and people in their 40s less than one it drops precipitously. Yes. Where is the the the I don't want to say cliff because maybe it's more gradual than that. after probably late 20s it starts declining. That's why I always tell patients, especially PCOS patients, to freeze by 28 to 30 even though they have tons of eggs. Listen, I get patients, they come to my office, they're like, "Doctor, new patient." I went to my fertility doctor. He doesn't know what he's doing. Why? 40, 41 year old. I put out 30 eggs and he couldn't make a single embryo through IVF. Yeah. Through IVF. You shouldn't put out 30 eggs at age 40. That's PCOS. This is so important for people to hear because I think egg count and elevated or high enough AMH is is sort of touted as the thing that people go and look at. It makes sense, right? I mean, they'll do an ultrasound, count count follicles. It's great as long as you're not missing PCOS because if you're if it's PCOS, then the quality of the embryo is bad, then the ovulation is suboptimal, the environment is suboptimal, and everything else needs to be fixed. And this is perhaps why some people go in in their their 30s, they might be doing IVF or something like that and they actually have relatively low egg count. They'll get, you know, maybe I don't want it's always tricky what what what low correspondence, but you know, three and and two, you know, three on one side, two on the other, but then the IVF works because you you don't necessarily need the quality of the eggs is higher, right? So, AMH, antimmalarian hormone, the easiest way to look at it is every uh 0.1 of AMH averages to one follicle. That's an easy way to calculate it in your head. Okay? So, if you have an AMH of one, you you should have about 10 follicles. But if you show up at 40 and there's 30 follicles in your ovaries, something's wrong. That's PCOS. You have to make sure it's not PCOS. have to make sure that you're not missing PCOS because that's why this woman is not, you know, getting pregnant. And can I tell you, Andrew, how many patients come through fertility clinic and they're not diagnosed with PCOS even by their fertility doctor? Well, the way you're describing the the sort of standards in the medical profession, it's it's both not surprising and really umad disheartening. Yeah, it's it's really sad. again why one of the reasons you're here today. I think this reframing of AMH and and egg number um or or follicle number is very important for people to hear. uh because um you know I know a number of different people done IVF do IVF and and this issue of of AMH and and follicle number is like kind of held as the thing right and 50 oh my goodness someone still has you know 20 20 follicles at age whatever you know um 41 or something and then and then they have they'll go through rounds of IVF and it's just it's it's I'm not a fertility specialist but I can tell you if at age 25 28 every three um eggs make one embryo. At 40, you might need 10 to 15 eggs to make one embryo. So if your AMH at 40 is 0.5, that means five follicles. So you might have to do two or three cycles of egg freezing or embryo freezing before you can hit that normal embryo. So that's why unfortunately insurance companies don't cover egg freezing, right? And I always say this when uh girls are young and they have beautiful eggs and their eggs are young and healthy and you want to freeze them, they can't afford it because it's very expensive and then when they can afford it, they're usually in their late 30s or 40s and the quality is down. So that needs to be fixed. And we had this conversation, I think, in the Bay Area. A lot of these big companies like Google and Facebook and these companies actually pay for their employees to freeze their eggs. They're smart, right? They don't want their employees to get pregnant. They're like, "I'll pay for your egg freezing. Keep working." But most women most women don't have access. And let me tell you, 50% of counties in this country don't have an OBGYn. 50% 50% of counties. A lot of these women have to drive two to four hours to see their OB/GYN. That's crazy. That's why these podcasts are a gamecher because if they don't have access, that's why artificial intelligence AI, these robotic chat bots that hopefully can someday diagnose these patients and treat them, you know, from home without having them have to drive, I don't know, four hours to see an OB/GYN who will then also dismiss their symptoms. Yeah, like you said, in some cases, technology may be better than certain physicians. I don't disagree with you there. At the end of this podcast, you'll believe in the robots treating Well, I'll believe in in in robots and technologies perhaps doing better than some clinicians and scientists to be fair. But I do think that spectacularly good clinicians like yourself and in other fields. I mean, I know people in different fields of medicine. I'm fortunate enough blessed to know people in different fields of medicine for whom you can truly say that there's no world where a robot or even 15 doctors can compare because there's something about you know knowing the principles of something knowing the principles below the principles principles below that and then being a longtime practitioner in a given field. Yeah. You know like true what we call true expertise deep expertise and lateral expertise. No, I was going to say, you know, most fields of medicine, let's take opthalmology, right? Every single opthalmologist knows about cataract. Thank you. So, it would be rare for you to go to an opthalmologist with cataract and not get diagnosed. Correct. So, why is it that the leading cause of infertility on this planet, 90% of women are not diagnosed? Women's health is with you." Now, that's an excellent analogy. Not not just because it's vision and that's my home area of science, but because I think humans are so dependent on vision. And just the idea of losing vision is uh for people who are cited is uh so challenging. Oh, I mean the number of of incredibly elegant feedback loops and the way the whole thing works like a beautiful symphony when it works also indicates that like small disruptions in these things are can cause um really downstream consequences. I'm curious why so much more PCOS or is it like so many areas of medicine where it probably was around a long time but uh we just weren't aware and you know I can point to the insulin resistance maybe it's how people are eating and they the downstream chronic inflammation from the traceral fat maybe it's the neuroscientist in me I keep thinking of these G&R neurons in the brain that are suddenly start firing abnormally you know I have all sorts of pet theories as to why that could be the case but of course I don't have any any data This affects it for sure. Disrupted sleepwake cycles. I would sort of default to that. But then you see these young girls who grow up in amazing loving families. They've never had any stress. They're you know they didn't have any trauma. They're sleeping well. They're eating well. Yeah. But they they start having these symptoms. The reason I'm saying this, I don't want um people to get this message that stress is starting all this because they really it's a it's a multi-system dysfunction. It's an immune system dysfunction. It's a insulin resistant dysfunction. It's a brain pituitary, ovary dysfunction. It's has a genetic factor. It has an epigenetic. And that's why the treatment plan is so important. That's why you can't throw birth control at all these pillars and say, "All right, see you later." Also, birth control means many, many things, right? I mean, there's the I love birth control, but you know, well, nowadays there's a bit of a push back. I noticed at least on Instagram for what it's worth. Um, sometimes we think Instagram is the whole world and I'll tell you everyone, it's not the whole world. There are a lot of people who are not on Instagram all the time, but many are. Um, and there seems to be a bit of a push back against um, certainly hormone based contraception. A lot of women um, I I hear from are convinced that it somehow they believe it damaged them and and I believe them. That's when the topic of endometriosis will come up and I would love to talk about that. But the reason birth control pills work for PCOS patients, it's one of the aspects. I don't like birth control pills for PCOS patients. Remember I told you they're moody patients. they're they have an anxiety, they're depressed. Um it's hard for them to take birth control pills in my opinion. A lot of times they complain of I'm eating more or I don't feel well or I'm more depressed or so I it's not my first go-to treatment, but I will tell you why it works. Remember I told you the ovaries are um the sex hormone binding globbulin goes down because of that high insulin. Birth control pills stimulate that sex hormone binding lobbulin that starts grabbing the testosterone and helps with their symptoms. That's why if you go to the doctor and you say I have acne, they're like birth control. I have hair loss, birth control. My periods are irregular. Birth control. We use it for all everything, right? But it does work to treat the symptoms of PCOS. It makes the periods regular. It helps with the skin. It helps with the hair loss. It helps with all of that. This is estrogen based or progesterine based birth control. You can do both estrogen and progesterone or there's a progesterone only birth control pill now called slend that helps with um it's very anti-androgenic that I try for PCOS patients who don't want to you know need a method of birth control but when it comes to treatment you have to hit the underlying um pillars right so we talked about the epigenetics I always start with there with that exercise walking after each meal meal, you know, walk for 10, 15 minutes. Make sure you're sleeping well. Make sure your diet is healthy. You're not eating inflammatory foods. You're avoiding, you know, u processed foods. Um, so lower your stress. So, you deal with that, but that doesn't work for these patients. That's why you need to address everything else. Insulin resistance is one of the main pillars that needs to be addressed. You have to lower that insulin because if you lower that insulin, you're lowering visceral fat. You're lowering inflammation. You're lowering the ovaries from secretreting androgens, right? So that insulin needs to be lowered. That's why a lot of PCOS patients get prescribed metformin, right? What does metformin do? Metformin basically makes us more insulin sensitive. It's opening these channels. So sugar clears the blood and goes into the cells where it turns into energy. Is it high dose metformin or low? No, high dose. High dose I mean I start patients on 750 twice a day but you have to start slow because uh PCOS patients especially the ones with insulin resistance which is 80% of them. Um I start with 750 because it can cause sometimes GI symptoms like diarrhea and it can also cause nausea. So I start with 750 at night. Then if they tolerate it, I um add the 7:50 in the morning. And for patients who um are tolerating it and they still are not ovulating, their periods are still not regulating and they still have symptoms, I might up it to a thousand twice a day. But you see these patients who come in on 500 milligram of PC uh of metformin once a day. That's not going to touch these patients. So metformin is one. But before Metformin and I don't know if you know this because of my passion for PCOS I actually developed a calculator it's called it's a platform called OV women can go on it obviously I can't diagnose on the on any website but I can tell them that ask them it's my algorithm that I've developed over the past 25 years and I can tell them very closely whether or not they have the likelihood of having PCOS. M so that it's there it's ov.com ovi.com it's free they answer some questions questions and I tell them whether they have the likelihood or you know if they're less likely to have PCOS and if they do PCOS is one of the very few conditions in medicine where supplements make a huge difference and these are for patients who don't have access to the doctor and these are patients who basically go to the doctor and they're not being they're being dismissed these These supplements work amazingly well. Why? Because um the OV supplement I created, I literally did it here. Diagnose yourself and if you're being dismissed, start with the supplement. They make a huge difference for these patients. Why? Because they address the insulin sensitivity. I'm sure you've heard of anacettol, different forms of anacettol that work um to uh to increase sensitivity to insulin. And that's why these patients when they take it, they say, "Oh, my periods became regular or I took it and I got pregnant." Because it does address that when it comes to this insulin resistance. They can either do the metformin, but what I like to do, I like to start them on supplements that has inactol in it and sub vitamin D. Did you know that low vitamin D makes you insulin resistant? Well, I'm convinced that I I was aware, but I think it's it can't be stated enough or emphatically enough because, you know, I know I'm always I'm really bullish about this sunlight thing. I'm always talking about sunlight. I don't want people to get sunburn. That's not what I'm talking about. But we spend so much more time indoors now under artificial lighting where the short wavelength lighting, everyone's low. It really disrupts how the mitochondria process energy and the long wavelength light from sunlight, the so-called red and infrared light serves as a protective feature against the short wavelength light. So, we're not getting enough vitamin D and we need that. That comes from the short wavelength light. I do have a question about inositol. Um there are a couple different forms. Uh there's my right. Um and and we can explore those in more depth. Um but um it is a well-known uh regulator and and can improve um insulin sensitivity, which is what you want. Sometimes people hear insulin sensitivity and they think that's the bad thing. You want your insulin to be sensitive. You don't want it to be resistant, right? Anything that will make you more insulin sensitive will help with symptoms of PCOS. So you want to bring down these pillars, right? without even thinking about birth control pill. You want to lower your insulin resistance. So whether it's metformin or supplements or exercise or low carbohydrate diet or lowering your stress and lowering your cortisol, all of that all of this system. That's why I wanted to explain all this because they all work together. Then you want to bring your inflammation down. You want to bring that visceral fat down. So you have to that's why I don't know if you heard this but you know in 2014 back then I had trulicity as GLP1 and that's what I used to use for my PCOS patients and they would lose 50 60 80 100 pounds and this is 2014. What did your colleagues think at that time that you were injecting patients with GLP? Um I actually learned it from a cardiologist who I used to work with Dr. Corandi and I used to send because I would screen for lipid panel on these PCOS patients and they were all you know we they had high triglycerides and they were overweight so I would keep sending them send my patients to him and one day he called me he's like listen ta there's this medication called trulicity do not stop sending your patients to me treat them with this medication they will lose weight and their cholesterol everything will get better so in 2014 I started putting these patients on truly and one thing I realized is their periods were getting starting to get regular their symptoms of PCOS would get better and the first thing they would come and tell me is doctor I feel less inflamed why do you think because you put them on these medications first of all PCOS patients chronically they have this insulin firing right and that's why this cascade starts what GLP1s do people think it's It's an appetite suppressant and that's how it works. Well, that's that's a side effect of it. But what it does, it actually regulates that insulin. So when you eat, it spikes your insulin up and clears that sugar out of your blood, right? It's like a scavenger, glucose scavenger, right? And it also makes you insulin sensitive. So again, clearing it, which is oxygen really for these PCOS patients. That's why I get so upset when patients comment about these GLP ones because in this subgroup of patients with insulin resistance who are overweight, who are not ovulating, and who have all these symptoms, these medications since 2014 have changed their lives in my practice. The push back on GLP1 says there are variety of reasons um probably a discussion for another time but they've clearly helped many many people uh as long as people still engage in the right behaviors muscle resistance training and people still need to take great care of themselves eat properly exercise sleep etc. You mentioned metformin several times. I'm aware of a um of an over-the-counter version called bourberine which I believe comes from a tree bark um which is supposed to be a pretty potent glucose scavenger as well. Is there any reason why bourberine is not advised? So I think there are some studies that say long-term bourberine is not uh advised. The problem with PCOS is it's not something it doesn't have a cure. You can't cure it. It's an ongoing issue. That's why you need to be on supplements that long term you can stay on and you know like you mentioned vitamin D uh curcumin uh chromium uh um anacettol there's so many things we can do to increase that insulin sensitivity lower the inflammation in the body I don't usually give bourberine long term but it definitely short term you can use it as pulse uh treatment for these patients and metformin it sounds like is a relatively safe drug. Is that right? It's very safe. I you know um even for my patients who are not PCOS um I recommend um metformin let's say permenopausal women with hemoglobin A1C's in the borderline range you know 5.7 you fall into the pre-diabetic range. Um, you know, I'm very lean. I've never been overweight, you know, but I have a long family history of diabetes. And, uh, my hemoglobin A1C was, um, 5.6 a few years ago. And I started taking metformin, and now I'm at 4.8. What um, dosages for people who are relatively lean or or lean? I start with like 500 at night just to see how they do. Metformin does have side effects and drops your blood sugar, right? And and no, it's mostly like the nausea and some people really get really bad diarrhea with it. That's why, you know, um you can I start them on the supplements. If it doesn't work, I go to Metformin. If that doesn't work, then I offer them GLP-1s. I see. But you can abs and I always ask the patients ask me, can I be on the supplement on uh metformin and on the GLP1? Yes. You just don't want to start the GLP ones with the metformin because they both cause nausea and you don't know which one's causing what. So if someone's morbidly obese and they really want to lose weight, I I start with the GLP1s and usually in about four months, my average since 2014, I can tell you four months of GLP1s done correctly, patients lose 24 pounds. That's my that's my uh that's my curve at my office of body fat and muscle or probably of muscle too. These patients are a lot of them are like they need to lose weight 300 lb. So it's hard to even assess that. But you know what? As they start losing weight, they become more motivated because it's the first time in their life that something actually works for them because you're actually regulating that insulin dysfunction that they have. And by supporting that, they become more active. They their self-esteem gets better. I had a 26-year-old in my office who I've been treating for many years for PCOS and these GLP1s and she came into my office a few months ago and when I walked in, she was videotaping me. She looked so good. She was so confident. Her hair was done. She had a mini skirt with these boots and she was always like, you know, very shy and she wouldn't talk. She was this different person that walked into my office. And I started hugging her and she started crying and she looked at me. She said, "Dr. This is the first time in my life I know what it means to be happy. Wow. Yeah. I mean, it's very clear that these GLP1s can help a lot of people. It's interesting that the the push back on GLP1s now is changing a bit because um a number of compoundingies make them now. So, you know, people tacked the GLP1s to quote unquote big pharma. You was kind of Yeah. Um and I understand people's gripes with big pharma insurance and things. It's, you know, if if everyone has been, you know, boxed out of of access to a drug or something like that and in had insurance issues, it could be very, very frustrating, even deadly. I mean, there's a whole discussion about this recently around cancer and cancer drugs. But to stay on point, I think now that some of these GLP-1 peptides are available through compoundingies, prices have come down. The big pharmaceutical companies don't like that. But it's also the case that people are are quote unquote micro doing them. They're taking the GLP1s at at doses that are below the threshold that would give them nausea. So, they're not losing weight quite as quickly. They're not going gaunt quite as quickly. Um, but nonetheless, they're benefiting from I think the appetite suppression, the insulin improved insulin sensitivity, and reduced inflammation. Yes. And it also seems that they adjust something about brain chemistry that make people feel better separate. It's impossible to separate it completely, but separate from a lot of the bodily changes. There's a bit of an anti-depressant function there. You know why? Because that noise that says eat, eat, eat, eat, which is an issue like you know that binge eating. I'm just speaking for my PCOS patients cuz I'm not an expert for obesity, but uh they have this voice in their head and it's a constant battle from the minute they wake up to the minute they go to sleep. And it's not like they're crazy. They're not, it's not like they're, you know, being sloppy with food. It's just this this brain disregulation of dopamine and serotonin that stimul that causes this brutal anxiety, constant anxiety. And every single one of them will tell me my brain is quiet. Wow. They're not drinking as much. Yeah. That's a clear quotequote side effect is people don't crave alcoholics. And I've said it for years. Just use it on alcoholics. Use it on alcoholics. I had a friend of mine who called me and said her son drinks a lot. The first thing I asked is can he tolerate micro doing of ompic because it shuts down their cravings because it's in some sense a sugar craving. It's a state craving of being under the influence of alcohol but it starts with a craving of sugar. Those two things are very closely paired. But that's why they feel better, right? But even without GLP1s, when you diagnose and treat these PCOS patients, their confidence comes back. They feel better. They know they're not crazy, which is why I'm here today. You are not crazy. If you're gaining weight, acne, hair loss, facial hair, body hair, if you're not getting pregnant, if you can't lose your weight, um none of this, you're not crazy. This this had these are the underlying conditions and these vicious cycles need to be addressed. And for people that want to get pregnant and treat their PCOS, uh, what are the success rates that you've observed in your clinic? Very good question. So, as I'm not a fertility doctor, but I'm trying to take these patients out of the hands of the fertility doctors. So, one thing I do, I put them on the supplement uh on my OV supplement. I give them metformin and I have them try and try to see if I can regulate their period. two things you can do easily and doctors can do it in their office. One is a medication called let and the other one is Clomid. Both of those basically um regulate that hypothalamus pituitary ovarian axis and pushes these patients to ovulate. With letol 60 70% of them I think ovulate and with Clomid it's a little bit less. So you can try those in the office for someone who wants to get pregnant. What I usually do, I have them try on their own for 6 months to a year depending on their age. If they're above 35, I say 6 months. If they're less than that and they're not in a hurry and their egg count is good and I've regular and I know I've dealt with their PCOS and their inflammation and their insulin resistance, then I have them try for a year, right? Because if you take um 100 couples regardless of age um and you have them have sex I don't know three times three to four times a week 50% of them get pregnant in the first 6 months and 90% of them get pregnant in the first year. But for patients with endometriosis or PCOS I usually have them try for like about 6 months and then check back in with me. you know if letol clomit uh trying on their own everything fails then you can send them to fertility doctors. Uh one thing that I want to bring up here which is my observation and it's nowhere in the literature but I'm saying it today and I know it's going to be published someday. I strongly believe that over 50% of PCOS patients also have endometriosis. Over 50%. And I've always said this, if you have a patient with PCOS, think about it. PCOS is already one of the leading causes of infertility. And in my opinion, 50% of them, because I I've seen it in my office, have endometriosis. And I have a path report and I've done laparoscopic surgery to prove it. If you only address PCOS and you're dismissing their painful period, then they're not getting pregnant. That's why you have to make sure you put a check in front of all these underlying conditions. I'd like to take a quick break and acknowledge one of our sponsors, Element. Element is an electrolyte drink that has everything you need and nothing you don't. That means the electrolytes, sodium, magnesium, and potassium, all in the correct ratios, but no sugar. Proper hydration is critical for brain and body function. Even a slight degree of dehydration can diminish your cognitive and physical performance. It's also important that you get adequate electrolytes. The electrolytes, sodium, magnesium, and potassium are vital for the functioning of all cells in your body, especially your neurons or your nerve cells. Drinking element makes it very easy to ensure that you're getting adequate hydration and adequate electrolytes. My days tend to start really fast, meaning I have to jump right into work or right into exercise. So, to make sure that I'm hydrated and I have sufficient electrolytes, when I first wake up in the morning, I drink 16 to 32 ounces of water with an element packet dissolved in it. I also drink Element dissolved in water during any kind of physical exercise that I'm doing, especially on hot days when I'm sweating a lot and losing water and electrolytes. Element has a bunch of great tasting flavors. In fact, I love them all. I love the watermelon, the raspberry, the citrus, and I really love the lemonade flavor. So, if you'd like to try Element, you can go to drinkelement.com/huberman to claim a free Element sample pack with any purchase. Again, that's to claim a free sample pack. Well, I definitely want to talk about endometriosis. Um, before we move to that, it sounds like going after the insulin resistance first with metformin and oitol, the other things in uh OV. Well, first people should go to the uh OVI site. We can put it in the show not take the quiz as it's a zerocost platform. You get some feedback there about what might be happening, what's likely happening. Um and then take care of the insulin resistance which presumably also includes things you mentioned trying to get best possible sleep, limit stress, exercise. Yes. And start with supplements first if your symptoms are not bad. You know, I've had like 50some patients get off OV because they got pregnant. All you're doing is addressing their hormone and metabolic health. That's all we're doing with it. But if it doesn't work, ask for metformin. If it doesn't work and you're you're having a hard time losing weight, ask for GLP1s. Ask your doctor for Clomid if you're trying to get pregnant. Ask your doctor for let first, Clomid second. And if all that fails, go see a fertility doctor. But before that, even if you're single and you don't have a partner and you're in your late 20s and you have no one uh and you know having a baby is something that will probably happen few years down the line, consider freezing eggs. Not because of the count, because of the quality of the eggs because PCOS patients again have tons of eggs but the quality is not that good. Endometriosis is opposite. endometriosis destroys your egg count and quality. I've seen a few papers um that suggest that co-enzyme Q10 and Lcarnitine might be beneficial for egg quality. Yes. And in males sperm quality, but we're talking about eggs here. Um do you include that? Yes. And I would say it's probably because of inflammation, right? We don't really have great tests for inflammation yet. like the number of tests, you know, that are coming online for um evaluating biomarkers is is quite quite impressive, but we don't really have a good test for inflammation as we don't have a test for PCOS. Wouldn't that be wonderful? But but it sounds like there's no single blood test that would do it because it's a constellation of things. That's why patients say, "My doctor said I don't have PCOS because my testosterone is normal." False. My doctor said I don't have PCOS because my uh I don't have any cysts on my ovaries. False. My doctor said I don't have PCOS because I'm not overweight. False. My doctor says my periods are regular so I'm not I don't have PCOS. False. There's so many myths that that's why it's important to understand the four phenotypes and how they differ. Understand that 70 to 80% of these patients don't ovulate. understand that that the 20 30% who ovulate ovulate sometimes, not all the time and that's why they're not getting pregnant. And understand that inflammation, insulin resistance, and this brain ovary axis are the main drivers. And then you add genetics and epigenetics, it starts a big chaos in the body. And that's why as a clinician, that's why it takes so much time, right? In this health care system, when you get 10 minutes with your doctor, do you think your doctor everything we talked about? I'd say I teach all of this to my patient, new patients with PCOS. How can you do that in 10 minutes? And on top of that, do their papsmear, check their hormones, talk about STD, talk about birth control, rule out endometriosis. How are you going to do that? A, patients don't have access to doctors. B when they have access either the doctors are not well trained or they don't have time to send spend time with these patients and they get you know even when they get diagnosed they get prescribed a birth control pill and off you go. Yeah. the thin end ed end of the wedge in this case really seems to be going after the insulin resistance um at least in terms of what people can do for themselves without you know because people can't start injecting androgen blockers without you know the assistance and and guidance of a physician so take care of your insulin sensitivity incur you know enrich it encourage it so sunlight limit stress sleep etc but these tools of inocl co-enzyme Q10 lcarnitine and these are in OV supplement. It…

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