In this episode of the Progress Your Health Podcast, we want to discuss questions you might want to ask your doctor when it comes to PCOS.
PCOS stands for Polycystic Ovarian Syndrome. The name can be misleading. Polycystic means, having multiple cysts on or in your ovaries. While this can be true, many women with PCOS do not have any ovarian cysts. PCOS is a collection of hormonal imbalances that may result in cysts and other unwanted symptoms.
During this episode, we talk about the diagnosis, symptoms, and questions to ask your doctor regarding PCOS. We explain that PCOS is more of a spectrum of symptoms as some women can have all the symptoms and others a few.
This is why it is important to have clear communication with your doctor on how:
Before we move on, let’s understand the basics with PCOS. The common symptoms that are associated with PCOS:
Common PCOS Symptoms:
Cysts: if you have not had an ultrasound, request that your doctor order you transvaginal ultrasound. As mentioned earlier, many women with PCOS do not have cysts on the ovaries. But if there is any thought that you might have PCOS, then you do want to have a transvaginal ultrasound. This will give us information on the size of the uterus and ovaries. If you have any growths or cysts. It will even check the thickness of the lining of your uterus.
Missing, Irregular Periods: It is very common in PCOS to miss periods for multiple months. Some women miss one month a year, and others can miss up to six months at a time. It is also common to have cycles that range from 25 days to 45 days.
Weight gain: Weight gain is one of the most common frustrations with PCOS. It is very easy to gain and hard to lose. Even with strict caloric restriction and a lot of exercise, women with PCOS will be frustrated because they cannot lose weight.
Hair loss: It is common in PCOS to have hair loss. Particularly on the top of the head and temples can appear to be especially thin.
Hair growth on the face and other areas of the body (except for the head): While it might be easy to lose hair on the head. In PCOS there can be hair growth on other areas of the body. Most commonly, the upper lip, chin and jaw, chest and pubic area before the belly button. We are human, and humans grow hair on our bodies. But in PCOS it might seem a bit more extreme.
Irritable: It is common to feel irritable not warranted for the situation in PCOS.
Lack of Conceiving, Fertility issues: PCOS is one of the top causes of infertility. There tends to be a lack of ovulation in PCOS. But there are many women with PCOS that have children. But there is a link between fertility and PCOS.
Elevated Blood Pressure: Some women with PCOS will have essential hypertension. Or elevated blood pressure that doesn’t seem to have a cause. So if you have PCOS, make sure to check your blood pressure regularly. These are some of the most common symptoms.
Other issues that can be part of PCOS are:
A typical basic lipid panel includes:
It is more common to see higher levels of triglycerides in PCOS.
Let’s say you meet with your doctor and he/she/doc tells you that you:
If this is the case, you are going to have a lot of thoughts and questions running through your head. From What is PCOS? to How is this going to affect my health? to How will this affect my fertility? and even Oh my gosh, that explains why I am feeling this way! .
We wanted to form a list of the most important questions to ask your doctor if you are looking at a PCOS diagnosis.
Questions to Ask Your Doctor About PCOS:
Why do you think I have PCOS?
What treatment can help my symptoms of PCOS?
How do I lose weight with PCOS?
Should I concerned about my ability to conceive and fertility?
What About My Thyroid Function?
What is my risk of developing Type 2 Diabetes?
Now your Doc may not have all the answers to these questions. And don’t expect them to have all the answers, as docs cannot be the jack-of-all-trades’. But it is good to have a discussion so your doc can refer you to the proper specialist(s).
Unfortunately, there are not a lot of helpful conventional treatments for PCOS. Most often, the common treatment is birth control pills, which we all know have numerous side effects.
Common Conventional Treatments for PCOS:
Birth Control Pills:
If you have PCOS than your gynecologist, GP, PCP will most likely offer your birth control pills. This will regulate the periods. And because birth control pills have an effect on testosterone levels, it can reduce breakouts and acne. But not everyone is a candidate for birth control pills. And many women have cannot tolerate birth control pills. Honestly, they are a band-aid that when you stop taking them. You are back to square one. This is especially true with conceiving. PCOS has an effect on ovulation and is one of the top causes for infertility. If a woman is trying to work on getting pregnant, then birth control pills are the farthest from her solution.
Metformin:
Metformin is actually a really good medication for insulin resistance and blood sugars. It is common in PCOS to have elevated levels of insulin and glucose. So metformin can be helpful. But not all women with PCOS have high glucose or insulin.
Spironolactone:
Spironolactone originally was used for heart conditions and blood pressure. Now it is very common to help reduce testosterone levels. It can be helpful for reducing the elevated levels of testosterone in PCOS.
By reducing testosterone, this can help with hair loss, acne, and mood. It can help periods, as well. If you take too much spironolactone for some women, it can cause spotting or frequent periods/short cycles. Also, it is a diuretic, so it can make you dehydrated. Also, you have to be careful with taking certain medications or supplements. Or ingest too much potassium. It is recommended to have your blood tested regularly, especially for potassium levels.
Blood testing for PCOS:
You don’t want to rely on symptoms alone to diagnose PCOS. It is important to have lab work that can support the diagnosis of PCOS. As you recall, PCOS is a spectrum of symptoms and hormone imbalances. Not all women with PCOS have the same symptoms or hormone levels. It is important to have labs to see what hormones are not balanced to be able to put together a proper treatment plan.
Below we are going to explain the proper lab testing for PCOS.
Both FSH and LH are secreted by the pituitary in response to ovarian function. In PCOS the LH is at least 2x or more higher than the FSH. For example, an FSH of 4 and an LH of 8 would warrant looking into PCOS. Or if the FSH were 4 and the LH was 19, that would show that PCOS is a strong possibility.
Androgens Are High on a Blood Test:
Testosterone and DHEA are androgens. Meaning men have higher levels of these hormones. The best way to test for DHEA is to do a DHEA-sulfate test as that is more accurate and specific.
Testosterone: Quest has a reference range of 2-45 ng/dL. And LabCorp has a reference range of 8-48 ng/dL. In PCOS you will see high normal to high out of range levels of testosterone.
DHEA-Sulfate: Common lab reference ranges are pretty vast for DHEA-S.
For example, a woman that is 35-years old gets her blood drawn for DHEA-sulfate. The reference range for a 35-year-old female is 23-266 mcg/dL. Usually, in PCOS, you will see high normal levels well over 200 mcg/dL.
Estrogen (Estradiol) Blood Test:
Estrogen levels are usually pretty normal in PCOS. But you sometimes see an elevation in estrogen, which can lead to Estrogen-Dominance. Because of this, it is important to test for Estradiol. Which Estradiol is much more specific than Total Estrogens
Progesterone Blood Test:
Without going into too much detail. It is important to note that progesterone is secreted from the ovary after ovulation. So in a perfect-28-day cycle, you will see progesterone levels rise starting at day 14, will peak at day 21 and then slowly decline until day 28.
Under the best circumstances, it is ideal to test progesterone after day 14, usually day 16 – 25. But in PCOS, many women are not getting regular periods. Making it hard to test progesterone. But regardless of where they are in their cycle. I always have women test their progesterone. Because in PCOS, it is common to see low to no levels of progesterone.
Cholesterol Lipid Panel:
A cholesterol basic panel includes:
As mentioned earlier is common to see triglycerides higher than 150 mg/dL in PCOS.
Insulin:
A fasting insulin on a typical lab reference range is huge. Quest’s reference range is 2-19.6uIU/mL. And Labcorp range is 2.6-24.9uIU/mL. Anyone that is fasting should not have an insulin blood level over 12. Ideally, an insulin level should be under 5 for optimal ranges. Five to twelve is moderate, and anything over 12 is high insulin. Having higher levels of blood fasting insulin will put you at risk for developing Insulin Resistance and Diabetes Type Two.
Glucose:
Fasting glucose should be 99 mg/dL or less. A glucose test alone is not sufficient for PCOS. while you want to make sure that the glucose is not too high. Often in PCOS, the glucose is normal or just over the edge of normal. But insulin and triglycerides are very high.
Hemoglobin A1c
A hemoglobin A1c is more specific for looking for Diabetes risk compared to a single fasting glucose reading. It is also a good marker to monitor the treatment of Diabetes. This is a good test to look for the potential risk for Diabetes Type Two in PCOS. Or if a woman with PCOS already has Diabetes Type Two, the Hemoglobin A1c is a good marker to monitor her treatment.
Cortisol:
Doing a cortisol saliva test is a good evaluation of Adrenal Dysfunction/Fatigue. The hormonal imbalances in PCOS make a woman more at risk for Adrenal Dysfunction/Fatigue. Blood testing for cortisol is as accurate as a saliva test.
Thyroid function: TSH, FreeT3, FreeT4:
Testing a TSH alone is not enough for monitoring thyroid function. Because of the hormonal imbalances in PCOS, it is common to see the thyroid function low. This can contribute and exacerbate the PCOS symptoms. Symptoms such as easy weight gain, hair loss, and extreme fatigue. For an accurate reading of thyroid function, you want to make sure to also get the FreeT4 and FreeT3.
You might not have all the symptoms of PCOS. But the ones that you do, you should ask your doctor for help.
There are supplement, dietary, lifestyle, and prescription options for PCOS. Again your doctor may not have all the answers. But he or she can refer to you specialists that can help you in these areas. If your doc just offers you birth control pills and tells you to go on a diet. That is not helpful, and then you may want to consider seeing another practitioner.
If you have PCOS, after listening/reading this, you might have a lot of questions. If you have questions about the best dietary program to follow for PCOS, download our KCCP (Keto-Carb-Cycling-Program).
Download Episode 060 Transcript
Dr. Maki: Hello everyone, thank you for joining us for another episode of the Progressional podcast, I’m Dr. Maki.
Dr. Davidson: And I’m Dr. Davidson.
Dr. Maki: On today’s episode we’re going to talk about something that we actually see and deal with on a quite consistent basis. Today we’re going to talk about PCOS.
Dr. Davidson: Which PCOS stands for “Polycystic ovarian syndrome”, which is a little bit misleading, because not everybody with PCOS has polycystic ovaries, but we’re definitely going to get into that later in the podcast, but mainly with this specific one we’re going to talk to you about is questions to ask your doctor if you think or you’ve been diagnosed with PCOS.
Dr. Maki: Yes, now, granted, PCOS has been around for a long time. I think it used to be called Levenstein something, named by a couple of doctors like 50 years ago so, PCOS has been around for a long time. It’s a syndrome, not a disease, we can kind of debate that, but it usually has some hallmarks as to the syndrome, which is usually just a collection of symptoms.
We think it even goes a little further than that, and we think that a lot of women sometimes if they don’t meet the exact definition of PCOS, they get kind of missed and lost in the shuffle sometimes, and maybe don’t get a proper diagnosis a lot earlier than they should.
Dr. Davidson: Exactly, and then, on the other side of the coin there, is a lot of women have been told they have PCOS but they don’t necessarily have it because their doctors are just basing it on their symptoms.
That’s where we wanted to kind of talk to you a little bit today about. What to ask your doctors, what to request and what you might be looking for if you think or you’ve been diagnosed with PCOS.
Dr. Maki: Yes, right. Now, I think it’s estimated that PCOS is the number one reason for fertility issues, so I think it’s estimated about 10 to 15% of the reproductive age population has PCOS. Oh, I think the number is quite a bit higher than that because that’s based on some conventional diagnostic parameters and I think that it goes a little bit beyond that in a lot of cases. We’re going to talk about that on a couple of future episodes.
So, why don’t we start off, what you and I see all the time? We end up in– a lot of times, not all the time, but a lot of times we end up diagnosing someone of having PCOS, or what we would call maybe even “PCOS-like”. Something that would have all the characteristics of PCOS but they’ve never been officially diagnosed with PCOS.
Dr. Davidson: Exactly so, let’s go over the symptoms. Now, we’re going to go over kind of the main symptoms here. Now, it doesn’t mean that if you have PCOS you have to have all of the symptoms, which is why we call it kind of like a spectrum or a syndrome, because you might have one, you might have all the symptoms, you could have anywhere in between, so I think that’s where women tend to get missed when we’re looking at PCOS.
Like I had mentioned to begin with, polycystic ovarian syndrome is you can have a bunch of cysts on or in your ovaries.
Dr. Davidson: Yes, so, that’s the obvious, just based on the name. Usually in order to have a cyst problem, there’s going to be some pain, especially around ovulation, it might be a very significant pain. Then, of course, you go to the gynecologist, they’re going to request a transvaginal ultrasound, and there may or may not be cysts present on the ovaries.
Dr. Davidson: Yes, so, if you think you have PCOS, or you’ve been diagnosed with PCOS and you haven’t had a transvaginal ultrasound, then request your doctor to do one, because you do want to find out if you have cysts or if you have multiple cysts.
Now, one thing, even though they call it “PCOS”, polycystic ovarian syndrome, a lot of women with PCOS don’t have cysts. In fact, there are more women with PCOS that don’t have cysts than women that do, but traditionally, as this has been around for many, many years, is what they call “the string of pearls”.
They do a transvaginal ultrasound, they look at the ovaries, and it really does look like there’s like, really pretty round pearls in the in the ovary. You will see that sometimes, but honestly, most of the time, you’re not going to see that.
Dr. Maki: Yes, right and as the name implies, polycystic ovarian syndrome, if you don’t have any existing ovaries, then you’re not going to fit into that conventional diagnostic criteria, because that’s– and believe me, the ultrasound, the transvaginal sound is usually the more common step to this process.
If that comes back unremarkable or there’s nothing present, then you’re kind of back to the drawing board trying to figure some things out.
Dr. Davidson: Another common symptom is missing periods. A lot of doctors will tell you have PCOS just by you telling them, “Well, I’ve missed periods for six months and no, I’m not pregnant”.
They just based that on their criteria as PCOS, but it is common with PCOS to miss anywhere between two to six months at a time with your periods, or one every other month, or some women with PCOS have regular periods.
Dr. Davidson: Right, right. That’s something that we see quite often, and also, maybe an obvious situation at that point, if they haven’t had a regular cycle, that would be the first thing that you and I would think of for sure, right?
Then we can go from there, and maybe do some blood work. If they haven’t had that transvaginal ultrasound, that would be the time to order it for sure.
Dr. Davidson: Now, granted, not all women want to have a period every month, and when you have PCOS, when you do have a period they can be pretty painful. When we see a patient and we’re like, “You know what? We’re going to get those periods regular”, they actually look at me horrified because they’re like, “I don’t want to have a horrible period every month”, but that’s where we balance the hormones to try to encourage that period to become more regular.
In fact, I had a– you probably remember her, my roommate in college. She had PCOS, but she was one that wasn’t quite overt, like, she didn’t have all the classic symptoms. She would miss her period for months, and I remember buying her pregnancy tests because I’m like, “Girl, if you miss your period, we got to check to make sure you’re not pregnant”.
We would do that all the time because she would miss three or four months in a row, but feel fine. Feel fine until she got that horrible period on the fifth month. It is something to definitely look into with PCOS is those missed periods.
Dr. Maki: Yes, now, some of the other things that definitely show up, certainly acne or complexion problems. That can certainly be on the list. Other things that are classified is hirsutism so, unconventional or unwanted hair growth in places that women don’t typically want it, especially if it’s on the face. You could even have it around the nipple area, even on the abdomen below the belly button.
Those are areas where men typically grow hair, women typically are not supposed to grow hair in those areas and that’s usually driven by an excessive amount of androgen production. We’ll get into that in a second.
Dr. Davidson: Yes, it’s unfortunate because there’s hair loss on the head, hair thinning particularly in the temples and the top of the head, but then, unfortunately, then it’s growing elsewhere. Now, we’re humans, humans grow hair and everybody’s different, so having a couple of hairs around the areola on your breast is totally normal, but if you are having PCOS-driven hair growth, it definitely looks like there’s more.
Dr. Maki: Right, right, right. No woman of any age– we deal with a lot of women that are having hair issues, either losing it or growing it, but no woman wants to be having either hair growth or hair loss issues so, that certainly becomes a priority. Of course, the skin issues, right?
That can become problematic as well. Probably the most common one that we hear a lot of, of course, is that weight gain, and also underpinned by the stubbornness to be able to lose that weight, right? We talk with a lot of women, and they’re working really hard and their weights not budging. They’re having a really, really hard time trying to have any weight loss success.
Dr. Davidson: Yes, we call it “unexplained weight gain”, because they gain it really fast and it’s so hard to lose. Now, a lot of times they’ll say, “Oh, let’s go on a diet and let’s just stop eating and exercise a whole bunch”. In PCOS that’s not going to do the trick here. You might lose a pound or two, but really it’s all about that hormonal imbalance.
Dr. Maki: Yes, right, yes, and we’ll talk more about the weight gain side of it. I think with any doctor that deals with women on a regular basis, especially if they deal with any kind of weight loss, they would say that the PCOS patients are definitely the most stubborn when it comes– not them as people, but trying to help them lose weight, that becomes a very stubborn process, because of what that PCOS is, it’s a very significant hormonal issue.
Like you said, going on a diet and exercising a bunch doesn’t always sometimes that actually makes the problem worse, which we’ll talk about later on future episodes. Another thing that goes along with the weight gain, we’ll talk about some labs here in a second, but another thing that we both see quite often is elevated blood pressure.
Dr. Davidson: Exactly, elevated blood pressure or borderline or moderate blood pressure, which you wouldn’t typically expect, but then of course, you definitely want to address that and make sure you bring the blood pressure down, but that’s one key characteristic is, they’ll come in and say, “Yes, I have this moderate blood pressure issue, but I’m on blood pressure medication, so it’s controlled”.
You want to take that into consideration, but like I said, on the flip side, there’s a lot of women that have PCOS that don’t have high blood pressure. In fact, they have low blood pressure. So, it’s definitely taking the collection of symptoms and putting them together before you throw out a diagnosis.
Dr. Maki: Yes, especially if a woman is in her 20s or 30s. She probably shouldn’t have hypertension in her 20s or 30s, and if her blood pressure is even borderline in her 20s or 30s, that is the same mechanism that creates the PCOS, which is an insulin-resistant issue, is the same reason why the blood pressure goes up.
Now, we’ll talk more about blood pressure and insulin and how that’s connected, but it has to do with what they call “The Renin-Aldosterone System”, and water retention, and increasing blood volume, it’s pretty complicated. But again, when you see elevated blood pressure in that kind of atypical person, it’s a clue that they might have a PCOS problem.
Dr. Davidson: Now, you mentioned insulin, now, I don’t want to bore everybody and put everybody to sleep, but insulin is one– I wouldn’t say it’s a symptom, because usually symptoms or something that you notice and you feel, but you can have elevated insulin, which then that can lead to weight gain in PCOS, but that can also lead to a risk factor or an increased risk factor for insulin resistance, pre-diabetes and eventually diabetes type 2, depending on the person.
Dr. Maki: Right, right, and that’s where it gets complicated, right? Because on the surface this is viewed as is a female hormone problem, but it’s a little more complicated than just estrogen, progesterone. Once that insulin level gets a little bit out of control, now it starts having an impact on the androgens– DHEA and testosterone, and that’s where all the symptoms manifest on the surface.
Whether it’s weight, whether it’s the hair growth that we talked about, or the big one we mentioned early on, is the fertility issues. This is the number one reason for women to have fertility problems, and you and I are not fertility doctors, but I don’t think fertility doctors necessarily work on the PCOS part.
Their job is to try to help women get pregnant, but they kind of ignore the PCOS, and if you don’t really deal with or take care of the PCOS part, getting pregnant it’s going to be a lot more challenging, a lot more difficult.
Dr. Davidson: Exactly, I mean, that’s their job. Fertility experts are working on having you make a baby, but at the same time, the reason there could be an issue in not conceiving is because of PCOS. Now, that’s what also I’m gonna say again, a lot of doctors will diagnose you as PCOS if you haven’t gotten pregnant in six months to a year.
They’ll say, “Oh, but you got PCOS”, without doing any diagnostics, without looking at any other symptoms. It’s just, “We’ve been trying, I haven’t gotten pregnant, it’s been ten months”, so that’s immediately what they tend to jump into, and then they jump into all the fertility meds are referring you to a specialist.
Do know, with PCOS there is a lack of ovulation, which can, of course, reduce down your possibility for conceiving, and that’s a big deal with a lot of women, is, “Yes, I’ve got PCOS, but I’m looking at possibly in the future having children” so, it’s definitely something you want to work on hormonally.
Dr. Maki: Yes, right. Definitely for couples that are trying to get pregnant and they’re not able to, that’s a really, really big deal, because there’s this pressure, there’s a finite amount of time, there’s this sense of urgency, and we always want with our patients we want everyone to be as successful as possible.
And again, sometimes the conventional approach kind of misses some of those bigger things, and that can greatly increase someone’s chances of conceiving and maintaining that pregnancy. Why don’t we go into–
Dr. Davidson: You forgot one of the most important common symptoms.
Dr. Maki: Which is what?
Dr. Davidson: Well, you talked about the high androgens, which are the testosterone and the DHEA, so you think having high testosterone is going to make you testy. Irritability is huge and PCOS, in fact, sometimes that’s the only complaint that women are really concerned about, is they can’t stand their mood.
Dr. Maki: That you’re right, yes, yes. Irritable for sure, it’s just kind of not angry necessarily but could be. Certainly have episodes of anger or rage, but just irritable at the littlest things. They just don’t have a tolerance for– now, granted, that also accounts for some other female hormone issues, but you’re definitely right, for PCOS that probably would be close to the top of the list.
Dr. Davidson: Yes, irritability, being annoyed at things that possibly don’t warrant that level of being annoyed at.
Dr. Maki: Yes. Now, granted, that maybe just personality, that might not necessarily be a hormonal problem, but a lot of times in the people that we deal with, it ends up definitely being hormonal problem. It gets better, right? Your mood lightens up, there’s a reduction to some of that irritableness on a regular basis, if that’s even a word. Then women tend to mellow out a little bit, which is good for them and for everyone else around them.
Dr. Davidson: Exactly so, now, we kind of went over the symptoms here with PCOS or some of the most classic ones. Like, I said, to have PCOS doesn’t mean that you have all of them, but you can have some of them. The next part, I think, especially when you’re talking to your doctor and your doctor says, “Hey, you have PCOS”, is to find out, well, of course, “Are you basing my PCOS diagnosis on just my symptoms or also on some lab tests?” We want to go over some of the proper lab tests that you can do for PCOS and how to interpret them.
Dr. Maki: Yes, right. Honestly, we deal with hormonal problems all the time, that’s pretty much what we do. For any menstruating-age woman, we’re always running these exact same tests, and when we’re preparing for this episode beforehand, we kind of realize, without realizing it, is that a lot of times, even if you go see a gynecologist, these tests might not be run until way later.
They’re not necessarily part of initial workup, unless you’re going to see someone that actually specializes in PCOS, which I don’t know if gynecologists specialize in PCOS necessarily, our primary care doctors. Certainly functional medicine-minded doctors that deal with women’s health issues, it’s going to be at the top of their list or at least on their list, because this is a relatively pretty common problem.
If it’s 10 to 15%, I think the number is, of the female population– I think the percentage is even higher than that, that’s going to equate to millions of millions of women across the country that are dealing with this, and not to mention around the world that have this kind of a problem.
Dr. Davidson: For me one of my favorite tests to do– granted, it’s a blood test, is to do the FSH to LH ratio. The FSH stands for “follicle stimulating hormone”, follicle-stimulating hormone, and the LH stands for “luteinizing hormone”, and they’re not really hormones but they’re, as they say, stimulating hormones that are coming from your pituitary, and they’re monitoring the overall hormonal activity in the body.
Don’t fall asleep here, I know I’m saying a lot here, but to back up, I do an FSH and an LH. Commonly your gynecologist will run an FSH. It tells you where you are, quote-unquote, “anywhere near menopause, anywhere near perimenopause or nowhere near either”, but a lot of times they don’t run the LH, and what you find in PCOS is the LH, the luteinizing hormone, is at least double or more than the FSH.
For example, I do FSH and LH, and my LH is 16 and my FSH is eight. That weren’t looking into a possible diagnosis for PCOS, granted, taking all the factors into consideration, or even in LH that’s 32 and their FSH is seven, then that LH is really high, or in LH at 12 and the FSH is at six. You’re seeing this pattern of the LH being double or more than that FSH, and that really does point to looking into PCOS.
Dr. Maki: Yes, right, and that ratio certainly does play out. Now, the next one, of course, we’ve already mentioned, but this is maybe more of the classic or the conventional, which is DHEA sulfate, not just plain DHEA, but DHEA sulfates or DHEA-S, which is just a metabolite of DHEA, and then of course testosterone.
Both of those numbers can be either both elevated, they both can be high-normal and still have the same situation. It may come back normal, within the reference range, but it might be on the high end of those reference ranges, but yet all the physical symptoms are still present. You combine that with the ratio you’re just talking about, and now it kind of paints a lot of a different picture.
Let’s go through the reference ranges for those two. For a woman, testosterone, two to 45, right? What would be a number on that testosterone where you start to maybe suspect that they’re on that spectrum?
Dr. Davidson: Right around 35 and higher. Granted, two to 45 is a huge reference range and it’s kind of pathetic that a female could be at 3 and be normal and could be at 40 and be normal for their testosterone, so yes, like you said, take into consideration the symptoms, but when you see 35 or more, you start thinking, “okay, this person has a little bit elevated testosterone compared to the rest of the population”, that we want to look at that PCOS.
I see a lot of teenage girls and their reference ranges are different pediatric, but they might be at like 30 or 35. I definitely, on teenage girl, when I see that, we want to jump into it and look at a little bit of PCOS, so we can work on that now rather than later when they’re older.
Dr. Maki: Yes, because of what PCOS is, the fact that it is what we would consider to be a metabolic hormone issue, a primary metabolic hormone problem, it tends to get worse over time. In the early stages, as a girl as in her teens or early 20s, by the time she’s 30 or 35, that problem has gotten way worse, because the time that she has gone through and life she’s living, and the stressors and all the different things, that hormonal issue tends to compound on itself.
The more time that goes by, in some ways, the harder it is for that problem to be resolved down the road.
Dr. Davidson: And the DHEA, which is an androgen, DHEA comes from our adrenal glands, mainly, and its job is to convert into testosterone, so it’s another way that we make testosterone is by way of DHEA, so you definitely want to check the DHA but, as Dr. Maki said, we want to check the DHEA sulfate because that’s a metabolite of DHA and it is a little more specific to understand if someone has elevated levels of DHA. Now, I’m getting the reference ranges like testosterone are huge, DHA is highest when we were young and that does down with time as we get older, so you want to take that into consideration but normally you will see with PCOS a high normal DHA sulfate, if not over the edge of normal.
Dr. Maki: Yes. So let’s say, a DHA reference range for a 25-year-old woman is probably 40 to 280, something like that, again, kind of just a ridiculous reference range. But rerun these numbers on pretty much all aged women because DHA sulfate also is a really good way to get an idea of what their adrenal status is because DHA is made in the adrenal glands and sometimes, depending on the woman, depending on the situation, you might think that it’s going to be an elevated number or high normal number and then it’s really low. You might see a number for a woman that you would expect it to be maybe 250 plus and it ends up being less than 100, but for PCOS that number is going to be definitely above the reference range or at least high normal so we like to see it for most age women somewhere between, would you say, 125 to 175?
Dr. Davidson: It does depend on the female but usually right around 150 because sometimes when it does get a little bit higher, you do notice acne. People always think of acne being caused by testosterone. I find DHEA causes way more acne than testosterone ever does. In fact, I’ve had plenty of patients that I’ll tell them, “Here, you need to take 5 mg of DHEA, maybe 10 mg, because we need to work on your adrenals.” They go home, or they go to Whole Foods, or they go and take their husband’s DHEA and it’s 25 or 50mg and when they come back to see me their face is covered in pimples, it’s really common, because DHEA will cause acne.
Dr. Maki: And then you do their follow-up blood tests and their DHEA is like 400. So for a menstruating woman that really wouldn’t be a good idea, that could easily kind of shut your period off because that’s what we’re talking about. If you’re supplementing for a menstruating woman you want to be a little careful with those androgens, for a woman that is no longer menstruating, she’s in menopause or has had a hysterectomy, you can get away with a little bit of a higher DHEA level and in some ways that can be very beneficial. But those cosmetic issues it can exacerbate the hair loss, it can exacerbate the hair growth and it can definitely, like you say, kind of aggravate the skin a little bit and no women wants any of those things.
Dr. Davidson: And especially if you have PCOS and you’re making more DHEA, so it’s not like, “I can stop taking my supplement, my skin clears up.” They’re making too much DHEA, they’re making in there, having the cystic acne which tends to be on the chin, in the jawline, that’s probably more specific where they get that acne, then they don’t know what to do. There are definitely options but that DHEA it’s a fine line.
Dr. Maki: Yes. Now, this is a female hormone issue so, of course, it would make sense to consider doing estradiol or estrogen, usually in the form of estradiol. We don’t do total estrogen. We don’t really find that to be a very useful test at all and then, of course, if I had to pick between the two of those I’d say probably more progesterone than estradiol. But the day of the month you’re not cycling then it’s really not important to do because that kind of tells us already if you’re not having a regular cycle, if you haven’t had a period in six months we already know your estrogen levels on the low end because, otherwise, you had a cycle already. But the day of the month if you are having a regular cycle either day 12, which is the peak of estrogen, or day 21 which is the peak of progesterone, we prefer day 21, but either one of those or at least close to those days would be beneficial to know because then that will also dictate the FSH and LH numbers as well too.
Dr. Davidson: Yes. So you don’t want to just do one of these tests. I’m a doc and I’m testing you for PCOS, I’m not just going to run the testosterone and that’d be it, you have to have the whole gamut. As I said, a lot of women with PCOS might miss a few months or their periods are irregular and they’re missing one month, three months, six months, you still want to do that progesterone because progesterone comes up only if you ovulate pretty much so, if you’re not ovulating, then you’re not can be making progesterone so, you do want to do that progesterone but at the same time you want to pair it with that FSH and LH at the same time, and then do the DHA sulfate with the testosterone. It’s not like one’s better than the other, you really want to have the whole picture.
Dr. Maki: Yes. Now, we’re not really big fans of cholesterol in the classic sense of statin drugs and lipid management. However, the cholesterol profile can be very helpful when you’re looking at some of these things and definitely, probably the number that we think is the most important of that profile is your triglyceride level. A reference range is anything less than 150, we prefer them to be less than 75 so the lower, the better. But the reason why the triglycerides are significant is because they’re directly correlated to insulin status, so the more triglycerides you have we can infer that your insulin is a little bit about auto whack and that’s really kind of the underlying issue of the PCOS in the first place.
Dr. Davidson: I kind of call it the triad. With PCOS you’ll see high triglycerides, you’ll see the elevated insulin and eventually, you’ll see the elevated glucose, so those hence the triad, the three. Those are the three main players that you’re looking at, especially when you’re looking at insulin resistance or that risk for diabetes type 2.
Dr. Maki: Yes, right. As that insulin tends to become more dysfunctional or imbalanced than your testosterone, it will eventually rise at some point. But that might not be the first step in that process, there are other things that are going on there and that’s why. If you just look at the DHEA or the testosterone, one or the other, you might miss some of these other clues that are giving you an idea of what’s going on, because you and I both know that, of all the pages we’ve dealt with over the years, even PCOS, every other hormonal problem for that matter, it never shows up with the exact way that the textbooks tell you, right? just never. You can see ten people that have a diagnosis of PCOS, you look at their lab work and you’ll see ten different sets of laps, they’re always different, some will have a high testosterone, some will have a high DHEA, some will have both of them elevated, some of them will have normal triglycerides, another person won’t so, piecing those little things together and they tell you a little bit of a story about what’s going on with that particular patient.
Dr. Davidson: Exactly, not only is the labs helpful in, quote-unquote, diagnosing PCOS, but it’s also helpful in having to treat PCOS. I had one teenage patient the other week and her testosterone is actually pretty low, it’s down there at 19, but her insulin is so high, it’s up there at 22.6, so that’s where we’ve got to focus on that insulin. And you’ll see that in other patients where that’s reversed, their insulin was a little bit lower, maybe about 9 or 8 but then their testosterone is up at 55, so you got to take that patient and treat them differently than the other one. This is definitely more of individualized medicine but you want to have this data so that when you help treat them, of course, the proofs in the pudding, they feel better but then you run the lab work again to see if you’ve had any changes with that objective values.
Dr. Maki: Yes, because month-to-month minus, let’s say, a woman that is not having appear at all since she gets period back, that’s great, but there might not be a lot of changes month-to-month for a while. The woman might not be experiencing anything and they get a little frustrated or they might get a little bit demotivated, they get upset because their bodies are not changing as quickly as they want to but now, you look at that objective information and say, “Your insulin is gone from 22.5, now it’s gone down to 15.5, it’s gotten down to 14.” Or preferably it’s less and where we want to see insulin is less than 5. Another example of a ridiculous reference range when it goes from 2 to 20 on a reference range and we think as other doctors like us think that that number ideally should be less than 5 on a consistent basis. And really the insulin, as we talked about, the confusing part most doctors won’t even run a fasting insulin, conventionally, if you’re part of regular insurance-based medicine, they will not even run your insulin level unless you ask and if you ask them to do, what they’ll say, “That’s not necessary.”
Dr. Davidson: But there’s a lot of people that have good relationships with their primary care physicians that they may run it, so it’s good that you know this so you can go to your doctor and tell them, “I really want this run.”
Dr. Maki: Yes, right. Even you and myself, we tend to get a little stuck in our ways, we try to be as progressive as possible and always trying to expand, grow our expertise, and help our patients, but at the same time doctors in general get a little bit habituated to what they do and the way medicine is done, it doesn’t evolve very much so you definitely have to be an advocate for yourself. We think these are important because these are the things that we see all the time and you need to see all of this collective information to be able to make the right decisions for your patients.
Dr. Davidson: Exactly. One really important thing, if you’ve been diagnosed, or you think you have PCOS, or you’ve been told you have PCOS, is you want to ask your doctor about your thyroid function because thyroid and PCOS go together very hand in hand. When the PCOS hormones are a little bit not balanced well, that testosterone is up, the DHA sulfates up, that progesterone is really super low and then the insulin is elevated, that can put a huge burden on the thyroid and then it reduces the function of the thyroid which then you’re down the rabbit’s hole with a whole bunch of other symptoms, or the low thyroid can actually exacerbate a lot of the PCOS symptoms.
Dr. Maki: And one of the best ways to have an impact on the female cycle is via the thyroid, especially when it comes to fertility. I mean, if pregnancy is what your ultimate goal is, and for a lot of women it certainly is, then the thyroid function has to be not just normal. You can’t look at a TSH and see someone’s thyroid is fine when it’s 2, 2.5, or 3.2, those numbers really need to be optimized because it will greatly increase their likelihood of getting pregnant.
Dr. Davidson: So the best test, we think, to really have a quick look at that thyroid function is to do the TSH, the thyroid-stimulating hormone, just like the follicle-stimulating hormone. It’s a stimulating hormone that comes from the brain and it monitors your overall thyroid level in your body. Like Dr. Maki said, you never want to base someone’s thyroid function or someone’s thyroid medication dose on a simple TSH test but, a TSH is important to have along with a free t4 and a free t3. Free hormones mean that they’re bioavailable, that they’re ready for use, so you don’t want to do the total t4 and the total t3, is just not specific enough. Just like the total DHEA or total estrogens, it’s not specific enough, you want to get more specific so to really test that thyroid function, TSH, free t4 and free t3.
Dr. Maki: We could probably throw on there, to be honest, just to be thorough, we could throw on the Hashimoto antibodies especially if fertility problems are present, that’s a really common reason. Literally 70% of hypothyroid cases are Hashimoto type so we could easily put those on, especially if it’s a screening test and you haven’t necessarily been told before whether you have Hashimoto’s or not, it should be definitely evaluated.
Dr. Davidson: Of course, probably one of the most important things to ask your doctor if you’ve been diagnosed with PCOS is, “What are some healthy options to help with my symptoms? What are some good treatment plans?”
Dr. Maki: Now, that’s kind of a loaded question because unfortunately, and this is part of the reason why we’re doing this, we know how the conventional system works and what they do. I mean, honestly, most of the time its birth control pills and/or maybe metformin. Metformin is a diabetes medication that is for the most part supposed to help with insulin sensitivity, which in theory makes a lot of sense, but not necessarily enough to completely change that situation.
Dr. Davidson: Yes, it’s not, “One pill fits all.” It’s really more of looking at it from a full approach, you want to look at the supplementation, you want to look at the dietary, you want to look at the lifestyle and then possible prescription options for PCOS. As Dr. Maki said, metformin can be a great medication for the particular individual when you’re also implementing it with other dietary or lifestyle. So, as Dr. Maki said, if a doctor tells you, “Here are some birth control pills and go on a diet.” That’s probably not the best option you want, not that they’re not trying to help but and not that primary care physician should be the jack-of-all-trades because they’re really not, but at least be able to help you find a specialist, or a nutritionist, or functional medicine doctors so that we can all work together as your healthcare team.
Dr. Maki: Right. Now, the other part of that is, like you said, you can’t just take a couple of medications. Now, one that we do actually use quite a bit for a situation like this is spironolactone. Spironolactone actually is a diuretic as a class of drug but it can actually have a really good impact on lowering testosterone levels which can help that situation in the short term. We both wouldn’t necessarily agree that it’s going to be a long term treatment by any means, and it’s usually for the most part fairly well tolerated and it can get those testosterone levels down fairly quickly while you’re working on the other things, lifestyle and supplementation things at the same time.
Dr. Davidson: Exactly, because we work with a lot of women with PCOS, especially with getting pregnant, and once they get pregnant they wouldn’t want to be on their spironolactone or whatnot, then we make a whole new treatment plan once they’re pregnant to work with the pregnancy. So, I guess, it really does come down to just work everybody as an individual, we’re a unique individual so where you are on that spectrum of PCOS is going to determine and what your goals are is going to determine where we’re going to work with.
Dr. Maki: Right. Now, one thing I do see a lot, especially when it comes to the weight side, we’re going to talk a little bit more about this in some other episodes coming up about weight in general but, I do see a lot of women that have PCOS or, at least on the spectrum of PCOS, it’s not an all-or-nothing, kind of a syndrome, there’s definitely a low moderate and a high level of severity of PCOS which we’ll definitely be talking more about that later. But I do see a lot of women that are doing the classic eating less and exercising more, you kind of alluded to earlier, so they’re going on a diet, starving themselves and exercising a lot, and sometimes with PCOS that can actually make the situation worse. It can drive up those hormones, it can exacerbate the whole situation. It is not about as they say, “No pain, no gain.” It’s about take more of a gentle approach and understanding how the hormones are affecting you and now you’re able to follow a strategy that is, one you’re going to be fairly easier for you to manage your overtime and then, hopefully, you’re going to get better results without having to necessarily work so hard on a week to week basis.
Dr. Davidson: Exactly. We have another podcast that talks about exercise and weight loss and whatnot, also definitely lots of blogs and articles about that as well, but we really just want to help you a little bit with what questions to ask your doctor because, a lot of people have lots of doctors all over the country that, sometimes, they get lost in a fold and they don’t really know what to really ask a doctor. Like I always say, write a list of your questions before you walk in because the second you get into that office, you’re going to blank, so write a list ask, “Does my blood testing reflect your diagnosis of PCOS?”, “What symptoms are you referring to that would be part of my PCOS?”, “What are some healthy options and treatment? And if you don’t quite know, which is fine, you have somebody can refer me to that can help me with my diet, with my supplements, with my lifestyle, with my exercise?”, “What possible prescriptions can I take and are they going to be safe? Are they going to be effective?” And then, most important, like I said, the thyroid function is huge with the PCOS and for a lot of women, the fertility is huge for them, too.
Dr. Maki: This is a complicated issue, there are lots of nuances to it, there is not really one way to treat someone. Like you said, it definitely takes a lot of an individualized approach [inaudible], there are some common things there and it tends to be similar from one person to the next but definitely it needs to be more than just take a couple of prescriptions and off you go, there are more tools than just that. Hopefully, this is giving everybody some insights if you are dealing with this or you are thinking you may have an issue or if you have really been diagnosed yet just know that it is not black or white either, it’s not just what you have and you don’t, there are definitely some shades, some absolute shades of gray there, and that’s the point that we are trying to get across, is for you to understand that are shades of gray and you might be on that spectrum somewhere and it gives you, at least, some more insight and you can advocate for yourself. Dr. Davidson, do you have anything else to add?
Dr. Davidson: No, no, this was really great. I hope it helped everybody, and if you have any questions, please, please, reach out.
Dr. Maki: Alright. Until the next time. I’m Dr. Maki.
Dr. Davidson: And I’m Dr. Davidson.
Dr. Maki: Take care, bye-bye.
Dr. Davidson: Bye.
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