In this episode, we continue talking about PCOS. As mentioned in the previous episode, we have seen three main types of PCOS. PCOS is more of a spectrum of symptoms. Some women have most of the symptoms of PCOS and others just a few. The varying degree of hormonal imbalances will help mold the three types of PCOS that we have seen. Many doctors that treat PCOS all can agree that there are different types of PCOS.
The three types that we have found with PCOS are:
In this episode, we are going to talk about the Common-Type of PCOS. In the previous episode, we spoke about the Classic type. And in the next episode, we will go over the Concealed Type.
The reason that we want to differentiate the Types of PCOS is because, in each type, there are different health goals, health consequences, and multiple treatment plans.
Common PCOS: This is the most common type of PCOS seen. The Common-types should be diagnosed fairly easily. But because they do not fall into the Classic presentation, they may get missed in diagnosis.
Symptoms that a PCOS Common-type will present with:
Typical lab work for a PCOS Common Type:
If you would like more information, visit our website: Progressyourhealth.com
We have a free hormone video series on PCOS, Perimenopause, Menopause, and Hypothyroid.
Thank you for being part of our Progress Your Health community
PYHP 064 Full Transcript:
Dr. Maki: Hello everyone. Thank you for joining us for another episode of the Progression Your Health Podcast, I’m Dr. Maki.
Dr. Davidson: And I’m Dr. Davidson.
Dr. Maki: So, the last episode we talked about our one of the three different types, we talked about the classic type of PCOS. Which is if you looked up again in a gynecological textbook would be, you know, that’s what the classic type is. All the different lab values, all the different clinical symptoms. That one is an easy diagnosis, but it doesn’t happen that often. That’s not necessarily “as common as you think it would be”. Today, we’re going to actually talk about what we feel is the common type. This one also should be diagnosed fairly easily but is often not.
Dr. Davidson: So, since we’ve been treating patients since 2004, we do all sorts of treatment for hormones and hormone imbalance. But in particular, with PCOS, we found three different types. The classic, which we just talked about in the previous episode or our previous podcast. There’s the common and then the concealed. So in this podcast, like Dr. Maki said is we’re going to talk about the common PCOS that we see. Which, as he mentioned, it should be diagnosed fairly easily, but because they don’t have all the classic symptoms, they tend to fall through the cracks and get misdiagnosed.
Dr. Maki: Yeah. It might take them a while to either getting a diagnosis, but because it’s not the classic textbook definition, that’s why it gets a little confusing and probably even a little frustrating because it takes a while for that to get teased out.
Dr. Davidson: Yeah. These women with the common PCOS, these women, they don’t have the string of pearls. When you do a transvaginal ultrasound, they don’t have all the cysts on the ovaries. Now, everyone is from our females, we might get a follicular or common cyst that’s normal. We don’t even know we have them. But with the common PCOS is they don’t have that string of pearls. They might get an ovarian cyst or complex or hemorrhagic cyst where it bursts and it’s painful and they might get that once every few years, but it’s not enough to point to PCOS. So that’s why women will just get like, “Oh look, you’ve got an assist. You don’t have that string of pearls.” And so they get blown off and they might even because, hey us ladies, we’re online. If we don’t feel well, we’re trying to find out what’s going on. So they might go to their gynecologist and say, “I think I have PCOS.” And they just get blown off because they don’t have those ovarian cysts.
Dr. Maki: Yeah. Right. Now granted, some of the things they might have of course from a clinical presentation, they certainly can have the weight gain, especially on the middle, now granted that it’s not enough just on that side. You might have some hair issues. Again, some of the irritability, some of the anxiety, certainly some of the acne problems might tend to show up and one that needs to be considered if there is any, as we talked about in the last few episodes if there’s trouble getting pregnant.
Dr. Davidson: Exactly. So, with the common PCOS, they might not have that string of pearls of all those cysts on the ovaries, but they will still have some of the hormonal imbalances creating less ovulation or reduced ovulation. But at the same time, the women with the common PCOS usually can get pregnant pretty easily if they do some type of fertility intervention like Clomid or IVF easy, so they definitely can get pregnant, but there are going to have reduced ovulation which would be reduced fertility, which isn’t quite like the classic where their fertility is pretty, very reduced that that’s definitely something that we hone in on if that’s one of their goals.
Dr. Maki: Yeah. Right. So, the trouble getting pregnant sometimes might even be like their number one complaint. Like they’ve been trying and trying. No one’s really been able to quite figure it out. I don’t really have a relationship with a fertility doctor specifically, but I don’t think they really addressed the PCOS portion of it at all. They might give them Metformin or something along those lines, but taking up a very kind of specific approach to the PCOS, they really don’t do. That’s the void or that’s the gap in the treatment of PCOS that we’re trying to feel and help people. So, now if they do have to resort to IVF or fertility treatment, they’re going to have much more success.
Dr. Davidson: And I think it’s because those reference ranges because we did a previous podcast on PCOS testing and diagnosis is those reference ranges. A lot of time that the common PCOS types will fall in the normal range. They might be the high normal, but it’s not enough to flag a doc to say, “Hey, you know what? Let’s look at this a little bit or put the picture together and look at it a little more comprehensively.” Because with the common types you will see, high normal androgens. So their DHEA sulfate might be high normal, their testosterone might be high normal. It might not be out of the range, but it’s enough to say, “Hey, you know what? That’s kind of a little bit high normal.” And then you put together that subjective information. Like you, Dr. Mackey had mentioned the acne, the common types will get cystic acne on the chin and the jaw, maybe not enough to go running off to Accutane but enough to say, “You know what? This kind of irritating.” So you put that together and say, “Hey, you know what? These androgens are, if they’re affecting the skin, if those high normal androgens are affecting the hair with the hair loss, it’s going to affect other things too.” Like you had mentioned with the ovulation and the fertility.
Dr. Maki: Yeah. Right. If you’re starting to get some of those and like you said, it might be very subtle, right. But some of those hirsutism type symptoms are going to start to show up and it might just be for the common type, as far as hair growth, it might just be a couple of little dark coarse hairs here or they’re, not enough to really pay attention. You might be irritating, you pluck it out with a tweezers. It might not be that necessarily that upsetting. It’s not that big of a deal. But it’s one of those little pieces to the puzzle that helps determine what’s going on.
Dr. Davidson: And like Dr. Mackey had mentioned, there is easy waking. It’s probably more vanity pounds. So that weight gain isn’t putting a tremendous pressure on the heart or on the glucose or anything like that. So it’s we’re on the liver, but it is enough to say, “Hey, these common types they’re really trying to maintain their weight, but it’s really easy to gain, especially you’ll see it in the middle, like the stomach maybe a little bit with the hips and the thighs, but definitely the stomach first and then the hips and the thighs.”
Dr. Maki: Yeah. Now, I know you talked the last time you talked about the FSH/LH ratio, wherein the classic type that total ratio is going to be there for sure, right there. LH is going to be 2 to 1 times are pretty close to–
Dr. Davidson: Or more.
Dr. Maki: Or more to the FSH level. Where do you typically see it in the common type?
Dr. Davidson: So, you definitely see that luteinizing hormone, the LH higher than the FSH. That’s one thing that triggers you that this is a common but not a classic. Is it might not be quite that 2 to 1 ratio. So like in a classic, you’ll see an LH at 14 and FSH at 7 and LH at 21 and an FSH at 7. So you know, that LH is 2 or more times higher than the FSH in a classic type, but in a common type, you’ll see it just a little bit like the, you know, that LH might be 10 and then the FSH might be 6. So it’s not quite double, but it’s enough to say, “Hey, that luteinizing hormone is higher than the FSH.” Granted with the cycle, the LH and the FSH do change. So you don’t want to base anything on one minute of one moment of your day on a blood test.
You want to collect these tests together and put the information, but you will see that LH a little higher than FSH were typically over the course of a, you know, I want to say a perfect 28-day cycle. Is the FSH and LH really should be even, they should be pretty much even Steven. So when you see that LH continuously a little bit higher than the FSH, that’s another piece of the puzzle for us.
Dr. Maki: Yeah. Right. So, on the lipid profile you might see maybe a total cholesterol will be normal, but now their triglycerides will be high normal or maybe right around that hundred and 50 mark. Now, I would like to see triglycerides really about 75, over half of the reference range.
Dr. Davidson: 100 or low, 100 or below.
Dr. Maki: If not even lower that in some ways the lower the triglycerides, the better. But they might not have anything else. But they might have that triglyceride level starting to creep up. The correlation between insulin and triglycerides is a fairly good correlation. So you can assume that’s why we pay attention to triglycerides because as their triglyceride level increases, we can assume that their insulin-resistant level is also increasing at the same time.
Dr. Davidson: So as we talked about on the last one, the classic, their insulin is high, and they had these ridiculous reference ranges through the labs, which is sad, but they’re like reference range up to 20 is normal for insulin. Anything over 9 or 10 is high. So with somebody with a classic, they’re easily going to be close to 20 maybe even over the range in the 20’s for the insulin fasting insulin levels, blood levels. But for the common, you’ll see it a little bit higher than you would think their dietary is. Like Dr. Maki had mentioned, hey, their triglycerides might be a little high normal, but the dietary and lifestyle doesn’t really seem to be the marker for that. And sure, there might be some genetics, family genetics for cholesterol, but then you look at the insulin and you think, you know what, they’re not eating a lot of carbohydrates or sugars are really working very hard with their diet, but their insulin is like 9 to 13, you know, 12 that’s another, like I said, a piece of the puzzle, another flag to put that together.
Dr. Maki: Yeah, right, exactly. It doesn’t come across as being overtly insulin resistant. It’s not a 25 or higher. But like you said 9 to 13, and I was thinking like 7 to 12. You know, where you’re kind of paying attention certainly when it’s in the double digits, maybe not 7, 8 or 9, but certainly when that insulin the fasting insulin gets to be in the double digits, 10, 11, 12, 13 that is where you get an idea. And usually, at that point when that fasting insulin is in the double digits, those others thing are going to start to look worse than they should.
Dr. Davidson: So it’s kind of like, we talked about the classic and they have it all. The common is just like one step below. So they’re going to have a little higher levels of insulin. They’re going to have a little higher normal levels of the androgens. They’re going to have a lot of the same symptoms but not quite as extreme as the classic. So it’s definitely like, right in the middle there and you will notice that they do have the lower progesterone so, but they still might be able to get pregnant, especially with some intervention. But they do have the lower progesterone, but they are cycling pretty much. They have irregular periods. So the common PCOS types do have a regular period, but they’re not so avert as a classic that it jumps out. So they might have five periods in a row and then miss one, they might have longer cycles, like up to 45 days. And then the next one is 33 days. So it’s, they’re irregular. But there, like I said, it’s not enough to really stand out.
Dr. Maki: Yeah. Right. Well, like you said, in the classic type, they probably don’t have hardly, maybe on a yearly basis they might have 2 or 3 periods a year. You know where this one, they might just miss a couple over the course of an entire year. They’re not going to have 12, but they might have 9 or 10, just enough to kind of throw things off. And like you said, based on those longer cycles, it might even end up being in a 12 month calendar year, might even end up being like more like 9. Those cycles are a little bit longer.
Dr. Davidson: Yeah. And they’ll say, “Hey, I’ve been always that way, that’s my normal to have longer cycles or to have 2, 3, then miss one or half 5 and then miss one, they’ll say, that’s my normal.” But to me we’re all different and we’re all unique and that’s okay. It’s still another bit of information that we can put away and put it all together when we’re coming up with our treatment plan. Because when you’re looking at the classic, I mean, first thing you’re thinking, we going to make sure this blood pressure isn’t going to go crazy. We want to make sure they don’t develop diabetes type 2 or if they already do have it, that we want to try to minimize that as much as possible. There’s some definitely some health consequences to having classic PCOS. But it’s the same thing with common. Is there going to be at a little bit more risk for diabetes type 2 overtime? They’re going to be at a little bit more risk for continuously gaining weight every year. They’re going to have risks too. So we definitely want to put that all together so we can figure out, well, how can we balance these hormones so we can get the best effective plan to get them feeling good now, but also preventative for the future.
Dr. Maki: Yeah. Right. Which again as we’ve talked about a couple of times, they cannot be done with just a prescription and needs to be a multifactorial approach, a diet, lifestyle, sleep. Sleep is critically important in all three of these types. Stress level is critically important. All three of these types. And we see people all the time, they have really high stress in their lives and they don’t sleep very well. In some ways, you could say that is the reason why their hormones are the way they are just because of all of that alone. Not to mention every other factor in America that leads to these hormonal issues.
Dr. Davidson: One other thing that you do see with actually all three types honestly, is that lower thyroid function or someone with classic might have complete hypothyroidism. You will see with that common type that they do have lower thyroid function. So we always want to address that as well because it’s pulling in, like we talked about on the previous episode is, hey, we’re pulling in the adrenals, we’re pulling in the thyroid function, we’re pulling in working on that insulin and glucose and cortisol kind of, I guess that interaction, we want to be upstream and then work on those female hormones downstream.
Dr. Maki: Yeah. And you know, conventionally thyroid is also one of those really controversial things. If your numbers, if your TSH is normal, 0.45 to 4.5, they’re not going to address it whatsoever. But in cases like this, it has to be addressed in at least somehow. So that TSH comes down, that free T3 goes up. That’s the clinical response that we usually want to see. So if someone has a low normal TSH and a higher normal free T3 that’s always a good place.
Dr. Davidson: Perfect. Yeah, exactly.
Dr. Maki: So, I think we’ve done a fairly good job of kind of differentiating between into this one is just a little bit more subtle than the classic type. Maybe in some ways, maybe a lot more subtle. Which is why it is not as diagnosed as often as it should be. The next episode we are going to talk about what we call the concealed type as we mentioned. And this one they’ve kind of struggled for a long time. They go to a lot of doctors and they have a hard time ever getting any real answers.
If you’d like more information about our hormonal approach, you can visit our website progressyourhealth.com. There, right on the homepage you can enter your email and get access to our free hormone video course. There we go through 4 specific profiles, PCOS, hyperthyroid, perimenopause, menopause, and we have some names and actually based on real patients that we kind of go through that kind of help paint a picture of what these different problems look like.
Dr. Davidson: Exactly and it’s free. So absolutely free to download, just enter your email and we’ll send it over to you. But just kind of a take-home message with this episode is the common type PCOS, there are enough flags that it will attract attention. There’s enough to say, “Hey, you know what? The symptoms with the high androgen symptoms and some of that blood work, that LH to FSH, that insulin looking fasting insulin looking a little odd.” There are definitely some red flags. So that way we can help that person and we can develop a treatment plan. It’s to concealed that those flags are so quiet that really have to kind of delve in a little deeper to pull that out.
Dr. Maki: Yeah. Right. So, we’re going to discuss that on the next one. So for this one, any last thing to add, I think we did a good job on the common type. Do you have anything else to add?
Dr. Davidson: No, this is great.
Dr. Maki: Okay. Until next time. I’m Dr. Maki.
Dr. Davidson: And I’m Dr. Davidson.
Dr. Maki: Take care. Bye Bye.
The post What Type of PCOS Do I Have? Common | PYHP 064 appeared first on .
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In this episode, we discuss the best way to reduce triglycerides. Sasha, a podcast listener, asked us how to lower her triglycerides. We then go into depth about triglycerides, how to lower them, and why they could be high in the first place.
How to read a lipid panel
Supplements for lowering triglycerides
Lifestyle changes for lowering triglycerides
What do high triglycerides mean?
Building blocks for triglycerides
Improving metabolic health
Can menopause increase triglycerides?
High triglycerides and thyroid hormones
Sacha’s Question:”I know this isn’t a hormone question but was hoping you could give me some direction. I was wondering what is the best way to lower triglycerides? thank you for your help!”
If you have a question, please visit our website and click Ask the Doctor a question.
Disclaimer: All content in this blog, including text, images, audio, video, or other formats, was created for informational purposes only. This video, website, and blog aim to promote consumer/public understanding and general knowledge of various health topics. This content is not a substitute for professional medical advice, diagnosis, or treatment. Please consult your healthcare provider with any questions or concerns youmay have regarding your condition before undertaking a new healthcare regimen. Never disregard professional medical advice or delay seeking it because of something you have read on this website. If your healthcare provider is not interested in discussing your health concerns regarding this topic, then it is time to find a new doctor.
In this episode, we discuss a podcast listener’s question. ‘Alesha’ is concerned that she should not take estrogen replacement therapy because she has fibroids. This is a common concern. The idea that estrogen can cause or propagate fibroids has left many menopausal women without support for their symptoms. Just because women have or have had a history of fibroids does not mean they are not a candidate for estrogentherapy. In fact, women with fibroid can take estrogen hormone replacement therapy.
In this episode, we go into depth about taking estrogen with fibroids. And we break Alesha’s question into:
What are fibroids?
Fibroids and estrogen replacement therapy
Can I take estrogen if I have fibroids?
What is adenomyosis?
Estrogen’s role in fibroids
Difference between perimenopause and menopause
How menopause can affect prediabetes
Alesha’s Question:
“Is there any hope for someone with adenomyosis take estrogen? If so, when is the right time? I know adenomyosis is stimulated by estrogen. I even had 1 dr offer a hysterectomy so I could take estrogen without any issues ??!! I have a history of heavy periods have had many trans vag ultrasounds and biopsy’s over the years Uterus was enlarged, lining was wnl. Had a hysterscopy to remove some cysts they found 4 hrs ago. Last ultrasound showed probable adenomyosis.i am almost 57and I am in late perimenopause. Cycles have been erratic just went 6 months without a cycle then had a normal cycle…for years of perimenopause I had symptoms of high estrogen. Most of the time for the last year I had symptoms of low estrogen. Poor sleep waking up 4-5x night, dry skin, vaginal dryness, night sweats, brain fog, difficulty concentrating which makes my job very difficult. I have also developed mild sleep apnea(sleep lab) and after my last physical I am on the edge of pre diabetes. ( am normal weight, I walk daily and lift weights, eat high protein diet with lots of veggies and healthy fats.) I am currently taking a progesterone troche( 1/4 lozenge 50mg 2x day) and vaginal estrogen. I was taking an oral progesterone 300 mg thought it would help with sleep but didn’t. The progesterone has helped with GI issues, puffiness, bloating, cramping and anxiety.”
If you have a question, please visit our website and click Ask the Doctor a question.
Disclaimer: All content in this blog, including text, images, audio, video, or other formats, was created for informational purposes only. This video, website, and blog aim to promote consumer/public understanding and general knowledge of various health topics. This content is not a substitute for professional medical advice, diagnosis, or treatment. Please consult your healthcare provider with any questions or concerns you may have regarding your condition before undertaking a new healthcare regimen. Never disregard professional medical advice or delay seeking it because of something you have read on this website. If your healthcare provider is not interested in discussing your health concerns regarding this topic, then it is time to find a new doctor.
In this episode, we talk about POI (primary/premature ovarian insufficiency) and earlymenopause. Samantha sent in a question about whether she is in menopause or hasPOI at the age of 36.We break Samantha’s question into:- What is POI (Premature/Primary ovarian insufficiency)?- Taking estradiol during perimenopause- Difference between perimenopause and menopause- What is an FSH?- Insulin resistance and perimenopauseSamantha’s Question:I am 36 and have been slowly noticing perimenopause/low estrogen symptoms for thepast year and a half. I went to an online provider and started HRT and haveexperienced so much relief! From mental symptoms to night sweats to dryness(everywhere) I have started to feel so much better being on estradiol and progesteronefor 3 months. I have been working with a functional nutritionist on my diet, walking daily,etc.i had gestational diabetes for all 3 pregnancies and also got my tubes removed lastyear. After I came off the birth control all of my symptoms started! I recently saw mynormal OBGYN so I could get my HRT through insurance and he agreed- but made itclear this isn’t menopause, could be POI, but seemed skeptical. I got bloodwork doneand my FSH has risen in the past few months from a 3.7 to an 8. But it’s still considerednormal. All of my thyroid and other bloodwork also comes back normal. Is POI apossible diagnosis? I feel crazy!!If you have a question, please visit our website and click Ask the Doctor a question.
Disclaimer: All content in this blog, including text, images, audio, video, or other formats,was created for informational purposes only. This video, website, and blog aim topromote consumer/public understanding and general knowledge of various healthtopics. This content is not a substitute for professional medical advice, diagnosis, ortreatment. Please consult your healthcare provider with any questions or concerns youmay have regarding your condition before undertaking a new healthcare regimen.
Never disregard professional medical advice or delay seeking it because of somethingyou have read on this website. If your healthcare provider is not interested indiscussing your health concerns regarding this topic, then it is time to find a new doctor.
Can you be in both in perimenopause and menopause? Can you be menopausal andperimenopausal at the same time? The difference between perimenopause andmenopause is not a line in the sand. It is not like crossing through the Peace Arch fromBlaine Washington to the country of Canada. And at times, there is nothing peacefulabout perimenopause or menopause.There is a gray area where you are just moving out of perimenopause and intomenopause, where you are not quite in perimenopause but are not completely inmenopause. We delve deeper into the place that is between perimenopause andmenopause:- What is the difference between perimenopause and menopause?- Can you be both in perimenopause and menopause?- The difference between perimenopause and menopause- What it feels like to go from perimenopause to menopause- Can you take estrogen or biest when you are going from perimenopause tomenopause?- Is bleeding in menopause considered perimenopause?- Top symptoms of perimenopause- Top symptoms of menopause- Are you a candidate for estrogen replacement in perimenopause?If you have a question, please visit our website and click Ask the Doctor a question.Disclaimer: All content in this blog, including text, images, audio, video, or other formats,was created for informational purposes only. This video, website, and blog aim topromote consumer/public understanding and general knowledge of various healthtopics. This content is not a substitute for professional medical advice, diagnosis, ortreatment. Please consult your healthcare provider with any questions or concerns youmay have regarding your condition before undertaking a new healthcare regimen.Never disregard professional medical advice or delay seeking it because of somethingyou have read on this website. If your healthcare provider is not interested indiscussing your health concerns regarding this topic, then it is time to find a new doctor.
In this episode, we discuss a listener’s question about how to apply estriol to your face. ‘Connie’ is confused about whether she can use her Biest cream on her face. And she wanted to know the difference between estriol and Biest when it comes to treating menopausal symptoms.
We analyze Connie’s question into:
Applying estriol to the face
What is biest?
What is estriol?
What is the difference between estriol and biest?
Applying estriol vaginally
It is not a good idea to apply biest to vaginal tissues if you have a uterus
Connie’s Question:
“HI there, I loved your article on estriol for the face. I was prescribed an 80-20 bi-est cream for HRT. My question is, how is that different from a 0.3 estriol cream for the face like the kind My Alloy makes? Could I just use more of my Biest cream on my face? Would that be stronger than the My alloy 0.3 estriol cream? Lastly, the .3 estriol cream is not supposed to affect your overall hormone levels, but the Bi-est cream is supposed to affect your hormones and relieve symptoms of menopause. Why does one estriol work differently than the other? Thank you so much for any guidance you may be able to offer. It’s so hard figuring all of this out!”
If you have a question, please visit our website and click Ask the Doctor a question.
Disclaimer: All content in this blog, including text, images, audio, video, or other formats, was created for informational purposes only. This video, website, and blog aim to promote consumer/public understanding and general knowledge of various health topics. This content is not a substitute for professional medical advice, diagnosis, or treatment. Please consult your healthcare provider with any questions or concerns you may have regarding your condition before undertaking a new healthcare regimen. Never disregard professional medical advice or delay seeking it because of something you have read on this website. If your healthcare provider is not interested in discussing your health concerns regarding this topic, then it is time to find a new doctor.
In this episode we talk about where to apply hormone creams. Sadie, our listener wants to know if she needs to rotate the application sites of her hormone cream.
In this episode we discuss:
Where to apply biest cream
What to apply testosterone cream for females
Places you should not apply your testosterone cream
Best absorption sites for hormone creams
Sadie’s Question:”I have been using hormones for a little over a year. I swear by them!! I have not rotated sites at all. I use testosterone/DHEA cream behind both of my knees and E3/E2 on both of my inner thighs every morning. I take a progesterone capsule at bedtime. My doctor and everything I read says to rotate sites. I found an article by Dr. Collins and now I found your article about not having to rotate sites, so I am going to keep doing what I have been. I put the cream on both of the backs of my legs and thighs. My question is should I alternate one back of knee and then the other and the same with the inner thighs or does it matter?
If you have a question, please visit our website and click Ask the Doctor a question.
Disclaimer: All content in this blog, including text, images, audio, video, or other formats, was created for informational purposes only. This video, website, and blog aim to promote consumer/public understanding and general knowledge of various health topics. This content is not a substitute for professional medical advice, diagnosis, or treatment. Please consult your healthcare provider with any questions or concerns you may have regarding your condition before undertaking a new healthcare regimen. Never disregard professional medical advice or delay seeking it because of something you have read on this website. If your healthcare provider is not interested in discussing your health concerns regarding this topic, then it is time to find a new doctor.
