Deborah Howell (Host): September is PCOS Awareness Month. PCOS is a common endocrine system disorder affecting women around the globe. But a PCOS diagnosis is sometimes overlooked in young women not trying for pregnancy because it can have many variable and subtle symptoms.

In honor of PCOS Awareness Month, Dr. Asima Ahmad joins us today. Dr. Ahmad is a double board-certified OB-GYN and reproductive endocrinologist at Fertility Centers of Illinois. She also started her own company, Carrot Fertility, where she now acts as Chief Medical Officer to increase access to fertility care. She's with us today to answer the top questions about PCOS. Welcome, Dr. Ahmad.

Asima Ahmad, MD: So excited to be here. Thank you for having me.

Host: I'm looking forward to it. We'll jump right in if that's all right.

Asima Ahmad, MD: Sounds good.

Host: What is PCOS?

Asima Ahmad, MD: PCOS stands for polycystic ovary syndrome, which as you mentioned, is one of the most common hormonal disorders in women.

Host: So, you were actually diagnosed with PCOS. Can you share your experience living with it and how it has influenced you as a physician?

Asima Ahmad, MD: There's probably two ways I describe how it feels to live with PCOS, at least for me. Frustrated yet empowered. And it's frustrating because I am 41 years old and I still get acne. I have brown skin, so those acne post-inflammatory hyperpigmentation, that can last for, you know, months at a time. And my periods have always been irregular and difficult to predict. So growing up, I didn't know when I was ovulating and have always been the type of person who was carried around sanitary pads with me because I never knew when I would start bleeding. Whereas so many women around me knew exactly which day their period would come or when they would ovulate.

And it's also frustrating that when I work out regularly, eat healthy, and even keep a normal range BMI, I'm doing all this work, yet due to the impact of PCOS on my metabolic function, I have to work so much harder to see things change. Then on the other hand, honestly, I feel empowered because now I have an answer. I know why it's happening. And with that, I know it's not just in my head or me complaining like this is real. And that's also because it took a while to get that diagnosis.

I think having it has also made me realize that you know your body. When I was first seeking evaluation, I didn't get an evaluation done right away because everyone said, "You're young. You're fine. Cycles are irregular," which initially they can be, it was put off for a while. So when something doesn't feel right, it probably isn't. So, I think I try extra hard to make sure I don't ignore or brush off any of my patient's symptoms, concerns or questions, because sometimes something smaller, maybe not so small, can be an indicator of a bigger problem. So, I always encourage patients to listen to their body. And if they sense something isn't right, that they get evaluated for it. Because in many cases, there may be an answer that they find and have a reason why they feel the way they do.

Host: Always, always a reason to get checked if your antennae are saying something and your body is doing something that's not really normal for you. So, how common is PCOS?

Asima Ahmad, MD: Much more common than I realized. When I was younger, I thought I was the odd one out when in fact I wasn't and that wasn't the case. As many as 5-20% of women can have PCOS. So, it's one of the most common hormonal disorders in women.

Host: Wow, I hadn't realized it was that high. And what are the symptoms?

Asima Ahmad, MD: This is the thing. It doesn't always present the same way in everyone. Sometimes women don't have those typical symptoms and it can be missed. But in general, symptoms can include irregular periods, which is due to the person not ovulating regularly or even at all. And they can have excess hair growth, for example, in areas like the face and the chest. They can have acne or even something called androgenic alopecia, which is hair loss. So because the presentation is variable based on the person, it's not always the same. When it comes to different people, it can present differently.

Host: Sure. And how is PCOS diagnosed?

Asima Ahmad, MD: PCOS is diagnosed both by evaluating a person's medical history, labs, and doing an ultrasound of the ovaries. I use Rotterdam criteria, which looks at three components, and you only need two out of three to be diagnosed.

So, one is ovulatory dysfunction, which means not ovulating regularly or at all, which the way that person can get a sense of that is that they have irregular periods or don't have periods on their own at all. But of course, when you're diagnosing this part, you have to exclude other causes. And then two is polycystic morphology ovaries, which has to do with the number of follicles you have in your ovaries or the size of your ovaries. And three is that you have symptoms of or blood tests that show elevated androgens, and androgens are male hormones. So, both females and males have them, but they can sometimes be elevated in females and give these symptoms that we talked about.

Host: Okay. And now the big question. How does PCOS affect fertility?

Asima Ahmad, MD: So, PCOS can affect fertility. One of the biggest ways it can is that someone might not ovulate at all or ovulates irregularly, so it's difficult to predict. And then, knowing when you ovulate is so important because when you ovulate that egg is only viable for about 12 to 24 hours. And in order to get pregnant, for example, if you're timing intercourse or even doing inseminations, the sperm has to be there in time to fertilize the egg. So when you're not ovulating predictably, you might miss that window.

Host: Okay. Now, are women with PCOS more likely to need fertility treatment to get pregnant?

Asima Ahmad, MD: In general, if you look at the entire population of those who have PCOS, yes. Like I mentioned earlier, there's many ways that PCOS can present. And for some women, because they don't ovulate regularly or predictably or at all, they may need help in these cases. But there are also women with PCOS who don't need fertility treatment to get pregnant, meaning that they might have the other symptoms of hair growth and polycystic-appearing ovaries, but ovulate relatively regularly and predictably. So again, it depends on the person and their specific case.

Host: Everybody's different. Okay. Now, what fertility treatment options are available to women with PCOS?

Asima Ahmad, MD: The good news is that for many of the women who have PCOS, more simple treatments like ovulation induction, using oral medications can help them ovulate and using that with timed intercourse. For many of them, once we get them ovulating more predictably, their chances of getting pregnant are close to other women in their age group. But of course, there's always exceptions to this. There will be some women who fail to respond to one oral medication regimen or another and may have to try multiple different types of protocols before they respond or even those that still do not find success and have to then incorporate other treatments like intrauterine insemination or in vitro fertilization or IVF.

So, in short, if PCOS is the only cause of infertility for that person, you can do ovulation induction with timed intercourse or you can then include intrauterine insemination with that, or if those don't work, even IVF.

Host: Okay. So many options. Well, that also begs the question though, should women with PCOS see a fertility doctor before trying to conceive?

Asima Ahmad, MD: I always think it's a good idea to make sure that you have someone like a reproductive endocrinology and infertility specialist that can help you manage your PCOS, and this even before trying to get pregnant. Because it's important to optimize your health even before you get pregnant so that, one, you're able to get pregnant. Two, you also have a healthy pregnancy. But yes, if you have PCOS and don't ovulate regularly, you don't have to wait those six to 12 months before seeking an evaluation or care with a fertility doctor. You can and probably should do that sooner rather than later.

Host: Sounds good. Good advice. Does PCOS affect more than just fertility?

Asima Ahmad, MD: Yes, and I think this part is just as important as the fertility component because PCOS increases the risk for cardiovascular disease, diabetes and metabolic syndrome. And it's not that this increased risk is just during a few years of your life, but it's lifelong. So, that means that you need to be keeping a close eye on your heart health and your metabolic health. So for example, you should be checking your body mass index, your BMI. See your doctor regularly, get your cholesterol panel checked, check your hemoglobin A1c or even assess for signs of insulin resistance. Because staying on top of this can help you prevent the onset or progression of these other medical conditions. And of course, a woman who has PCOS, this is especially frustrating because, as I mentioned, I feel like I have to work twice as hard as my counterparts to see the results I want. But again, at least I'm empowered, at least I know why. And that keeps me motivated.

Host: Absolutely. You said lifelong. Well, so then I need to ask about nutrition. Is there any ideal diet for those affected by PCOS?

Asima Ahmad, MD: Well, PCOS can present differently in people, so I personally don't have a specific diet that I universally tell all my patients to follow. But in general, I provide guidelines. So, a diet that includes protein, healthy fats. Fresh fruits and vegetables is a good start. Trying to eat more fresh and organic foods as opposed to processed foods with high contents of sugar, for example, is important.

Host: As it is for all of us.

Asima Ahmad, MD: Yes, very true.

Host: All right. Besides all that, what are some other ways to manage PCOS symptoms?

Asima Ahmad, MD: It depends on the symptoms, but there's a few things that I like to highlight for my patients as important things to keep in mind. For example, when it comes to the symptoms around androgens, or the male hormones, such as excess hair growth, acne or even the hair loss, there's several medications that can help treat some of these. However, if you are actively trying to get pregnant, they aren't recommended. So if that's the case, sticking to topical treatments like waxing or threading for hair growth or topical treatments for acne is preferred.

The other thing that's extremely important is that if you're having unpredictable periods that are, for example, really far apart, like missing, skipping months between your period, your uterus may be getting exposed to longer periods of estrogen and you're not shedding that lining regularly. So, this puts you at risk for developing endometrial hyperplasia, which puts you at risk for uterine cancer. So, again, when you're not trying to get pregnant, do something to protect your uterus. This could mean taking birth control pills, progestin pills or even a progestin IUD, to name a few options.

Host: Again, your doctor is the best one to inform you about all these choices, right?

Asima Ahmad, MD: And what will work best, yes.

Host: That's right. Now, what advice would you give to someone who thinks they might have PCOS?

Asima Ahmad, MD: If you think you have PCOS, don't hesitate to get a workup to determine if you do indeed have it. One, I think it's important to diagnose so you know what you have, how to manage it and what your treatment options are. And then, you can focus on optimizing your health if you have PCOS and know your risk factors and how it impacts your fertility. But two, it's also important to rule out other medical conditions that sometimes mimic PCOS symptoms. For example, you could have ovulatory dysfunction or those irregular periods that could also be secondary to something like a thyroid or a pituitary condition. And sometimes excess hair growth or other symptoms where we see these elevated androgens, they can also be secondary to having something like an androgen-producing tumor or something called congenital adrenal hyperplasia. So, one, get your work up and diagnosis so you can empower yourself to be an agent of your own health and optimize your health, but two, rule out those other causes.

Host: Well, Dr. Ahmad, we cannot thank you enough for being with us today and for helping us understand so much more about PCOS. Is there anything else you'd like to add?

Asima Ahmad, MD: You know your body best. If something doesn't feel right, get it evaluated. And in many cases, you'll get answers. And that's important, not just for the short term, but for the long term.

Host: Great advice. That was Dr. Asima Ahmad, a double board-certified OB-GYN and reproductive endocrinologist at Fertility Centers of Illinois. You can schedule an appointment to talk to a fertility specialist at 877-324-4483, or visit fcionline.com for more information. And if you enjoyed this podcast, you can find more like it in our podcast library, and be sure to give us a like and a follow if you do.

This has been the Time to Talk Fertility podcast. I'm your host, Deborah Howell. Have yourself a terrific day.