Amanda Wilde (Host): Welcome to the Live Greater podcast series, information for a healthier you from the University of Maryland Medical System. For Women Living with PCOS, bariatric surgery can help, dramatically. We'll be talking about how bariatric surgery affects PCOS with Dr. Alexander Aurora, Director of Advanced Minimally Invasive Surgery and Bariatrics at UM Upper Chesapeake Health.

I'm Amanda Wilde. Welcome, Dr. Aurora. Thank you so much for being here.

Alexander Aurora, MD: Thank you very much for having me.

Host: PCOS can be confusing for many women. How do you explain it in simple terms?

Alexander Aurora, MD: So PCOS, as you said, is complex both for patients and even for doctors. PCOS usually is diagnosed by a combination of symptoms that the patients can identify. Very often, they might note having some excess hair growth on either their chin or on their arms. They may have some male pattern baldness, losing some hair on their head. And notably, obviously what we're talking about is maybe having difficulty, irregular menstrual cycle and difficulty with fertility or having children.

Host: And why do weight challenges often go hand in hand with PCOS? From my understanding, weight doesn't cause it, but it does make it worse.

Alexander Aurora, MD: Right. So I would say there's probably about 10% of the female population that is in the childbearing age have PCOS and that's the primary source of infertility in those women. I would say about half of them, or a bit more than half of them probably have obesity. So obesity is very often associated with the problem.

 Why does it happen? Well, we think that the excess fatty tissue changes the hormonal regulation in the body due to altered levels of estrogen and testosterone, and that balance is thrown off by the excess fatty tissue.

Host: So how does bariatric surgery help women with PCOS?

Alexander Aurora, MD: So, I mean, the obvious thing is weight loss surgery or bariatric surgery helps them lose weight and so gets rid of the excess fatty tissue and thereby normalizing, in part, their hormonal levels. In the literature though, it's not really clear that it's directly related to the changes in all of the hormone levels such as estrogen, but we do clearly see that women that have weight loss surgery usually can get pregnant successfully within a year or a year and a half of losing their weight, to the point it's actually necessary to take precautions and to recommend that your patients use some type of contraception even during their weight loss journey. Because very often they'll get pregnant before they're even ready for it, and we don't really want them to get pregnant while they're still losing weight because that can add excess stress to the pregnancy and cause problems for the pregnancy.

Host: So, weight loss can really remedy that situation for many women. What other changes do patients see in their health when they get the bariatric surgery?

Alexander Aurora, MD: First of all, there are studies showing that weight loss in general will help improve those hormonal levels, but usually not to the same degree as weight loss surgery, in part because weight loss surgery, I think is usually more successful at helping them lose more weight.

But there is such an indicator that it's not only the weight loss itself. The success after the weight loss is, I would say if the problem with their cycle and their ability to get pregnant is due to PCOS, then usually those patients can almost always get pregnant. So I would say 90% recovery from that, also helps stop the male pattern baldness, decreases the whiskers growing. And I think more importantly puts them in a safer place for actually having children. We know that women with obesity trying to have children or pregnancy put themselves at risk with preeclampsia, which is very high blood pressure, h aving problems with safe growth of the fetus. Losing the weight also will decrease the likelihood of them having malformations after birth and then also decreases the risk of the mother having complications at the time of pregnancy with bleeding and other problems.

Host: So that sounds like significant improvement and significant improvement in quality of life as well, would you say so?

Alexander Aurora, MD: Yeah, for sure. One of the things I didn't mention was also, it is noted that patients with PCOS and obesity are also at increased risk for endometrial cancer. And so that risk is also significantly decreased with the weight loss. There are quality of life studies, there's lots of them out there and lots of them show that losing the weight and resolving the PCOS drastically increases their quality of life. That's one of the major identifiers that we've seen in studies.

Host: So how do you guide women in deciding whether this is the right step for them?

Alexander Aurora, MD: We have a very comprehensive bariatric program. We've been around for a long time and I tend to be one that practices on a very individual patient to patient basis and consultation. It's pretty rare that we ever have any group meetings for the patients and the first thing I always tell the patients is I'm there to give them recommendations for healthy lifestyle changes.

And hopefully with those changes they'll get healthier. And then in addition, hopefully they'll lose weight. At the end, if they've been successful losing weight on their own and they want to continue that way, then they should. But if they still need help and want to go the extra step to have surgery, then I'm ready to do that.

And I would say that patients that make those lifestyle changes and are successful with that and have been cleared and safe for surgery, go through with surgery, 90% success, usually at losing the weight, getting rid of diabetes, getting rid of hypertension, sleep apnea, and PCOS.

Host: Wow. I don't hear any downside to this. Is there?

Alexander Aurora, MD: Well, obviously there is the risk of surgery, but we're in a situation where the flip side of not doing anything about it or not losing the weight is significantly worse than any risk you could have with surgery. Surgery itself these days, even in patients that are super morbidly obese at very high weights, it's actually still very safe. We do all the procedures are planned laparoscopically or minimally invasive. We also use robotic assisted surgery very often, and that leads to really good outcomes. Minimally invasive incisions, quicker recovery. And the risk of complications is less than 1% most of the time.

Host: Those are pretty astounding statistics. I'm glad you emphasize that you use minimally invasive techniques and I'm wondering are there any common myths or misconceptions you run into with your patients or the community at large about bariatric surgery and PCOS?

Alexander Aurora, MD: So in particular with respect to bariatric surgery, I get patients often coming in from different places that have already had weight loss surgery, probably not with me. And believing that the commonest thing I see or hear from patients reading on the internet is that their pouch has stretched and they need another surgery.

 Having another surgery is very rare and for very specific indications that I think only the physician would decide. So that's the first thing. With respect to PCOS and weight loss surgery, I haven't really heard too much thrown out there other than, maybe the success rates are not as good as with medically managed weight loss. But the research pretty much shows that with weight loss surgery the success rate is significant.

Host: For those women, like the ones who come to you who've already had a surgery, or for people who just feel discouraged or stuck with PCOS, what is a piece of advice you would give those women?

Alexander Aurora, MD: I would say that you are still in control of your own life and your situation, and you can make a difference by making good decisions. So the first part always is to start off looking at what your habits are. And I think most of them are pretty common sense. What is a good habit versus a bad habit?

Having another bag of chips or having an apple, going for a walk or watching another video. Those are common sense things. And so we reiterate that and reinforce that. We have a good support team here that helps guide you through that. And so my advice is if you're wanting to resolve the PCOS and or have children, you should definitely look into healthier lifestyle habits to help you get healthy.

And if you need extra help, you can come and ask us some questions. We never pushing anyone into having surgery. Like I said from the beginning, my first visit is always that you know, most patients can actually do this on their own, but it takes so much discipline and patience to lose the weight on your own. It's pretty rare that a patient goes through all that by themself without having surgery.

Host: Yeah, surgery and just the additional support means so much, and just the reminder that you are in the driver's seat, that you still are empowered. Thank you, Dr. Aurora, for your work, your minimally invasive surgery, and for really helping people who have PCOS.

Alexander Aurora, MD: You are welcome. No problem. Thanks for talking to me.

Host: Dr. Alexander Aurora is Director of Advanced Minimally Invasive Surgery and Bariatrics at UM Upper Chesapeake Health. Find more shows just like this one at umms.org/podcast and on YouTube. Thank you for listening to Live Greater, a health and wellness podcast brought to you by the University of Maryland Medical System.

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