Melanie Cole, MS (Host): Thanks for tuning in to Back to Health, the podcast that brings you up to the minute information on the latest trends and breakthroughs in health, wellness, and medical care. Today's special episode is part of our Women's Health Wednesday series, which features in-depth conversations with Weill Cornell Medicine's top physicians and issues surrounding women's health throughout the life course.

Listen here for the information and insights that will help you make the most informed and best healthcare choices for you. I'm Melanie Cole. And today on this Women's Health Wednesday, we're discussing PCOS, or polycystic ovary syndrome. Joining me is Dr. Rekha Kumar. She's an Associate Professor of Clinical Medicine at Weill Cornell Medicine.

Dr. Kumar, thank you so much for joining us today. I'd like you to tell the listeners a little bit about polycystic ovary syndrome. Is it a gynecological or endocrine disorder? Tell us a little bit about how we classify this.

Rekha Kumar, MD: Sure, I'd love to talk about it. Thank you for having me. Polycystic ovary syndrome can be considered both a gynecologic disorder and an endocrine disorder. It can actually also be considered a metabolic disorder in some people, meaning that there are various presentations of it, so it looks different in many people, it is heterogeneous. Not everyone's PCOS looks the same. So for some people, it can present as a gynecologic disorder with irregular periods or no period, or it can present with infertility. That might be the first sign of it. In others, it might show up as acne or unwanted hair growth on the face, what we call hirsutism. And in some people, it is actually weight gain and inability to lose weight, that is the first sign. So, it can look quite different in different people, and it overlaps the spectrum of gynecologic disorders, endocrine disorders, as well as metabolic/carbohydrate insulin resistance disorders.

Melanie Cole, MS: Well, I think that that really goes to the thing of women in general. All of our disorders and things that we go through every month are different for each one of us. And that's what makes some of these challenging when you're working with patients that have these disorders. So, how has our understanding of the underlying causes of PCOS evolved and some of the key features, Dr. Kumar, that differentiate our new modern approach to women with PCOS from traditional methods? As you said, we're all different.

Rekha Kumar, MD: Yeah. So, I would say that our understanding of PCOS has evolved over the past 50 to 70 years. We used to think it was actually primarily a pituitary gland problem. So, our pituitary gland is a small gland in our brain, kind of at the base of the brain, way behind the nose. And it is what we call our master gland in endocrinology. It controls the release of hormones throughout the rest of the body. And 50 to 70 years ago, we would look at a ratio of two hormones made by the pituitary called the LH-FSH ratio. And we would diagnose polycystic ovarian syndrome based on that ratio and certain symptoms.

What those symptoms are, or were even at the time, are irregular periods or lack of ovulation; polycystic ovaries, meaning you do an ultrasound and you see cysts on someone's ovaries; and three, this picture of what we call hyperandrogenism, which means levels of elevated male hormones like testosterone. It could be a blood test or it could be features of it, such as hair growth on the face that shouldn't be there or cystic acne, hormonal acne. So, some presentation of those features would be seen in PCOS. Someone might not have all of them.

The other piece of it is this inability to lose weight. So, some people might have a portion of that, not all of it. As our understanding of PCOS has evolved, we have learned that one of the underlying causes is something called insulin resistance or a carbohydrate metabolism disorder. And in the setting of insulin resistance, the ovaries don't behave normally and make an abnormal amount of male hormones versus female hormones. And ovulation and the period is irregular. That's fairly complex and again, it's different in everyone. And also, environmental factors are relevant. So, it's also how your biology interacts with your environment that will determine what pieces of this syndrome somebody has.

Melanie Cole, MS: Well, it's very complex and you're explaining it so well, Dr. Kumar. So, you've mentioned these symptoms. And before that, you mentioned acne and some of these other symptoms that we would notice. And some of them happen to us anyway, as we said. So, tell us a little bit about diagnostic criteria. How do you diagnose this?

Rekha Kumar, MD: Yeah. So, I agree with you. Some of this can be completely normal and hormonally cyclical for many women. So, it's really the degree to which it's abnormal. And we use something called the Rotterdam criteria. And that's when a patient meets two out of three things on a list. What those three things are, are irregular periods or lack of a period signifying lack of ovulation. Two is any evidence of hyperandrogenism, meaning evidence of high testosterone, such as acne, cystic acne, unwanted hair growth on the face. And the third is the evidence of cysts on the ovaries. When somebody meets two out of those three things, we can diagnose them with PCOS.

So, what's interesting with those three criteria is It is a clinical diagnosis, meaning that it doesn't always require extensive testing. You can meet criteria for PCOS without even knowing what your ovaries look like if you meet the first two, so irregular periods, lack of a period and evidence of hyperandrogenism. Or you might not even know you have this condition until blood work and an ovarian ultrasound are done. So, that's why this is so tricky, because of the heterogeneity of the diagnosis and the presentation.

Melanie Cole, MS: Now, tell us about treatments. And does treatment differ if a woman's trying to get pregnant or done with her reproductive years? Because I would imagine throughout our life course, all of these kinds of conditions change. So, tell us a little bit about treatment and where it fits in to our reproductive years.

Rekha Kumar, MD: Absolutely. So, I would say that I base treatment based on what I think or what the patient tells me is the most pressing issue. And sometimes they might say all of the issues are pressing. So, that means that their cycle's irregular, they want to be pregnant. They're bothered by the acne and the hair growth, and their weight's a problem. So, you could have all of those issues and it is possible to treat all of them. It does depend on where in the reproductive lifespan somebody is. So, of course, if somebody's actively trying to get pregnant, and they are 40, there is some urgency to prioritizing the fertility. If somebody is 25, we can kind of attack the whole picture at once, we can use medicines to treat the high testosterone, we could use metformin to treat the insulin resistance, we could put somebody on a birth control pill to regulate the cycle. We could attack each of those. But if fertility is the priority, depending on the age of the patient. So if it's semi-urgent, as in their advanced maternal age, I would say often going right to reproductive endocrinology and considering induction with either medication or hormones is an option. When somebody desires pregnancy but they're younger, it gives us a window to say, "You know what? Let's take three to six months to see if we can treat the underlying root cause of the insulin resistance with a medicine like metformin and a low-carb diet and if we can restore the menstrual cycle and fertility through that." It kind of depends on how much time you have. Sometimes we meet people as teenagers. Pregnancy is not desired. They may want contraception. In that case, we put them on a birth control pill. We prescribe metformin for the insulin resistance, and we prescribe a medicine called spironolactone to lower the testosterone and treat the acne and unwanted hair growth. So it kind of depends on age, stage of life, and desire for pregnancy and whether you're in that reproductive window.

Melanie Cole, MS: What about things we can do, Dr. Kumar, as women? Lifestyle modification, self-care, our good health advocacy, because that's what these Women's Health Wednesdays are really all about, is learning to be our own best health advocate. And sometimes we feel that our doctors aren't listening to us, and we're trying to tell them these things. I'd like you to speak to all of that, including self-care. Lifestyle behaviors, things that we can do that can help us get through some of these uncomfortable symptoms.

Rekha Kumar, MD: So, the first thing I would say to that is think people can be more in tune with their body if they are becoming concerned about symptoms related to possibly PCOS. So really, knowing your cycle, is it regular? Perhaps considering tracking ovulation to even see if there are abnormalities there.

The other thing that we can do is there are people that will say that they cured their PCOS with ketogenic diets, very low carb diets. It's a little extreme and not always But watching sugar, added sugar, and total carbohydrates can treat the underlying insulin resistance. So, nutrition and fitness always matter. Less sugar, strength training, those are ways that make your body more insulin sensitive, which is a way of improving PCOS symptoms. It's often challenging to fully overcome it, depending on the degree of the PCOS.

And I would say just being your own advocate, if you feel that you're not being listened to, seek out a second opinion and say why you're concerned and what you've read. I think that we should expect that our patients are seeking out information on their own because it is available. And I certainly respect that, and I want to hear what my patients have read, and I would love to review it with them and either verify, support or explain why perhaps what they're reading may not actually match their symptoms.

Melanie Cole, MS: I love that you said that because that's so important for us to feel heard, especially if we're in pain and dealing with something that's scary and frustrating. Before we wrap up, Dr. Kumar, speak about how this multidisciplinary approach is really such a helpful way to go about dealing with PCOS, how you and other clinicians collaborate to optimize the care of women with this condition.

Rekha Kumar, MD: So, I work in the Women's Health Center. So right here on my floor, I have endocrinology, GYN, internal medicine. And there are actually times that I will see a patient and I will tell her that I'm going to have a huddle with their other doctors and talk about an approach that is not only satisfactory to the patient, but includes the opinions of all the other providers that touch the syndrome of PCOS.

So for example, I am treating the underlying hormonal part, but I want to make sure their GYN who is across the hall from me is comfortable with me initiating an oral contraceptive pill. I'm using it for the hormones, but maybe there's an opinion by the GYN where they will have a preference of which pill I use.

And the patient's internist might have an opinion on, well, is there some reason that one pill over another is safer? Or is there something about the family history of blood clots that I should know about before I proceed? So, I think it's really important because of how complex the condition is to be multidisciplinary and include the opinions obviously of the patient, but also of their other care providers.

Melanie Cole, MS: Do you have any final thoughts you'd like to leave women with if they are worried that they have PCOS or if they're dealing with it? Whether they're a teenager or a little bit later on in years, tell us what you'd like us to know.

Rekha Kumar, MD: I would seek out an endocrinologist or GYN doctor that has an interest in the condition and the specialty because you'll probably get more time and have a more in depth conversation versus feeling like you might be blown off by someone that it isn't their priority. And all of us physicians have strengths and weaknesses and interests like everyone else does. So, I think it's important to learn about what your physician is interested in treating as well.

Melanie Cole, MS: Great advice. What an informative episode, Dr. Kumar. Thank you so much for joining us today. And Weill Cornell Medicine continues to see our patients in person as well as through video visits. And you can be confident of the safety of your appointments at Weill Cornell Medicine.

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