PCOS Inflammation Insulin Resistance and Thyroid Health (Episode 426)

Full Transcript: Episode 426

Lisa Hendrickson-Jack: Welcome to the Fertility Friday Podcast, your source for information about the fertility awareness method and all things fertility. I’m your host, Lisa Hendrickson-Jack. I’m the author of The Fifth Vital Sign and the Fertility Awareness Mastery Charting Journal. I’m a certified fertility awareness educator and holistic reproductive health practitioner with nearly 20 years of experience teaching women to connect to their fifth vital sign through menstrual cycle charting, balancing hormonal health, and optimizing the menstrual cycle without hormones. I’m outspoken about hormonal birth control and its impact on fertility and overall health, because you have the right to know how your body works and how artificial hormones disrupt that natural process. I teach women’s health professionals how to utilize the menstrual cycle as a vital sign in their practices, and I host live coaching programs to help you achieve optimal fertility and health, because it’s important to have healthy menstrual cycles regardless of whether or not you want to have babies. I’m also a wife and mother of two beautiful boys. I know I’m a busy girl, but I managed to fit it all in. This podcast is designed to empower you to take full control of your cycles, your fertility, and your overall health, and I’m so excited that you’re here with me today.

Last week I shared a brand new solo episode to go through the difference between AHA and PCOS. As I shared in last week’s episode, I’ve always felt that they’re quite different, and especially if charting is the main modality that you’re looking at — if you’re looking at the menstrual cycle, then it’s fairly easy to differentiate. Because although somehow these conditions are often confused with each other, they’re very different. They have different presentations, different reasoning, different diagnostic criteria, and once you know what they are, it’s actually fairly simple to distinguish between the two. And so I thought a great follow-up to last week’s episode would be my interview with Dr. Fiona McCullough, author of Eight Steps to Reverse Your PCOS. In this interview she goes into PCOS, provides us with a really great explanation and understanding of what it is, and also talking about some of the key factors towards supporting and improving and restoring menstrual cycle health and fertility with PCOS. So without further ado, let’s go ahead and jump into today’s episode.

And so we’re going to be talking about the connection between PCOS, inflammation, gut health, thyroid conditions, and whatever else we can squeeze into our interviews. So thank you so much for coming on the show, Fiona.

Dr. Fiona McCulloch: Thanks for having me, Lisa. It’s great to be here.

Lisa: Well, congratulations on your new book, and in our pre-chat I was saying to you how nice it was to meet you in person. So Dr. Fiona and I were able to actually meet in Toronto at a couple of events that were happening here. So it’s really nice to be able to put a face to your name and to get a chance to meet you.

Dr. McCulloch: And likewise. I know we’ve done an interview before, and I feel like I’m always seeing you online, but meeting you in person was awesome.

Lisa: Yeah, it’s so nice to connect. It’s nice to bring the offline world into reality, into the real world. So why don’t you take a moment and introduce yourself to listeners. For the listeners, we do have a previous episode that we did together, so if you want kind of the full bio you can go back and listen to that, which I’ll link to in our show notes page for today’s episode. But maybe you can just tell us a little bit about your book and how the release and everything went.

Dr. McCulloch: Oh sure, I would love to. So yeah, I’m a naturopath and I practice in Toronto. I’ve been practicing here for over 15 years now, and I have a clinic which is called White Lotus Integrative Medicine, and we practice a lot of women’s health and fertility — that’s our main area of focus. And so I have PCOS myself, which I found out after many years of not knowing — in my early 30s I finally found out that that was the cause of a lot of my issues. So over the past decade or more of my practice, I’ve been really trying to learn a lot about PCOS, because it’s a really complicated condition and it’s been quite mysterious. So of course I love things like trying to figure things out, so it became a challenge to me, and also having it personally became interesting to me to try to figure out my own problems as well. And so yeah, I practiced for a while treating lots and lots of patients, and I started to see different patterns emerging in women, just seeing the differences in different women with PCOS and sort of connecting all the dots. And then I thought, I should really write a book about this, because a lot of the information on PCOS is kind of dated, or everyone is treated the same, and there’s just so much out there that women can benefit from. So I decided that I was going to write this book, and that was about — I would say two to three years ago. So I wrote it very slowly, it took me a while, but I did end up finishing it, which is great. And it turned out to be quite a long book, but I find that a lot of the patients or the readers are really liking the detail in there, because I tried to include all the newest research and all of the most up-to-date information that we know about PCOS.

Lisa: Well yeah, it’s definitely an amazing resource, an excellent resource for women who think they may have PCOS. And so just to delve right in — I guess one of the first questions I have for you — the more that I learn and read about PCOS, the more that it seems like the word “PCOS,” polycystic ovary syndrome, doesn’t tell the half of it with what’s really going on. It’s kind of like this lovely name that someone decided to call it because of the impact on a woman’s ovaries, but then it’s just not really about her ovaries. So I’ve read that there’s a push to change the name to cardiometabolic syndrome, or another term that’s more suited to the process that’s actually happening behind the scenes. Did you want to speak to that a little bit?

Dr. McCulloch: Yeah, so that’s absolutely right. There’s a lot of push towards changing the name, and because when it was named it was really a long time ago, and this was when they didn’t really understand very much about PCOS — they just knew that there was an association with these multiple cysts in the ovaries. But now we know that actually you don’t have to have those cysts, or that they can come and go, or they may dissipate as a woman gets older. So it’s not really a good name for the condition. And really PCOS is more of a hormonal-metabolic condition — so it affects the woman’s entire hormonal system and also her metabolic system. The change of name is a bit controversial, and some people disagree with that. And in some ways I can understand that, because people finally understand what PCOS is — like they’re hearing about it, they know about it — and maybe changing the name might confuse people or make it really difficult to get the awareness out there, because it’s been quite a fight. For a condition that affects one in 10 to 15 women, it’s been a long battle to get any awareness going. So rather than focusing on the name, we should really — in some ways — be focusing on getting research for this condition. And you know, thinking about all the things that have to be rewritten and redone, all that energy could be spent — and this is what Dr. Catherine Sharif was saying one time. She’s one of the most experienced doctors who treats women with PCOS, and she’s a researcher. And she was saying, you know, we should spend that time and energy actually finding good treatments for PCOS.

Lisa: One for the listeners — I did an interview with Dr. Catherine Sharif, episode number 60, and it’s very enlightening. And in a way, it’s always a little bit frustrating to hear about the ideal scenario of how to treat illnesses like this, especially knowing that many women don’t get that treatment.

Dr. McCulloch: Oh yeah, it’s so frustrating. And it’s a complicated syndrome. So even the name that was proposed — which is metabolic reproductive syndrome — in some ways it has some limitations, because it’s not just a reproductive syndrome. And this is one of the problems with PCOS, is that it’s not just for women of reproductive age. It starts in childhood, it lasts right up past menopause. So there’s just a huge spectrum of how it evolves throughout a woman’s life, so it’s really hard to figure out a name for this.

Lisa: Yeah, no, definitely. So that leads me into a question that can get us into the meat of what we’re talking about here. For the listeners who aren’t too familiar about it, you just said that it’s something that starts in childhood, which is really interesting, and can go through a woman’s whole reproductive life. And I think that when women think about PCOS, they think of it more in terms of how it’s going to impact their fertility. So maybe you could talk a little bit about that connection between PCOS and insulin, and how it’s then connected to a woman’s chances of getting diabetes later on in life.

Dr. McCulloch: So it basically does appear that you do have to have certain genes for PCOS to occur. And then there are certain environmental factors that can turn on these genes, and it seems that many of them are related to metabolic dysfunction — so this would be related to insulin resistance, which is basically the secretion of a lot of insulin when you eat compared to other people, and that can set you up for diabetes. And they even find in children who later develop PCOS, some of the underlying factors in insulin resistance is dysfunction of the fat cells. And we often think of the fat cells as just like a storage unit, you know, where you just pack energy in. But our fat cells are actually like an endocrine organ — they secrete hormones and they receive messages from the brain as well. So the fat cells in children who later developed PCOS have been found to secrete lower levels of certain hormones like adiponectin that really protect us from becoming insulin resistant. And then throughout life, you know, as we gain weight when we enter the reproductive years, we become more insulin resistant. It’s just it’s easier to gain weight when you have PCOS — by far it’s harder to lose weight. And that underlying predisposition for insulin resistance really can set you up to develop type 2 diabetes, particularly as you get older with the natural insulin resistance that comes with age.

Lisa: It was interesting, because I was preparing for one of my interviews and I watched this kind of segment on TV, and it was about PCOS and fertility. And there was a gentleman there who had a bunch of supplements and he was talking about how there’s been a lot of research done with certain supplements that sensitize a woman to insulin and kind of improve some of her symptoms. And one of the questions that was asked then was, well, is this something that women who are not trying to get pregnant might want to look into — is this related to health overall or just fertility? And he kind of brought the conversation back to fertility and how it can improve IVF outcomes. And I thought that was really interesting, because like I said, the more that I learn and understand about PCOS, the more that it seems like fertility is more of an effect of it.

Dr. McCulloch: As opposed to it — yep, absolutely. It’s exactly right. You know, it’s infertility — or I even call it just subfertility with PCOS — because it’s not a different sort of infertility. It’s more variable, it’s changeable, depending on a lot of different factors. And in each woman it presents differently. And some women with PCOS have no fertility problems at all. But it’s really the insulin resistance and the inflammation that affect the egg quality, and affect implantation, and affect the ovulation as well. So those are really the — exactly what you said — the outcomes of having some of the symptoms of PCOS, or some of the characteristics of it.

Lisa: Well, and I’d love to delve into inflammation. I love in the book that you have an entire chapter on it and its relation to PCOS. So what exactly is inflammation? It’s a word that we hear a lot, but I think it’s kind of a vague concept for a lot of listeners and a lot of women, and men I suppose. But what is it, and then what is causing us to be inflamed?

Dr. McCulloch: Sure. So inflammation — it’s a good thing in our bodies and it’s there for a reason. So inflammation is basically a chemical output by our immune system — actually both chemical and the cellular changes that happen in the immune system — and this happens for a reason. There are lots of different reasons that we need inflammation in our body. One of them is, you know, when we get an infection, the inflammation is the mounting of the immune response against the infection, and our immune system ramps up and creates — it gets a whole bunch of blood cells into the right position, and they basically are able to kill off viruses or bacteria with inflammation. So it can be a very good thing. And it’s also used in cellular repairs — if we’re injured, our immune system will come in and clean up. If there are cells that die off, our immune system comes in and cleans up. So basically inflammation has a lot of good functions in our body — it’s a vital process. But if you have inflammation at the wrong time, or all the time, or in the wrong way, then we’re dealing with some issues. Because just as inflammation can damage invader cells like bacteria or even viruses, inflammation can also damage our own cells. So it creates oxidative stress, and this is in part by how it works to kill some of these organisms — but this can actually cause changes in our own cells if they’re exposed to inflammation all the time, or in a random sort of way. So in PCOS there’s a lot of inflammation, and this actually comes once again from the fat cells and the dysfunction of the fat cells. So in PCOS the fat cells are larger than they are in other women of the same weight. You know, you could take two women of the exact same weight — the woman with PCOS, her fat cells are enlarged, and they tend to spill more of what we call free fatty acids out of them, and this causes an inflammation in the bloodstream. The other thing that happens is the thicker our fat cells get — because fat is not a very well-circulated tissue — and this happens in all fatty tissue, but in the middle part of our fat tissue, some of the cells actually start to die, and that’s called fat necrosis. And the immune system has to come in and clean that up, and associated with that is inflammation. So this is why there is that chronic — what we call low-grade — inflammation, which just means that there’s kind of inflammation there all the time. It’s sort of similar to what you would see in someone with diabetes or cardiovascular disease. This just sort of metabolic inflammation related to fatty tissue dysfunction and insulin resistance. And so you’re getting a lot of those chemicals in the bloodstream that are sort of doing damage to the arteries, the blood vessels, different cells including the ovary, and affecting how the ovary functions. So this is basically what the inflammation is in PCOS, and they’ve actually found as well that the inflammation triggers the insulin resistance of the cells that are surrounding the inflammatory tissues.

Lisa: Yeah, that sounds pretty scary, because then it’s kind of this chronic thing that’s going on in the background, it’s interfering with your cells. And so then what is the connection — I have all these questions — what is the connection between inflammation and food sensitivities, and say autoimmunity? Like, how are all these things connected?

Dr. McCulloch: Okay, yeah, so that’s a really good question. So autoimmunity — I can address that one first, because it is a kind of inflammation, but it’s very specific. So it’s more that the inflammation or the immune response is directed against self-tissues more specifically. So just as the immune system would recognize a specific bacteria or virus, our immune system might recognize our thyroid as being something that it needs to attack. So that’s autoimmunity. And women with PCOS are more prone to autoimmunity for sure — we know that there’s an increased incidence of Hashimoto’s. And it’s really just because that chronic low-grade inflammation just triggers the immune system in a general way and causes it to be a little bit more dysfunctional in certain ways. When it comes to things like food sensitivities, food sensitivities kind of add to the general inflammation. So if you’re having something that you’re allergic to or sensitive to, and your immune system is over-responding to that, that’s going to add to that kind of overall background inflammation and make more of it. And so it just kind of adds more to the issue that’s already there.

Lisa: Okay, and so then for a woman who’s listening who potentially has a PCOS diagnosis, or thinks that she may have PCOS, and she hears this — is there a way to actually target that inflammation and to reduce it and to improve her symptoms that way?

Dr. McCulloch: Yeah, absolutely. So the most important thing would really be nutrition — so following a nutrition plan that’s whole-foods-based, does not stimulate a lot of insulin secretion, because the more insulin secretion you’re stimulating when you’re already the type of person that makes too much insulin, the more fat you store, the harder it is to lose weight, and then you kind of have that chronic low-grade inflammation. That’s really the basis, and it’s the most important thing. Exercise and nutrition — those two things can make such a big difference, more than anything else that you can do. It’s just profound. So that’s obviously like the number one. And then there are a lot of other things, so you’d want to look at where are the other points of entry for inflammation in my body. Is there something going on with my gut? Because if you have an issue with your gut, or if you have food sensitivities, then you’re getting more inflammation. So you want to look through — are there any other areas where there’s inflammation that’s contributing? Do I have an autoimmune condition? So that you’d want to look at having that treated. And then there are some supplements too that are anti-inflammatory, that can actually reduce this chronic low-grade inflammation as well, when combined with the nutrition and exercise. So there are supplements like, for example, N-acetylcysteine, which is an antioxidant and it’s anti-inflammatory, and it quenches that oxidative stress that’s caused by the inflammation. So there are lots of ways to look at the inflammation — you sort of want to figure out what’s triggering it, and also work on that chronic low-grade inflammation too.

Lisa: Yeah, no, that’s huge. And I remember in the interview that I did with Dr. Sharif, she really talked about the profound impact that diet can have. So it was really refreshing to have a medical doctor on the show who was talking about how she recommends dietary changes, and what a significant impact — and it was even surprising to her in terms of her patients and how they would respond to it, how reducing those insulin levels through dietary changes would have such a profound impact for them.

Dr. McCulloch: Oh, it’s amazing. I mean, it’s probably the women’s health condition that responds the best just to nutrition alone. You can see people’s cases turn right around — from having hardly ever ovulating, they change their diet and they’re ovulating just suddenly, just like that. So it’s pretty amazing.

Lisa: Well, and I’d love to spend a little bit of time talking about the hormones, so that whole hormone cycle that’s going on. So maybe you could talk a little bit about the androgen excess aspect of PCOS — so the raised testosterone levels and why that happens.

Dr. McCulloch: Oh sure. So this is actually so central to PCOS. And it’s thought really that it must be present in some way. In the Rotterdam criteria, which are the criteria to diagnose PCOS, androgen excess isn’t required as a symptom — there are two of the three. One is ovulatory dysfunction, so delays in ovulation. The second one is androgen excess. And then the third one is the polycystic ovaries. But the androgen excess is really present in many women — it’s just that it’s hard to measure. And so that’s why it’s not really required as one of the criteria. And this is the problem — like, I’ll see a lot of women with PCOS come in, and you know, they’ve got hirsutism, which is the growth of hair on the chin, coarse hair. And this is a sign really of too much testosterone. And this testosterone causes this sort of hair growth — a very specific kind of hair growth, just simply like what you would see on a male’s beard. And they’ll come in and their testosterone levels are normal — they’ll have gone to the doctor and they’ll be like, well, you know, you don’t have high testosterone, so that’s not the cause. But the real problem with the androgens and measuring is the measurements and the lab tests — they’re very, very inaccurate for women. They’re more accurate for men at the higher concentrations, but for women they’re not accurate at all. And the other thing is that the reference ranges are extremely inaccurate as well. So those reference ranges include women who have PCOS first of all, and also women who are at various stages of life. And we know very much that women’s testosterone decreases with age in every woman. So unless you look at a lot of testosterone levels in women, it can be very misleading to use that as a criteria. So that’s why the symptom for androgen excess — the symptoms are also valid. So if you have hirsutism, if you have acne particularly on the jawline as an adult — that is significant, moderate to severe — and or hair loss that’s in an androgen-like pattern, particularly at the front of the head, so any combination of those things would qualify for the androgen excess symptom. And then there are so many different kinds of androgens as well. And some women have high testosterone, some women have high dihydrotestosterone, which is the one that affects the skin, and then some women have high DHEA-S, which is an androgen that’s produced predominantly by the adrenal glands and not by the ovaries at all. So it can be very easy to miss the androgen excess, but in many, many women it’s present. To have PCOS — it’s quite — and the Androgen Excess Society, which is the other main body that researches PCOS, they require that androgen excess is present in order to be diagnosed with PCOS.

Lisa: Well, that’s really interesting. So then if a woman’s testosterone is checked and she is told that it’s normal, then it’s very possible that that is a meaningless thing?

Dr. McCulloch: Exactly — it could be totally meaningless, right? Exactly. The reference ranges are just — I look at them sometimes, I’m like, oh, you know, because they’ve included a lot of women with PCOS in that reference range.

Lisa: So in terms of the hair growth on the face — what does that look like? Are we talking about a couple of sprigs of hair on our chin, or does it have to be a full beard, or anywhere in between?

Dr. McCulloch: Well, yeah, it’s a couple of sprigs — I mean, that could be enough. It really depends on your heritage. So some people’s genetic backgrounds, they have more hair growth. Whereas, you know, for example, Asian people — they rarely have any hirsutism, even if they have sky-high testosterone. So if you have a couple of sprigs and you come from a background where there’s more hair growth, that’s not really as noticeable. But the hirsutism — the way it presents classically — is like a stubble, almost like a beard, very coarse. Not like a thicker hair but a coarse hair, like on a male’s beard. So that kind of rough stubble is exactly what it often presents like.

Lisa: Well yeah, no, that’s really good to know. And I’m really glad that we talked about that, because I think that part would confuse a lot of women — especially if they’re thinking that, or especially if their doctor is telling them, well, it couldn’t be PCOS because of this, or your levels are normal, and meanwhile they still have male pattern hair growth and hair loss in a male pattern way and acne.

Dr. McCulloch: Yeah, yeah. I think hirsutism is about 90% specific for PCOS. So if a woman has true hirsutism, where it’s that coarse hair — especially on the chin, usually on the bottom of the chin is where you’ll see it first, like underneath — if they have that, it’s about 90% specific for PCOS.

Lisa: Okay. Well, and since we’re talking about hormones, maybe you could take us through what’s happening in terms of cortisol, and even progesterone and estrogen. One of the symptoms, I guess, of PCOS — especially in the work that I do, which is the charting aspect of it — when you’re looking at a woman’s chart, often you’ll see a chart and it’s not always the same, right? But sometimes you’ll see a pattern where a woman has a super long pre-ovulatory phase, and she’ll often have like a mucous patch indicating that her body’s kind of trying to ovulate, and then she won’t. And then trying to ovulate again, and she won’t. So you just have this long, long estrogen phase, and then a shorter luteal phase. And in a healthy cycle we’re supposed to see approximately an even follicular phase and luteal phase. So maybe you could talk a little bit about what’s happening in terms of the estrogen-progesterone-cortisol relationship there.

Dr. McCulloch: Oh sure. So yeah, so that’s exactly right. Basically it takes a long time to ovulate, and the reason for that is that the testosterone that’s within the ovary — regardless of even if you’re seeing a lot of it in the blood — most women with PCOS have higher amounts of testosterone within their ovary itself, and that testosterone slows down the ovulatory process. And what you’ll see in a lot of women with PCOS — particularly in leaner women, but also in the more classic types of PCOS — you’ll see this as well: high LH on the beginning of the cycle, and the LH feeds into the testosterone. And what’s supposed to happen actually when you start your cycle is that FSH is supposed to become the dominant hormone, and it’s supposed to push the estrogen out of the egg and get the egg to develop. And the granulosa cells are supposed to be making a good amount of estrogen and making a nice big peak, and that’s supposed to surge the LH and get you to trigger ovulation. But in PCOS, the FSH — it’s often low, actually it’s lower than in other women — and so the granulosa part of the follicle doesn’t develop properly and it doesn’t make estrogen very well. And instead, the cells which are stimulated more by LH are making testosterone pretty consistently, and because of that you’re not going to get that nice big peak and that triggering of the ovulation. But you do get more estrogen for longer — you may or may not have high estrogen. Estrogen might be kind of medium, like it should start off low and go up to a nice peak right before ovulation, but in PCOS just as you said, it could go up a little and then go down, and up a little and go down. But then you just end up with a longer period of time with more estrogen. And then finally, after a while, in many women the granulosa cells will develop enough to make that nice peak, and then you’ll trigger ovulation. And that could be many, many days later than where it would normally be. And then finally you get the progesterone. So the ovulation is really overridden by the testosterone that’s there in the ovary. And the way that the adrenals and cortisol can impact here is that if a woman has — in particular — something called adrenal androgen excess, which is where she makes more DHEA-S, which is that hormone from the adrenal glands, any kind of a stressor can actually cause more testosterone production, because that feeds into the testosterone production by the ovary as well. So it becomes an added impact on that delayed ovulation.

Lisa: So then if a woman is experiencing whatever type of stress in her life, then that’s just going to make it worse?

Dr. McCulloch: Yes, yes. Fantastic — only in specific women, though. Yeah, like some of the women with PCOS, they don’t have high DHEA-S, so for them, stress is not good for them either, because it impacts the opiate system of the brain — and that’s also altered in PCOS, which is really interesting. But there’s only this certain subset of women with PCOS that have this adrenal type. And for them it’s even worse, so they have to be really — and that’s why I always encourage women to ask for that test, because then you’ll sort of know, you need to put more effort into really working on that stress reduction, or make sure that you go meditate, or do deep breathing, or yoga, or something to help keep yourself down more.

Lisa: And that’s the test — the DHEA-S — to get a sense of whether or not their adrenals are producing excess testosterone?

Dr. McCulloch: Exactly, yeah. The DHEA-S — it’s not produced by the ovaries at all, so we know for sure it’s only coming from the adrenals. And that actually isn’t even affected by insulin resistance — it’s almost like a separate kind of PCOS. But then to make it even more confusing, most women who have that also have the other type of PCOS too. But yeah, if you check that, and this is another one that is misdiagnosed a lot, again because it decreases with age. So a 40-year-old woman’s DHEA-S would not be above that reference range even if it’s high. So you have to sort of be familiar with what does that look like in a 38-year-old woman — is that high for her? So unfortunately, a lot of the time, you go to the doctor and unless it’s in that flag column on the right, then you’re normal. So I do have some information in the book about how to know where it should be for your age — there’s a chart on that.

Lisa: Yeah, I think that it’s — the endocrine system is like this rabbit hole, right? And then when you go down it, it’s so complicated. Like it’s complicated, but in some ways it’s simple if you understand it. But just the picture that you painted right there — that there is a curve based on age, and so what’s normal for say a 20-year-old is not going to be the same for what’s normal for a 40-year-old. And if the doctors are using the same labs for everybody all the time, then this is going to be a problem. That’s such useful and important information.

Dr. McCulloch: Oh yeah, it’s so, so important. And then further to that point, the same goes for teenage girls. It’s very interesting — when a girl goes through puberty, her LH — so what happens is basically her body needs to gain weight to get ready to reproduce, so she becomes insulin resistant. This happens for all women — we all gain weight around 11, 12, that age. And that’s called adrenarche — that’s when our adrenal glands activate and we start making a lot of cortisol, and we also make DHEA-S. So we all become a little bit in that androgen excess at that age. And a lot of studies show that girls at that age are really good in sports — they’re really strong — and it’s those androgens that have kicked in. And then as they get their first periods, the LH hormone is the first one to kick in again, and they’re still androgen-dominant. So all teen girls are like that as they’re in puberty. So they all kind of have a PCOS-like look to their picture. And so a lot of the girls go get an ultrasound and they’re going to have PCO ovaries on the ultrasound, they’re going to have really high DHEA-S — that’s normal for them, there’s nothing wrong with them — but they’re all getting diagnosed with PCOS and put on the birth control pill. And meanwhile, this is not really anything abnormal. What happens in a woman who does not have PCOS is that FSH becomes the dominant hormone after a while, and after around two years her cycle should become regular. The woman with PCOS — the LH hormone stays the dominant hormone, and they kind of get stuck there. It’s almost like you’re kind of stuck in puberty in a way, hormonally.

Lisa: Wow, that’s so interesting on like a hundred different levels. But it’s so interesting because the way that you describe the process of maturation and how a teenage girl then is kind of like in this — not really — it’s like this temporary PCOS limbo while her body is maturing, and eventually the FSH becomes more dominant and then her cycles become more robust. It’s so interesting, because I’ve had a number of guests on the show who are not specialists in the area of PCOS, but they talk about a similar thing in the sense of — they just don’t talk about it specific to what’s happening hormonally. So I’ve had a number of guests who talk about how women go through a maturation process. So a teenage girl — her cycles tend to be not always ovulatory, and they tend to have the same symptoms that you’re describing. So they talk about it in a different way. And then I did an interview with Dr. Jerilynn Prior, who in that interview talked about how it takes about — she said it takes about 10 years for a teenage girl’s cycles to fully develop and mature into adult cycles. And then there are all these other things that are going on. So the exact number of years is up in the air — however many it takes for that woman. But suffice it to say, it takes several years before her cycles become robust, ovulatory, and consistent the way that a grown woman’s cycle should be. So what you just talked about in terms of the PCOS and the hormonal interplay of things that are happening — that is so interesting, because it’s kind of like another very detailed description of what’s happening in the maturation process.

Dr. McCulloch: Yeah, absolutely. That’s really interesting that that was said, because it makes complete sense to me, and it’s exactly what happens. And we all know that teenagers get acne — it’s very common to have acne. So it’s normal to have androgen excess, and it’s just that aspect. It does affect the reproductive maturity. And the other interesting thing too is that women with PCOS also hit their reproductive peak later and go through menopause later. So there’s that whole delay in everything.

Lisa: Well, and so this is not scientific but it’s an observation — so then if women in their teens are identified as having quote-unquote irregular cycles, which is not abnormal, because teenage girls before their cycles have matured by definition will have irregular cycles. So then if they are diagnosed with this irregular cycle thing and then they’re put on the pill — so I’ve had a number of guests on the show talk about the pill, and basically it’s kind of putting your cycle maturation on pause. So then you go and you take the pill for 20 years, and then you come off of it, and oh wait, you have PCOS.

Dr. McCulloch: Well, maybe. Yeah, it’s the cycle. And then you’re saying that women who have PCOS — their cycles take longer to develop, and then they go through menopause later. Well, this is all very interesting and disturbing. Yeah, it’s a bit disturbing. And I also — the newer guidelines by the Androgen Excess Society, they’ve suggested that PCOS not be diagnosed in teenagers, but if it is to be diagnosed, they have to have all three of those Rotterdam criteria rather than two of the three. So they have to have the androgen excess — clinical but also bloodwork — and they have to have the anovulation, and I believe they said it has to be more than two years. And they also have to have the polycystic ovaries. Plus, they have to really look like they have PCOS — a clinician can often tell. But a lot of teens, by the time they’re 20, all those things have gone, whereas you could have given them a diagnosis according to the Rotterdam in their teens for sure.

Lisa: And you mean by the age of 20, those symptoms have kind of gone away — is that what you mean?

Dr. McCulloch: Yeah, yeah. Like the PCOS-like symptoms are usually gone by around age 20, because in most women, they’ve matured.

Lisa: Interesting. So I’m not going to continue to go so far on this tangent, but then I have to pose the question for the benefit of the listeners — which is, if these women were not put on hormonal contraceptives at age 15 or 16, and their cycles were allowed to mature naturally, would they then be having the same problems when they’re trying to conceive?

Dr. McCulloch: Yeah, it’s so hard to know. I mean, it would be interesting to study. I’d be really fascinated to see. And what I find is that there are women when they come off the pill, they look like they have PCOS but they don’t — it goes away in some time. And that’s not real PCOS, that’s like a pill-induced kind of PCOS-like hormonal problem. But yeah, I don’t know about that — if putting on the pill at a young age, what that does, I have no idea. But I’d be very, very interested if somebody would research that.

Lisa: I think somebody should. Yeah, so someone’s listening that has the capacity to research that, because maybe that’s one of the ways that a woman’s cycle is — if her cycles were not allowed to mature naturally on hormonal contraceptives, then maybe that’s what’s happening for some women where this is part of their maturation process, except that it’s happening when they’re 30, because they were on the pill for all those years. So I would like to know.

Dr. McCulloch: That would be good, that would be good. Because there’s a lot of women who’ve been on it for so long, right? So there’s definitely people you could study.

Lisa: Yeah. And it sounds like the PCOS issue is becoming kind of more of an epidemic — it’s very, a lot of women are really struggling with this and it’s becoming more and more common.

Dr. McCulloch: Yeah, it’s just a huge issue, and especially the metabolic issues are just — I was down at the PCOS Challenge Symposium for my book launch, and it was like a patient and practitioner-centric event. So it had a lot of patients, and I was doing some talks, and it’s just really — the impact of it on lives is so profound, especially with respect to the cardiometabolic issues. I mean, these are causing serious health problems for people — really, really serious. Diabetes, really — it’s just something really needs to be done. And the fact that it gets, I think, 0.2% of NIH funding, but it affects 7 to 14 million women estimated in the US. It’s crazy — it needs it. It’s really one of the ways that we can prevent chronic disease is to identify and address PCOS in young women.

Lisa: I couldn’t agree more. And you mentioned before as well, and in the interview and also in your book, the connection then between PCOS and cardiovascular disease. Did you want to talk a little bit about that?

Dr. McCulloch: Oh sure, yeah. So it’s so interesting. So even the lean women — so when I was in Atlanta, I did my talk on lean PCOS, and I’ve always found lean PCOS is very interesting. So there’s hardly any research on it, but one of the things that was learned is that it’s really a spectrum of the same condition. And the women with lean PCOS — what they found is actually, when your insulin goes up in your body, there’s something called capillary growth that happens. And basically insulin should stimulate the growth of capillaries in your extremities. And when your blood vessels are insulin resistant, this does not happen. So we know that in people who are on the heavier side, this is a problem — there are circulatory issues. But what they find is the very lean women with PCOS — some of them, they don’t appear to be insulin resistant at all. So you can do all the bloodwork for it, you can check the fasting insulin, even the detailed bloodwork, and they won’t show up as insulin resistant. But what they found is that the capillaries and the blood vessels are the first place that you can find insulin resistance in the human body. So each tissue has a different capacity to be insulin resistant. The ovary, for example, is very sensitive to insulin. Whereas the rest of the tissues may be insulin resistant, but they found even in the very lean women that they had this problem with the capillaries — the same as the heavy women did with PCOS. So they had the vascular insulin resistance — it’s just something we are not able to measure with normal bloodwork. So you can see that aspect of the cardiovascular system — the way that the blood vessels become insulin resistant — starts at the very earliest stages of the condition, and this just, over years and years, leads to cardiovascular disease.

Lisa: Well, see, that’s so scary. And I think that’s why with PCOS, trying to really get a handle on the fact that it’s this disease process that’s happening in the background — yeah, and some of the effects are related to fertility, but really to understand the impact that it can have on a woman and treating it regardless of whether or not she’s trying to conceive, because if it can increase her risk of cardiovascular disease and heart attack and all the things that are associated with that, that’s a really significant health risk for women.

Dr. McCulloch: Yeah, it’s huge. Like it’s just huge. And it’s in men too — like, men have the same genes, and you just see it in women because it affects the menstrual cycles. But if it didn’t, we wouldn’t know what that was. But we can identify it in women for that reason. And it definitely affects your fertility, it affects your ability to implant and carry a pregnancy, or to have a healthy pregnancy — prevent diabetes — I mean, if you treat PCOS, you’re improving the health of the woman’s entire reproductive system, the health of her baby, and her future health as well.

Lisa: Yeah, it’s such an important conversation to have. And so as we kind of draw towards the end of the interview, there’s one other topic that I want to bring up. It’s a big topic — we could do a whole show on it. But I just wanted to talk about that kind of comorbidity when women with PCOS also have thyroid-related issues. And so I would just love for you to take a few minutes and just to talk a little bit about that connection there, and then perhaps some suggestions for investigating that further for women who suspect they might have a thyroid issue.

Dr. McCulloch: So in my practice, I always — I practiced doing fertility for a really long time — and I think, you know, we all know that the thyroid is very, very important, and there are certain reference ranges for thyroid and for fertility that are different in general. Right, thyroid is really something that’s very individual, I find. Like so everybody has their own set point where their metabolism functions the best with respect to their thyroid. But if you think about what the thyroid hormones do in our body — they enter the cells and then they actually change the way our cells metabolize everything. Basically every single thing in our body — like everything we produce, every hormone, every protein, how we metabolize energy — so the thyroid kind of rules the rate at which our metabolism goes. And women who have PCOS are definitely — they have high insulin levels more after they eat, they have higher insulin levels between their meals, and they kind of have higher insulin levels all night long. And insulin has two main roles — one of them, which is the most well-known, is to take the sugar from our blood and put it into our cells, so it keeps our blood sugar from being too high. The second role of insulin, which is very important — which most people don’t know or think about too much — is that it blocks fat breakdown. The reason it does that is because insulin is an anabolic hormone — it helps us to grow tissue, store energy. It’s not a hormone for breaking down. So whenever we’ve eaten, we’re certainly not going to be using a whole bunch of energy to break down fat. So it blocks fat breakdown. So having high insulin all the time just slows the rate of fat breakdown constantly, like throughout the day — even when you’re not eating, you’re not breaking down fat like other people do. And so if you have a low thyroid, which is giving you a slower metabolic rate, and then you couple it with this insulin resistance and this high insulin and the blocking of fat breakdown, you’re now making it ten times worse. It’s going to be so much harder to lose weight. And being hypothyroid is clearly associated with metabolic issues and insulin resistance. So it’s really the worst two to have in combination with each other — the thyroid with the PCOS. So it’s just really super important. And then the second thing is that it’s much more common for women with PCOS to have the thyroid problem, and the reason for that is that Hashimoto’s thyroiditis, which is the autoimmune thyroid condition I was talking about before, actually is the most common cause of hypothyroidism in the developed world, of course where we have enough iodine. So basically there’s an increased incidence of hypothyroidism in women who have PCOS. And in addition, I find that to be true in my practice — there are a lot of women with PCOS who I just take a glance at their bloodwork and right away I can see they have a thyroid problem or they have antibodies. And several studies have looked at the link, and they’ve actually found that — for fertility — women with PCOS do better at that lower reference range for TSH. And our thyroid hormones — they’re not just TSH, which is like the pituitary hormone. It’s kind of like the FSH for the thyroid — it causes — it’s your pituitary signal to your thyroid to tell you to make thyroid hormones. That’s not the only one that’s important. But what they find is that when that one’s lower, just like it should be for fertility — in that same range, under 2.5 or under 2 — then women with PCOS, their metabolic function is improved. And when they’re outside of that range, their metabolic function is worse, or their insulin resistance is worse. So there is that kind of special consideration for PCOS, and that you don’t want to have a sluggish thyroid at all — like you want your thyroid to be almost perfect if you can. So yeah, that’s the main connection there.

Lisa: No, that’s really interesting then, because it’s interesting that there’s a sweet spot for your thyroid. So if your thyroid is at a really good place, a really good level, then your PCOS symptoms won’t be as bad, I suppose. And then if your thyroid slips out of that sweet spot, that good range, then that worsens your PCOS symptoms.

Dr. McCulloch: Yeah, I suppose it’s not surprising that it would — the worse the one is, the worse the other one is. I don’t think that’s a big surprise to anybody. But I think it’s interesting to note that there’s that connection, where if a woman has PCOS, then she’s kind of more likely to have a thyroid issue as well.

Lisa: Yeah, absolutely. It should be checked in every woman. And I always recommend to get the full range of hormones — so the TSH, the free T3, the free T4, anti-thyroid peroxidase — which is one of those antibodies that picks up Hashimoto’s — and anti-thyroglobulin. So those are the two main antibodies. And then if you can, you can ask for reverse T3. It’s often not covered by testing — you do have to do it at the same time as free T3. But women who have PCOS — they have more insulin resistance, and that can cause an increase in this reverse T3. Reverse T3 is a totally inactive hormone. So if you know you’ve got really high reverse T3, then basically your thyroid hormone is not even working — it’s not doing any good for you. It’s just kind of going into this inactive state, because your body really thinks when you’re insulin resistant that it needs to preserve energy, and it’s in energy conservation mode. Because the insulin is high, so it’s not going to be in fat-burning mode, so it tends to shunt some of the hormones into that inactive form.

Lisa: Well, that’s a really interesting connection between the reverse T3 and that. So it sounds like women do need a lot of support in this area if they’re struggling with PCOS, and they would benefit from working with someone who specializes in this area and really has a good understanding of how to interpret those test results, and to actually request the proper tests as well.

Dr. McCulloch: Yeah, yeah. And so we’ve talked about a lot today. Given our discussion, what is the one thing that you’d want our listeners to take from our conversation?

Lisa: I would say the most important thing is — you know, if you think you have PCOS, it’s definitely worth advocating to get the tests done to learn if you have this, because it’s not only — it’s not just about fertility, really. It’s about your overall health as well. And if you do have PCOS and you’re listening more for the fertility end of things, don’t forget too that once you have your baby, you still have PCOS. So don’t forget to take care of yourself and learn the best ways that we know now to prevent a lot of the chronic outcomes from it.

Dr. McCulloch: Well, and if there’s a myth about PCOS or a general understanding that you’d like to see corrected, what would it be?

Lisa: I think probably the biggest one is that it goes away when you go through menopause, because it’s there for your whole life. And it’s really just — not a reproductive-age concern. It’s almost like, just, people who have PCOS are really good at conserving energy — that’s really what it comes down to. So in times where there was famine, and there’s a lot of interesting research on this, in times of famine women with PCOS did pretty well. They were really good at conserving energy, and they could actually reproduce well at those times. So it’s just in our modern society where we have lots of food, those genes are — they’re still good at conserving energy, and that can be a bit of a problem.

Dr. McCulloch: Well, then if they’re in the plentiful, excessive society that we’re in today, with tons of sugary things that give us plenty of reasons to raise their insulin all the time, then they don’t do as well.

Lisa: Exactly. Yeah, and in my book I have the new insulin demand of food, which tells us basically how much specific foods raise our insulin. And this was developed by the same researchers who developed the glycemic index at the University of Sydney. So it’s a really new concept, and so we have a meal plan based on the insulin demand of food. So it actually affects the exact issue in PCOS, which is insulin.

Dr. McCulloch: That’s really interesting. Yeah, there are so many interesting things on that — there are things like the glycemic index that are really interesting, that you wouldn’t think, like how whole wheat bread raises your blood sugar the same way that table sugar does. That kind of stuff.

Lisa: Yeah, whole new understanding of the way food impacts our blood sugar. And last question of the day — what advice, if any, would you give to a couple that’s struggling to conceive, especially in light of our conversation about PCOS today?

Dr. McCulloch: So with PCOS, the one thing I would say is — stay hopeful. Because most women with PCOS will conceive. It just takes longer. It takes a bit more time. And you’re not as much against the clock, so you have that on your side. So don’t panic, and just take the steps that you need to take care of your health and make sure that you’re assessed properly, so that you understand the specifics of how your presentation of PCOS is affecting you.

Lisa: Okay, well thank you so much, Dr. McCulloch, for coming back on the show. That was one fantastic conversation, and I think my head is still spinning. Because you are really smart and you know a lot of stuff, and I’m so excited to share this interview with the audience because it’s really mind-blowing information that you’re sharing, and so important for women to know. So thank you so much.

Dr. McCulloch: Oh, thank you for being such a great interviewer and for making this amazing show. I see it everywhere, and it’s doing so well, and it’s getting the word out there to so many people. So thank you.

Lisa: Oh, thank you so much. I’m really happy that it’s been impacting women in a positive way, and I’m just going to keep doing it and hope to make a difference.

Dr. McCulloch: Keep doing it. You can share my passion — women need to know this stuff.

Lisa: Yeah, knowledge is power. Thank you for listening. If you enjoyed today’s show, please share it with a friend. You’ll find the show notes page for today’s episode over at fertilityfriday.com/426. I hope that you enjoyed today’s episode with Dr. Fiona McCulloch. She’s such a wealth of knowledge and really provides accessible explanations for PCOS, the underlying factors that contribute. I really love how she described the connection between PCOS and that kind of early adolescent phase when you have your menarche, and how that should be looked at given that it’s a transition phase, especially within the first few years after your first period. So there’s so much great information there, and also how PCOS interacts with thyroid inflammation. And her book, Eight Steps to Reverse Your PCOS, is my go-to resource on PCOS — it’s one of the books that I recommend for my practitioners in my Fertility Awareness Mastery Mentorship program. So highly recommend it if you are wanting to learn more about PCOS. So that said, I hope you have a wonderful week. And of course, as always, until next time, be well and happy charting.