I want to scream in this mic and say, let me tell women what they deserve to know.
If you take PCOS, 75% of these women are not diagnosed.
If you take endometriosis, over 90% of these women are not diagnosed.
Wow.
Endometriosis with PCOS, they're the leading cause of infertility on this planet.
Hey everyone, welcome back to On Purpose, the place you come to become happier, healthier and more healed.
Today's guest is someone that I'm extremely excited to talk to, because it's a subject matter that so many of you have been asking me about.
If you have questions about PCOS, this episode is for you.
If you have any questions about endometriosis, this episode is for you.
And if you're someone out there who has friends or family that are struggling with fertility, this episode is for you.
I'm speaking to the one and only Dr A, who is an authority in this space, someone who has helped so many people go through their fertility journey.
Please welcome to On Purpose, Dr. A.
Dr. Ray, it's great to have you here.
Jay, I'm so excited.
I'm so excited for you to give me this mic and I'll tell you why I'm so excited to be here.
You know, I've always listened to you and you speak so amazingly to these women, to your listeners, basically talking to them about calmness and how to get to that calm, about mental health, about meditation.
And one thing I want the world to know is that there are millions of women out there that cannot get to this calm space, not because they're not trying hard enough, not because they're spiritually weak.
They can't get there because they have an underlying condition, like PCOS and endometriosis, that affects their hormones, their inflammatory pathway and their nervous system.
And that's why they can't find that calm.
I sit with women all day long.
These are women who've struggled for years with endometriosis and PCOS, debilitating pain that they can't even you know.
Stand up straight.
And just because no one ever believed them, no one, and they dismissed their symptoms.
You know, you have these 13 year olds who are literally on the bathroom floor with every period, thinking this is normal life and that's life for them and they can't really complain about it.
Or they have women who are ashamed of their body and they go to the doctor and all they hear is well, just eat less, exercise more.
But no one really addresses the underlying condition.
And I've done this for decades and I reached a point in my life that I said enough.
Enough is enough.
Enough dismissing women, enough normalizing their pain, normalizing their symptoms and telling them it's in their head.
They're crazy, they're anxious.
It's none of that really.
And it's time to really start listening to these women and dealing with these underlying conditions.
And that's why you know millions of women are affected by PCOS and endometriosis and majority of them are never diagnosed.
So that's why I'm so excited to be here, to take at least this hour to bring some awareness to these two conditions.
So thank you for having me.
Let's dive in because like I said, my audience really wants the answer to these questions.
I really want to shed light on this topic.
I really want people to feel seen, heard, and understood as they're navigating this.
But you've actually said that we're in the middle of a fertility crisis.
What does that mean?
So when, you know, let's say you take 100 couples and you have them go try to get pregnant.
You tell them have sex three to four times a week and then come back in a year.
50% of them on average get pregnant in the first six months.
90% of them are pregnant within a year and 10% don't get pregnant.
We're in that 10% category.
If you take male fertility out, majority of those patients have PCOS and endometriosis.
The problem is if you take PCOS, 75% of these women are not diagnosed.
If you take endometriosis, I think over 90% of these women are not diagnosed.
So they fall under this unexplained infertility because doctors are not diagnosing these underlying conditions.
What is PCOS?
Define it for us.
So PCOS is a chronic hormonal metabolic, inflammatory and neurological condition that affects 15 of women in this country.
If you go to countries like India, that number can go north of 20%.
The problem with it is that 75 of these women are never diagnosed and they go through life not getting a diagnosis.
In order to diagnose PCOS, it's very simple.
You need to meet two out of the three criteria.
Number one, is basically ovarian or ovulation dysfunction.
These are women who have irregular periods.
They get their periods not every 28 days.
They get it like every 35 days, 37 days or they get less than eight periods per year.
So that's criteria number one.
Criteria number two is PCOS looking ovaries on ultrasound.
So PCOS is not polycystic ovary syndrome, is not cyst.
To this day, doctors say, oh, you don't have a cyst on your ovary, so you don't have PCOS.
Polycystic ovary syndrome is a group of follicles.
It's a specific finding on ultrasound.
These are ovaries that are enlarged with at least 20 follicles and it's a specific finding on ultrasound.
Again, a lot of doctors don't know what to look for.
So that's the second criteria.
And recently for this criteria, they added high egg count or high AMH to this criteria.
Before women who can have access to ultrasound or they don't, you know or their doctors miss this ovarian morphology on ultrasound.
So elevated egg count also counts as the second criteria.
And the third criteria is elevated testosterone or androgen symptoms.
What are these symptoms?
Facial hair, body hair, facial acne, body acne, oily skin, male pattern, hair thinning or hair loss.
You don't have to have all of these symptoms, you have to have one.
So this is the third criteria and you need to meet two out of these three criteria.
PCOS patients, for reasons I'm going to go into details, struggle with anxiety and depression.
They have mood disorder.
They're moody people.
They have really bad PMS.
They usually have someone in their family who's PCOS, diabetic, overweight, insulin resistant.
A lot of them have an eating disorder or disordered eating and they end up in these eating disorder centers because their PCOS is not being diagnosed.
It's the leading cause with endometriosis, leading cause of infertility on this planet.
75 of these patients gain weight even though they're eating exactly what you and I are eating, exercising exactly the same, but they cannot lose a pound.
25% of them are lean, lean PCOS patients.
Even these lean PCOS patients have eating disorders.
So imagine take this young girl who's gaining weight is in high school.
Let's say, gaining weight acne, facial hair can't lose her weight.
She's moody, she's anxious, she has really bad PMS and she goes to the doctor and the doctor says there's nothing wrong with you, you're probably eating too much.
So wait, you would know as early as then?
Oh my God, yes, teenagers.
That's, you know what I always say, if you want, if you go knock on the doors of these eating disorder centers, your PCOS patients are sitting behind those doors.
So why is it not getting correctly diagnosed?
If it's such a big issue it's affecting so many people and there's so many symptoms through which you can measure it why is it not diagnosed?
So I think it's multiple reasons.
Number one.
Doctors don't consider they don't know enough about PCOS and PCOS presents in different morphologies.
Once we talk about it, you understand why.
You don't have to have irregular period to have PCOS.
There's a morphology of PCOS patients who don't have any elevated testosterone symptoms.
They just have the irregular period in the PCOS.
So remember I said two out of the three criteria.
You have different combination of these symptoms and different presentations of these patients.
Some are lean, some are overweight, some have irregular periods, some have acne, some have hair loss, some have facial hair and body hair.
They present differently, so it's very confusing to doctors.
That's why I'm here to tell you, you only need to meet two out of the three criteria.
And if you meet those criteria, then you look for the anxiety and the depression and the eating disorder and the weight issues and the insulin resistance and the fertility issues and you put this picture together and you can find your PCOS patients.
I always say you don't need a doctor to really diagnose you.
If you listen to this podcast from home, you can self-diagnose.
I'm giving you the tools to diagnose yourself.
But because PCOS has these underlying pillars that affect their entire, their whole body.
So it's not just a fertility issue.
It's not just a period issue.
It's a total body issue.
It affects your mental health.
It affects your reproductive health.
It affects you metabolically.
It affects your hormones.
And until you address every single underlying pillar of the driver of these symptoms, you can make these patients feel better.
So if a woman is listening to this right now and feel she has PCOS, what's the next thing she should do?
Very good question.
So the domino, imagine the first domino of this PCOS storm is insulin resistance.
You have to understand insulin resistance.
What is insulin resistance?
When we eat carbohydrates bread pasta pizza chocolate, ice cream our body breaks it down into glucose.
Glucose stimulates our pancreas to release a hormone called insulin.
The job of insulin is it goes at a cellular level, opens up the receptors on our cells.
The receptors grab the sugar and put it inside the cell where it turns into energy.
This is what's supposed to happen.
But PCOS patients genetically have insulin resistance.
So when they eat carbohydrates and their body releases insulin, their cells are insulin resistant.
So these channels don't open for the sugar to go into the cell and turn into energy.
So the sugar bounces in the blood and pushes the insulin to go up.
Insulin is a fat storage hormone.
It's an inflammatory hormone.
You don't want your insulin to go up.
So what happens when this insulin goes up?
Few things happen.
Number one, insulin tells your liver, the cells are not taking up this sugar to turn it into energy.
Take this sugar and store it as fat.
The problem is the fat that gets stored with insulin resistance is not the good old fat under our skin.
It's the visceral fat around our organs, liver and our inner abdominal organs.
That's highly, highly inflammatory and we'll get into it later.
So one, the high insulin tells your body take this sugar and store it into this inflammatory fat one.
Two, high insulin stimulates their ovaries to secrete androgens.
So, and this is the first domino.
Why?
Because when the ovaries start secreting androgens, our menstrual cycle completely goes out of whack.
I want to take a minute to tell you what a normal menstrual cycle look like and what it looks like for these poor PCOS patients.
So in a normal menstrual cycle, our brain, our hypothalamus, releases GnRH, which is a hormone that affects the pituitary gland, another gland in our brain that releases two hormones, FSH and LH.
When this GnRH is being released slowly, the pituitary gland releases a hormone called FSH.
FSH stimulates our ovaries, the follicles in the ovaries, to start growing for that cycle.
And these follicles, as they grow, they start releasing estrogen.
The estrogen they release, it gets the lining of the uterus ready for pregnancy, because that's the job of the ovaries helping us get pregnant every month.
So these ovaries basically release these follicles, release these estrogens, and the estrogen stimulates the lining of the uterus.
While these estrogen is being released, it has a negative feedback on our brain.
When the estrogen levels hit a very high level, it actually stimulates this GNRH secretions from the hypothalamus to go faster.
And when the GNRH starts firing faster But the FSH slows down and the LH surge comes, and LH is a hormone that is a luteinizing hormone and it causes the ovulation.
So it pushes one follicle out and that's when the egg gets released.
And if we're trying for pregnancy, the sperm comes up, the embryo forms and now the lining of the uterus is nice and juicy and the embryo implants and the pregnancy happens.
What happens with PCOS patients?
Remember the insulin resistance.
That first domino starts stimulating the theca cells in the ovary to release androgens.
When you start having androgens in the ovary, it freezes these follicles and doesn't let them grow normally.
So then the estrogen starts becoming erratic, And when your androgen levels go up, the androgens stimulate the GnRH to go faster, and then the LH starts going faster, and the LH constantly stimulates these ovarian tissue, the theca cells, to release more androgens.
So you start in PCOS patients, you start getting this environment of high androgens And these irregular estrogen secretions that not only block ovulation, block implantation, it causes irregular periods, but it starts affecting our brain because the androgens affect our mental health and we can go over that later.
But this is what happens, and this is why 70 to 80% of PCOS patients don't ovulate.
Of the 20, 30% of them who ovulate, they ovulate sometimes.
Even the ones who have regular periods.
The regular periods it's not because necessarily they're ovulating, it's because they're getting withdrawals from this estrogen.
It gets very complicated, but the women's hormonal system is so beautiful when you really understand it.
It becomes very complicated with these PCOS patients and that is why it becomes a vicious cycle right.
So the insulin resistance starts producing androgens in the ovary.
The androgens affect the brain to release more LH.
The LH affects the ovaries to secrete more androgens out, and this becomes a vicious cycle that doesn't stop.
And so the first underlying condition is this insulin resistance.
The second underlying pillar is this androgen being secreted.
Before that second one, is there anything women can do about that insulin resistance?
Absolutely.
What do they do?
Let's focus on that one and then we'll move to the others.
Absolutely.
So for this pillar of insulin resistance, you want to make patients insulin sensitive, right?
So there are many supplements that can make patients insulin sensitive.
And that's why, I don't know if you know, I have an OV platform and I have a supplement.
PCOS is actually one of those conditions that supplements actually play a huge role in it.
Why?
Because by making a, you want to reduce for this insulin resistance pillar a, you want to reduce the glucose in the blood right, so you tell the patients decrease your carbohydrates.
If you're eating carbohydrates, go for a walk 10 minutes, 20 minutes after each meal.
When we walk we actually wake up these insulin receptors and they start grabbing sugar out of the blood.
So we lower the sugar.
So low carb diet by having a 10-minute walk after eating.
After each meal.
So eat less carbohydrate, walk 10, 20 minutes after each meal.
Exercise makes a huge difference, obviously, in addition to the walking after each meal.
Then we go to supplements.
There are supplements like my OV supplement.
These supplements work at a cellular level to make open up these channels and pull the sugar in.
The myov supplement also has wild mulberry leaf in it and what that does if you take it before your heaviest meal.
If you take the supplement before your heaviest meal, it actually blocks the absorption of carbohydrate in that meal by 40 percent.
So now you're decreasing the load of sugar.
And whatever gets absorbed, you're pushing it, you're opening these channels and pushing it into the cell.
So you're clearing that sugar out of the blood.
By doing that, what happens?
Your insulin goes down.
When insulin goes down, your fat storage goes down, your weight management becomes easier.
When insulin goes down, your ovaries are not secreting as much androgens, your androgens go down.
Androgens go down, what happens?
Your ovulation becomes more regular.
The inflammation goes down.
So that's how the supplements work.
And the OV has a lot of anti-inflammatory supplements, but there's prescription medication metformin.
What does metformin do?
Metformin makes us insulin sensitive.
Anything that makes you insulin sensitive, again, lowers that insulin.
Are there any side effects to either of those?
So the supplements don't have any side effects.
Metformin does have side effects, but patients get used to it.
The most common side effect with metformin is nausea or diarrhea, but most patients do really really well.
The next thing patients can do are GLP-1s.
I'm sure you've heard of the Ozempics and the Wagovis and the Terzepatides.
So in 2014, I started treating my PCOS patients with GLP-1.
So almost 12 years ago.
So none of these medications are new, but back then I had Trulicity.
GLP-1s, why do PCOS patients love GLP-1s?
I started treating them and one thing I realized is not only they're losing a lot of weight, but GLP-1s regulates their insulin and makes them insulin sensitive.
By doing that, that's why patients say, oh, when I take, I don't know, Metformin, or when I take Ovi, or when I use these GLP-1s, I get brain clarity, I get pregnant, my periods are becoming more regular.
Because at its core, you're fixing this insulin resistance.
So for this pillar, this underlying condition, I say low carbohydrate diet.
Walk 10 to 15 minutes after each meal, exercise cardio at least four times a week.
I recommend the OB supplement.
It works amazingly well. ask your doctor for a metformin prescription.
The minimum dose of metformin to affect insulin resistance is 1500.
So you wanna start with 750 at night.
If you have no nausea, no diarrhea, you wanna increase it to twice a day.
Then if you have weight issues, if you have a hard time losing weight, if your bmi is in the obese category or if you're overweight, with high blood pressure or high cholesterol, then i recommend the glp-1s.
You can do the ozempic wagovi.
They all work really really well.
Talk to me about the nutritional impact of being on GLP-1, because the friends that I know that have been taking it.
They're not getting nutrients because they're not eating as much anymore.
And that obviously sounds like it has terrible effects on the body to not be able to actually eat.
You lose weight, but you're not eating.
Yes, but remember, we're talking, I'm talking right now about my PCOS patients.
I'm not talking about that, you know, perimenopausal woman, or someone out there who wants to lose 10 pounds, five pounds.
Well, patients who are already underweight and they want to lose 10 more pounds and you know they're not eating.
This is for PCOS.
This is for PCOS.
I mean, 2014, I started using these medications.
It's a gain.
And how long would someone stay on it to conceive?
So it depends, it depends.
So for someone who wants to lose 100 pounds, you know you, they might have to stay on it for two, two and a half years, and the reality of it is um.
You know, Insulin resistance, metabolic health, is not a one-size-fits-all.
Someone who loses 100, 150 pounds with GLP-1s is probably never going to get off of these meds.
But there are patients my PCOS patients who I don't know.
They lose 30 pounds, 40 pounds, 50 pounds on these GLP-1s.
But what I do, I keep them on OV. and metformin after they lose their weight.
So if someone has insulin resistance, you give them GLP-1s and you stop it, what's going to happen?
They shoot back up, right?
Take a PCOS patient.
Her insulin resistance is not going away.
You give her GLP-1, you address her insulin sensitivity.
You regulate her insulin.
She loses 50 pounds.
You stop it.
The patient comes back three months later.
She's like, doctor, I gained all of my weight back.
Why?
Because you did not address the underlying condition.
So what I do with my patients if you're starting on GLP-1, in about three, four months, when they get used to the glp-1, that's when i uh introduce the metformin.
And right when i start them on the glp-1s, i have them take the ov supplement.
So when i'm ready to stop the glp-1s, they're already on the ov supplement, they're already on the metformin.
I'm addressing their inflammation, i'm addressing their insulin resistance, i'm decreasing the load of carbohydrate that's being absorbed in their diet and then I wean them off of the GLP-1.
You have to address the underlying disorder, if that makes sense.
So what's the second pillar?
So the second pillar is the hormone pillar that I was explaining.
When the insulin resistant stimulates your ovaries to secrete androgen, the androgen actually affects your GnRH secretion.
It makes it very rapid.
And this rapid secretion of GnRH causes a shift in the LH FSH.
So the FSH kind of stays down and the LH chronically stays up.
So instead of only going up mid-cycle causing ovulation, all month this LH is firing.
What does LH do?
It stimulates your ovaries to release androgens.
So then it becomes a vicious cycle.
You have these androgens that block ovulation and you have these androgens that are free-floating in the system, causing facial hair, body hair, irregular period acne, oily skin.
And on top of that, these androgens are affecting your brain, which we'll talk later.
So this is the second pillar.
And for this pillar not only.
You want to deal with the insulin resistance.
This is when we give patients birth control pills, right.
And birth control pills help regulate this vicious cycle.
The third pillar, which is extremely important and nobody talks about, is chronic inflammation.
These poor PCOS patients have chronic inflammation in their body.
This chronic inflammation.
Remember I told you, with the insulin resistance, the liver takes this sugar and turns it into a visceral fat.
Visceral fat is highly inflammatory.
Insulin resistant increases this inflammation.
PCOS patients are stressed out.
They have high cortisol.
Cortisol increases inflammation.
These follicles that I tell you freeze in the ovaries and they're not ovulating, are highly inflammatory.
These PCOS patients have sleep disturbances.
Sleep disturbance causes increase in the inflammatory markers in our body.
These PCOS patients have gut dysbiosis, increases this inflammation.
So they have so many reasons for this inflammation to go up.
As this inflammation goes up, it makes their insulin resistance worse.
Inflammation stimulates more androgen secretions from the ovaries, and inflammation again affects their mental health.
So this again, this third pillar adds to the first two pillars, just pushing androgens out and increasing the inflammatory.
What do you suggest for that third pillar?
The third pillar, you have to address insulin resistance, which is the key form.
Antioxidants, anti-inflammatory diet is very, very important.
So there are lifestyle changes.
Lifestyle changes.
Exercise, you know, dealing with that visceral fat, blocking that visceral fat, lowering your stress.
Exercising sleeping, anti-inflammatory diet, that lifestyle.
I read this somewhere that your genetics load the gun, but your lifestyle pulls the trigger.
And that's exactly what happens with PCOS.
If you're not sleeping, if you're stressed, if you have a a poor diet, if you're not exercising, you're pulling that trigger and making all these symptoms so much worse.
The last pillar, which is your pillar, is the pillar, is the neurologic pillar of pcos, which is huge.
So, with the first pillar, with the second pillar and with the third pillar, what do we have?
Unstable estrogen levels that fluctuate.
We have high androgens pumping in their blood every single day and we have high, high inflammatory markers.
In a woman with a normal menstrual cycle, when the estrogen is normal, when the cortisol is leveled, when there's no insulin resistance, when the inflammation is down, estrogen normal estrogen levels actually are calming on the brain.
Normal estrogen levels stimulate serotonin in our brain, lower anxiety and depression.
They regulate our dopamine in the brain, so we're more motivated.
Basically amygdala, which is the part of our brain where all the emotions are stored.
It's regulated and it calms our amygdala down.
Estrogen has a calming effect.
Progesterone has the same calming effect.
It binds gaba receptors in the brain and it calms it down.
What happens with pcos?
There's unstable estrogen, there's lack of progesterone and the androgens are going crazy.
So if you think of our limbic system, which i'm sure you talk about all the time, our limbic system is our amygdala, our hippocampus and our hypothalamus.
This is the emotional headquarter of our brain.
So all the emotions are in these three areas of our brain.
Estrogen and progesterone calms it down.
But when estrogen is unstable, when progesterone is low and when androgens are going crazy, serotonin levels go down.
As serotonin levels go down, we become anxious, depressed, irritable.
The dopamine goes crazy.
Our motivation goes down.
We feel tired, fatigued, unmotivated.
The amygdala goes crazy and becomes hyperactive.
That's our fear center.
We get anxious.
We get scared.
We can't control our emotions.
And as the inflammation goes up in our brain, what happens?
We start having brain fog.
We feel like our brain is not functioning.
We feel like we're not sharp.
So take a PCOS patients all day long with unstable estrogen, progesterone that's low.
You have this androgens pumping up in this, inflammatory markers high up in their brain, making them feel anxious and sad and depressed and irritable and brain fog and all of it.
And what happens?
People tell them you have a personality disorder.
You're crazy.
Go see a psychiatrist.
And on top of all this, with the inflammation, with all these hormones changing in the brain, with insulin resistance, they get food cravings.
They binge eat, that's why they have eating disorders.
So I'm here to say that, if you're sitting at home, if you have irregular periods, if you're gaining weight, if you feel inflamed, if you have acne, hair loss, facial hair, body hair, if you're anxious, if you're depressed, if you're not motivated,
All of these could be PCOS.
It is probably PCOS.
And until you deal with these four pillars and address each one of them, you can't feel normal.
So throwing a birth control pill at these patients, that's why they don't feel better.
And you know, to this day I listen to podcasts when even gynecologists, very well-known gynecologists, show up and when they're asked what is the treatment for PCOS, they say birth control, a birth control pill.
That's one of the... Why would they suggest that?
What would that do?
What's the hope?
To regulate the periods and help stimulate the sex hormone binding globulin.
That's low in the blood, that causes elevations in these androgens.
It works with their symptoms.
It regulates their periods, their acne, clears up their facial hair, body hair, hair loss gets better, but you're not addressing their inflammation, you're not addressing the core insulin resistance and you're not addressing this neurological effect that PCOS has.
These poor patients, I mean, my heart aches.
That's why I take time out of my office to come and sit with you here on a busy day, because I want to scream.
I want to scream in this mic and say, doctors, healthcare providers, listen to your patients.
But unfortunately, our healthcare system is not built to listen to women.
People still say.
Doctors are still telling these patients you don't have a high testosterone in the blood, so you don't have PCOS.
That's not true.
You don't have irregular periods so you don't have PCOS.
That's not true.
You don't have cysts on your ovaries so you don't have PCOS.
But I want I come today to tell you, especially for women listening to your podcast, with anxiety, with depression, with eating disorders, with a lack of motivation, with a hard time getting themselves to this beautiful calm that you can get yourself to.
You know, it's because their body is on fire, their brain is on fire, their hormones are raging, their androgens are out of control.
And their inflammation and inflammatory markers are off the chart.
And someone needs to go to their rescue.
Someone needs to start listening to them.
Yeah, it's so hard to hear that so many people have sadly been given the wrong advice and people are struggling and suffering.
And is there a checkup that you can do to get diagnosed or is it just diagnosed based on symptoms?
Like, is there an actual way of knowing and checking?
Thank you for this question.
I, because of years of doing this, I actually created a free calculator, free.
It's on Ovi, ovii.com.
Goal, answer, I ask questions that I ask my patients in my office.
And with a very smart scientist, I figured out an algorithm.
Obviously I cannot diagnose online, but I can tell patients with very high accuracy if they have the likelihood of having PCOS.
And this calculator does that for them.
So if they go on OVIIcom answer these questions for free, I can tell them whether or not they have PCOS.
And if they have PCOS, I want them to listen to this podcast too.
You know I created SheMD just to give women this information, because until you make them become their own health advocate, they will get dismissed in the healthcare system.
So by listening to these podcasts, they become their own health advocate.
So they can fight for their symptoms for when they go to that OBGYN visit, they are ready.
They've listened to this podcast.
They already know they probably have PCOS.
They go take the OV test.
They know, you know, based on the OV test, whether or not they have the likelihood of having PCOS.
And if they listen to my podcast, I literally give them the bullet points.
They can print it out, take it to the doctor and become their own health advocate.
Honestly, until we have a better healthcare system and we educate our doctors not to dismiss women, this is what we have for now making women become their own health advocate.
Yeah, that's a real masterclass on PCOS that I think is gonna help so many people figure it out quickly.
And I like those steps of being able to understand it, whether you have it yourself, being able to do the test and then going to your doctor and being able to list all the symptoms and have an educated conversation seems like an important step.
Absolutely.
And, you know, to this day, I get patients, they're like, you know, I listen to your podcast.
I went to my doctor and I said, I have insulin resistance.
You need to give me metformin.
And the doctor says, well, you're not diabetic.
Metformin is for diabetes.
Do you know what I'm saying, but that's why these podcasts are so important.
So what i'm trying to tell to your listener is listen to this podcast.
You don't need a doctor to diagnose you.
If you meet one, two of the three criteria that i listed at the beginning, you know you have pcos, right.
Learn about it.
Learn about all these pillars that i'm telling you.
I'm literally giving you the tools of what you can do at home with diet, with exercise, with supplements, with lifestyle changes to help yourself.
And then you can address all these things.
Sometimes I start my patients on the supplement and they come back and they're like doctor.
This month my PMS symptoms were better.
But they can't figure out why.
Why?
Because when you address that metabolic health issue at its core, the puzzle falls into place.
The inflammation falls into place.
The brain health falls into place.
The periods, the hormones, everything starts working.
Let's talk about endometriosis.
My first question was around, do periods have to be painful?
Should they be painful?
No, so painful periods are not normal.
So what does that mean?
It's okay to have cramps.
You know we all have cramps.
You take a couple of advils, it gets better.
It doesn't disrupt your life.
You don't end up in the emergency room, you're not in the urgent care, you're not calling your mom to pick you up from school, you're not on the bathroom floor vomiting from pain.
That's normal.
But if it starts disrupting your life, then it's not normal.
If i could print a t-shirt that said painful periods are not normal, i would do it Because to this day, unfortunately in our healthcare system, women are told that painful periods normal, that it's in their head that they're being dramatic.
None of it is true.
So if moms are listening, if women who are listening are experiencing severely painful period that disrupts their life, if they cannot have sex, and when they have sex with deep penetration they're having pain.
If they have recurrent bladder symptoms they go to the doctor.
Their urine culture is negative but they keep having bladder symptoms burning with urination.
If they have painful bowel movements, if they have chronic pelvic pain, if they have chronic bloating and they chronically feel inflamed.
That's endometriosis, until proven otherwise.
Endometriosis with PCOS together, they're the leading cause of infertility on this planet.
Can you imagine?
And majority of these women are not being diagnosed.
Define endometriosis for me.
So endometriosis is a chronic inflammatory and neuroimmune condition that affects 10 to 20 of women on the planet.
Close your eyes and think of these women right, so you know someone is the point.
Absolutely every single one of us have someone right with endometriosis.
And basically endometriosis is when tissue similar to the lining of the uterus is outside of the uterus, around the tubes ovaries, on the bladder, on the bowel, on our diaphragm and in rare cases, you can find it in the lungs, in the brain.
And what happens if you think of the menstrual cycle.
Every month our ovaries are trying to get us pregnant, so they secrete estrogen to get the lining of the uterus ready for pregnancy.
And when we don't get pregnant, at the end of the month, the lining comes out.
Well, once a month, when these ovaries are secreting estrogen, these endometriosis implants also get stimulated.
And as they get stimulated when we don't get pregnant and the lining breaks down, these guys also break down, but they break down and bleed outside of the uterus.
Blood is an irritant and it causes inflammation, bloating, pain, scar tissue, adhesions.
What's interesting about endometriosis is there are so many theories of why so many women have it right.
And one of the main theories is that when we get our menstrual cycle, as we're bleeding, the blood that's shedding the lining that's breaking some of those cells come from the endometrial cavity into the tubes, out the tubes and they implant into the pelvis.
In a normal immune system, our immune system attacks those cells and clear it up.
Patients with endometriosis, their immune system is not functioning well.
So when these cells retrograde, flow from the uterine cavity out inside the tube and implant into the pelvis, their immune system, instead of getting rid of these cells, actually help these cells stick to the walls of the pelvis.
And once they stick there and there's inflammation around them, it's literally like a horror movie.
They start grabbing onto vessels and they grow nerve fibers.
And these nerve fibers start causing these pains.
And depending on where this nerve fiber is, it can cause different kinds of pains.
It can cause bladder pain, bowel movement pain, sciatic pain, back pain, leg pain. pelvic pain.
So, but the worst part of this eventually, as these nerve fibers start firing and firing and firing, our central nervous system becomes sensitized.
So what happens is their brain starts basically cranking up the volume on these pain fibers.
So they start experiencing more and more and more severe pain.
So that's why it's not only a pelvic pain issue, a fertility issue, a pain issue, but it's a central nervous system issue.
And chronically.
Because it takes doctors nine to 11 years to diagnose these women And because majority of these women go undiagnosed, this chronic pain, this chronic inflammation that comes from these inflammatory tissue in the pelvis starts affecting their central nervous system.
They start becoming anxious.
Brain fog depression, their amygdala, their limbic system is literally on fire 24-7, to a point that they become so fearful and so anxious of these periods.
And because doctors are not addressing it, what do they do?
They start taking pain pills.
They become addicted to these narcotics.
They start second guessing themselves because they keep going to the doctor saying i have painful periods, i don't feel well, and the doctor says there's nothing wrong with you, that it's in your head, that you're anxious, that you're crazy, that you probably need to see a psychiatrist.
Do you understand what i'm telling you?
Yeah, it's.
I mean it's.
It's shocking and traumatic.
That's why they have PTSD.
That's why they end up in therapy.
That's why they end up getting ketamine treatment.
That's why they end up using MDMA psilocybin, because doctors are not addressing this and they literally feel crazy.
Can I tell you, on Fridays I operate, majority of the patients I operate on are endometriosis.
I mean, I have endo, endo, endo.
It's a lineup of endometriosis patients.
Will you believe me if I told you that Every single patient, when I diagnose them in my clinic with endometriosis, or when I wake them up from surgery and I tell them the stage of their endometriosis, the first thing they do they cry and they say I feel validated.
The problem with endometriosis is the same.
Doctors who are dismissing these patients are telling these patients that the only way to diagnose endometriosis is surgery.
That's an old school way of thinking about endometriosis.
I'm here to let your listeners know that endometriosis is a clinical diagnosis and yes, the patient can self-diagnose at home.
If you have debilitating pain with your periods, that's disrupting your life.
You're missing school, you're not going to work, you're changing your social calendar.
You plan your trips around your periods.
That's endometriosis, until proven otherwise.
If you have painful...
Sex with deep penetration.
If you can't have sex, that's endometriosis until proven otherwise.
If you have chronic inflammation, bowel movement with pain, your bladder pain, these are all telltale signs of endometriosis.
And all we need to do is our healthcare providers to start listening to these patients.
You need to listen for five minutes to diagnose endometriosis with over 90% accuracy.
Surgery is not to diagnose.
Surgery is to treat only if hormonal suppression fails.
Why endometriosis implants?
These tissues in the pelvis are highly inflammatory.
And what they do, they're estrogen dependent, but they don't depend on the estrogen from the ovary.
That inflammation actually stimulates this enzyme aromatase in the tissue that starts producing estrogen.
So they become self-sufficient, they make their own estrogen, they cause their own inflammation, they have their own blood vessel, and they have their own nerve fibers, that's constantly firing and until the central nervous system becomes sensitized.
So what happens to these implants, they love estrogen.
So you don't want to give it estrogen and they become very progesterone resistant.
So one of the ways to treat them hormonally is to either give them progesterone or take the estrogen away.
How do you give these implants progesterone?
Progesterone, birth control pills, progesterone IUDs Kylena Mirena, Lyletta there are different forms of progesterone.
IUDs work amazingly well for these patients.
However, sometimes patients with the progesterone iuds are still having pain.
Why?
Because these implants are progesterone resistant.
So if you start with a progesterone, birth control, progesterone iud and you're still having pain, you can actually take medications that are gnrh agonists or antagonists.
These are medications like oralisa, myfembri.
That what they do?
They actually take that estrogen away.
And by taking that estrogen away, they calm down these endometriosis implants.
The problem with this group of medications are because they take the estrogen away, they can cause hot flashes, night sweats, mood changes, and these patients are already anxious and depressed, so sometimes they don't tolerate it well. but if all fails then you do laparoscopic surgery to resect endometriosis but here's the problem with laparoscopic surgery i honestly can sit here and tell you that less than one percent of gyns can operate on endometriosis with advanced disease and what counts as an advanced disease how long In deep infiltrated implants, in bowel, in bladder, you know, endometriosis causes a lot of adhesions, so you have to be able to know to operate on that.
So you're saying there's no cure, it's more hormonal balance.
Hormonal balance in surgery makes a huge difference.
It's still gold standard to treat these patients.
But because these patients don't have access to surgeons who are familiar with endometriosis surgery, it's always best to start with hormonal suppression first.
And if they need surgery and they still having painful sex and they still have experiencing pain with their periods, then I would recommend searching for an endometriosis surgeon.
How long does hormonal suppression take to actually have an effect?
At least four months.
At least four months.
Because your body is not a light switch.
You can't say on, off, on, off.
Have you seen success with people coming to you and taking your advice?
Are you seeing people... cure and recover and feel completely different?
Or is it more that people are just managing it?
There's no cure.
But in my practice, it's extremely rare for me to have a patient with chronic pain.
I fix everyone.
I always start with hormonal suppression.
If that fails, or if they're actively trying for pregnancy and they can't get pregnant, then I do laparoscopic surgery.
Here are the points with laparoscopic surgery.
A, you need a laparoscopic surgeon who's done endometriosis surgery.
B.
In my opinion, if you give 100 gynecologists, hundred laparoscopes and say, go operate, half of them will wake the patient up and say you didn't have endometriosis.
Wow.
How's that possible?
I know.
I swear to God, I want to cry when I talk about these things, because I see these patients in my office.
Why?
Because endometriosis implants can be glandular where they're purple.
There are these purple spots in the pelvis.
You have to look for them to find them.
You can't quickly scan the pelvis and say it's not there.
Sometimes it takes me ten minutes to find them.
They're tiny, but they're very inflammatory and painful.
So you have to be patient.
You have to know what they look like.
But there's a type of endometriosis that's stromal endometriosis, from the stroma, the connective tissue around the gland.
These, when you look for them, don't have that typical purple spot.
They're just these fine white lines.
In my opinion, these stromal endometriosis implants are more inflammatory and more painful and have more debilitating pain, but 90 of the time they get missed during laparoscopy.
So these are patients that already people are telling them they're crazy.
It's that painful periods are normal, that it's in their head.
They, on average, see 10 doctors.
Average age of diagnosis is 32.
Nine to 11 years they wait to finally for someone to say, you might have endometriosis.
And then they take them to surgery, wake them up and say, you didn't have it.
It's crazy.
Talk about gaslighting.
Yeah, it's crazy.
Put yourself in that girl's shoes.
And to make the matters worse, in my opinion, more than 50% of PCOS patients have endometriosis.
So what's the cost of ignoring this?
Like if someone's listening right now and they've been kind of feeling all this, but you kind of just let it go, what's the cost every year of not diagnosing?
The most devastating part for endometriosis is fertility, because endometriosis is a highly inflammatory condition and it destroys the egg counting quality.
I said it on Huberman podcast that I have a 14 year old with an egg count of a 40 year old.
And yes, I do check egg counts in a 14 year old with debilitating pain.
It's whenever I'm not saying every single girl on this planet at 14 needs to know her egg count, but I think until doctors start diagnosing endometriosis we need to have a baseline egg count at 18.
I absolutely fight for that every single day.
I, every single day in my practice, I see someone in her twenties or thirties ready for pregnancy with an egg count of zero because of years of pain, dismissed by the healthcare system.
So to answer your question, fertility is the biggest price they pay.
So if you have painful debilitating periods, absolutely check your egg count.
It's a simple blood test.
It's called AMH.
AMH tells us about the ovarian reserve.
A low AMH doesn't mean you're not gonna have a baby.
A low AMH means your reserve is down, be careful.
So if you can afford egg freezing, freeze early.
That's why I wish egg freezing was free.
I wish it wasn't this expensive.
I always say, when you're young and your eggs are healthy and you want to freeze them, you don't have the money.
When you're old and your egg count is down and the quality is down.
That's when you have money to freeze eggs.
To the endometriosis patients, I say, check your egg count, absolutely.
If your egg count is low and you can afford it, freeze eggs.
If your egg count is low, immediately do hormonal suppression and decrease the inflammation in the pelvis.
If you can find an endometriosis surgeon with debilitating pain, excise those endometriosis implants.
By doing that you bring down the inflammation in the pelvis, especially patients with endometriomas.
These are chocolate cysts in the ovary.
Those are the ones at most, at the highest risk of losing other egg count and quality.
So that's the biggest price they pay, painful sex.
There's so many women who can't have sex.
Imagine these are young girls who either don't get married because they can't have a relationship, because they can't have sex.
So that's debilitating.
Chronic pain causes severe anxiety and depression and lack of motivation.
A lot of them, unfortunately, become addicted to these pain meds.
So these are long-term side effects of it.
So it affects their mental health, their nervous system, their inflammation in the body, their fertility.
Yeah, it's just devastating.
It's, it's there's no words for it.
I mean i can sit here, you guys and i.
I mean i can talk for another 10 hours.
I'm touching the tip of the iceberg.
I'm traumatized from years of seeing these patients.
I swear to god, they come to my office, they cry.
I cry with them because i can't, i can't take it anymore.
I'm glad that you're able today, as we're talking, to give people the help that they need.
I've got.
I wanted to ask you about how there's a lot of mixed information about birth control pills and then, when you're off them, whether they block you from conceiving.
What's your take on that?
So first of all, you see, I got emotional talking about these girls.
It's my trauma.
Literally their trauma is my trauma.
Anyways, I love birth control.
So birth control pills for endometriosis patients is the difference of having children and no children for some patients.
Why?
So because birth control pills especially if you're on progesterone-only birth control pills what they do?
They suppress these implants.
Remember I talked about inflammation destroying the egg, destroying the egg quality.
So by putting these patients on these progesterone birth control pills, what you're doing, you're bringing down the inflammation.
You're hopefully suppressing these inflamed endometriosis tissues outside of the uterus.
And by doing that, you're preserving some of their ovarian reserve.
So that's number one.
Number two when you give these patients birth control pills or progesterone IUDs, what you're doing, you're helping their pain so they can start having sex.
They can start having relationships.
So the answer to the question of birth control pill is absolutely wrong.
You know, there are a lot of moms or grandmas who tell patients, don't take birth control pills.
You're going to be infertile.
No, you're going to be infertile if you're not taking birth control pills.
You want to be suppressed on these birth control pills until you're ready to have children.
But then why do people struggle then when they do that?
So one thing to remember is there are many women who stay on birth control pills past seven years.
There's a small percentage of women when they take birth control pills that chronically suppresses their ovulations.
When they stop it, their ovarian reserve never recovers.
So for that reason it's important to you know, I always say, after seven years of suppression, make sure you're checking your egg count.
Make sure you're checking that ovarian reserve.
And if it's suppressed and you've been on birth control for so many years, stop the birth control pill.
Maybe go to a progesterone IUD at that point.
I've seen this numerous times when patients come and they're like, my ovarian reserve is really low.
I've been on birth control pills.
Yes.
And when you stop their birth control pills, their ovarian reserve recovers.
So that's why I'm such a big advocate of checking, doing a pelvic ultrasound, which should be mandatory for every single girl who's sexually active and goes for a well woman exam.
Check a pelvic ultrasound, check the follicular count, check their ovarian reserve if you can't just do a simple amh blood, just to see what that reserve is, especially for endometriosis patients.
If someone can't afford to freeze their eggs right now yes, what are their other options?
Suppress suppress suppress, suppress.
Put a progesterone iud.
Take a progesterone birth control pill.
Take my Fembri or Alyssa.
Go have laparoscopic surgery.
But here's the problem with laparoscopic surgery.
Do you know?
I had a patient once in my office who came in.
She's like I'm here for my 12th laparoscopic surgery.
Every year she checks herself in for a laparoscopic surgery.
That's madness.
That's scary.
That's so scary.
That's so scary.
And you do not need that.
The reason these patients keep having surgeries is because no one's suppressing them.
Imagine someone has colon cancer and you go in and you resect their colon cancer.
Do you ever tell them, okay, sir, go home, I'll see you in six months?
No, they're gonna come back in six months with cancer everywhere.
What do you do?
You give them chemo.
Endometriosis is not cancer, but that's exactly what you need to do for these patients.
When you do laparoscopic surgery and first you want to resect all the implants.
Once you do that, you want to suppress immediately.
In my case, almost every single patient I take to surgery, unless they're actively trying for pregnancy.
I put a progesterone IUD at the same time because I want to freeze the pelvis the way I'm leaving it.
And as soon as they start having pain again, then in addition to surgery and the IUD, if they have more pain after surgery, if they have advanced stage, I put them on these GnRH antagonists like oralisa and myfembri, to just completely kill it.
That's why my patients.
It's very rare for me to operate for the second time on my patients, unless they have advanced disease.
How much is all of this affecting other functions in the body, whether it's the microbiome in the gut, whether it's?
Oh, thank you for asking that.
In my opinion, 90% of endometriosis patients suffer from leaky gut.
They have SIBO, 90%.
What's a leaky gut?
Basically, they get disruption in the lining of their gut, so harmful substances start getting absorbed.
As harmful substances get absorbed, what goes up?
Inflammation.
When inflammation goes up, it becomes a vicious cycle, right?
They get brain fog, they get bloated, they get tired, they get insulin resistant if they have PCOS and they just feel terrible.
And on top of that, they start gaining weight.
But I always say and these are patients who end up having colonoscopies, having endoscopies, seeing GI doctors bouncing from doctor to doctor and no one stops to tell them are your periods painful?
And why, unless you treat the underlying condition, which is endometriosis, you cannot get rid of their leaky gut.
They keep having these symptoms of bloating and fatigue and inflammation.
So what i do in my practice is, once i operate on them and i suppress them with iud, i have them monitor their symptoms of bloating.
And if they come back in a month, in two months, and they say doctor, you know what my pain is, so much better which is usually the case, but I'm still bloated when I eat then I treat their SIBO.
Do you understand?
And that's how it works.
Now patients with advanced disease, Patients who go through years of pain and central sensitization of their nervous system being ignored.
Sometimes, when you operate, when you suppress and you treat their SIBO, they still have pain, they're still anxious, they're still depressed because their brain is rewired after all these years of pain.
For those patients, one thing you can do is use neuromodulators like medications like Effexor Cymbalta Gabapentin Lyrica, because once you address their pathology, it takes sometimes time to rewire that brain and calm their nervous system down.
And you tell them to listen to your calm.
By the way, I listen to it every night.
But do you understand?
Yes, that's helpful.
I'm glad I asked that because I'm always intrigued as to the side effects.
It feels like with the body sometimes, especially with traditional medicine you're trying to solve one thing and you negatively kick off something else.
There's all these things happening back and forth that people don't usually think about, because doctors are just trying to solve one thing.
Like I know someone who and we'll talk about IVF in a second but I know a friend who is going through IVF but then something they were taking to make that more successful triggered their autoimmune.
And then, you know, now you're dealing with that.
And then that's affected.
So it's like, I'm always just intrigued as to the correlation.
Let's talk about that.
That's so important.
First of all, number one like you said, every doctor is treating what they know they're treating right.
A GI doctor is only treating the SIBO.
In my opinion, every GI doctor needs to know about endometriosis, because endometriosis is causing this leaky gut.
So if you're missing endometriosis, you can never treat your SIBO patient.
Number one.
So we have to start treating patients holistically.
I'm a gynecologist.
I check everything metabolically, let's say in my PCOS patients.
I check their ApoE, I check their ApoB, I check their lipoprotein little a, I check their hemoglobin A1c, I check for prediabetes, and I'm a gynecologist.
I screen for anxiety, I screen for depression.
I check for fertility.
I do my part, and I do everybody else's part too, because doctors are not having this holistic approach to patients.
So that's extremely, extremely important.
And the second thing I want to talk about, you're absolutely right.
Let's take endometriosis.
In endometriosis, your own immune system is attacking your own tissue, right?
So it is a form of autoimmune.
When you have one autoimmune condition, you have a 30 chance of having another autoimmune condition.
So in my practice, if I see someone with endometriosis, I immediately think to myself am I missing lupus?
Am I missing antiphospholipid syndrome?
Am I missing Sjogren's in them?
Am I missing psoriasis?
And I start asking questions and, believe it or not, when they start trying for pregnancy, if they have any other symptoms, if they complain of a little bit of a joint pain, a little bit of a malar lash, any symptom of any kind of autoimmune disorder.
I do a full autoimmune lab on them.
So this friend of yours who's in IVF, right?
I'm assuming this because I see this every single day and I've done it for decades.
She might have an endometriosis that was undiagnosed, right?
So what happens during IVF treatment, they blast her with estrogen.
When they blast her with estrogen, they stimulate her endometriosis.
So the pain sometimes gets really hard for these patients during IVF.
But because they're at risk of having other autoimmune disorders.
The IVF did not cause the autoimmune.
The IVF pushed it out, just like pregnancy pushes it out.
But if we know that endometriosis is an autoimmune condition, A, diagnose it correctly.
Don't dismiss these patients.
And when you diagnose it, look for other autoimmune disorders.
You will not be surprised with patients like that got it.
Yeah, i think that's the point right, like i appreciate that.
Well, you said that hey, we're going to look at everything and that makes sense because the body's so connected.
It makes no sense to be like we're going to treat this in a silo and hope it doesn't affect anything else, when of course, it's going to affect your entire body and mind.
And i feel like a lot of patients just get thrown around different departments going, oh well, now you're gonna have to sort that out, and now you're gonna have to sort that out, and it it doesn't add up for them like it's a painful process to go through.
Bingo yeah it's, it's terrible and i've seen it happen to so many friends where they're constantly running around trying to solve another problem now that was triggered by something else they were trying to solve.
I i wanted to ask you if, if a woman in her mid to late 30s wants to conceive, what should she be doing and thinking about if she hadn't frozen her eggs previously?
You come to my office, you're 35.
You show up to my office for a well woman exam.
I love this question.
Number one, take a good history.
I wanna rule out endometriosis because no one's diagnosed it.
I wanna rule out PCOS.
These are the top leading causes of infertility.
They need to be ruled out on that visit.
Three, I do a pelvic ultrasound.
I look at her anatomy.
I look at her ovaries.
I look for PCOS looking ovaries on ultrasound.
I look to make sure she doesn't have chocolate cysts.
I look to make sure she doesn't have any abnormal cysts on the ovary.
Then I go to the uterus.
I make sure she doesn't have any fibroids, because fibroids, when they come closer to the lining of the uterus, they can cause heavy periods, painful periods or they can cause fertility issues and miscarriages.
I look for polyps in the lining of the uterus.
PCOS patients, especially because of that hormonal changes they have a lot of polyps in the lining of their uterus.
So that can block them from getting pregnant.
So I look for that.
I do a 3D image of their uterus on my pelvic ultrasound to make sure they don't have a septum.
You'll be surprised of how many patients go through fertility clinics do.
IGF embryo gets transferred.
They don't get pregnant.
They end up in my clinic and I'm like, you have a large septum.
So these are all the things that I do.
Then after I'm done taking a good history, doing a pelvic ultrasound, I send them to my lab.
I check all their hormones.
I check their thyroid hormones.
I check for thyroid antibodies.
I check for prolactin.
These are hormones that can affect ovulation.
I check their testosterone levels if I'm suspecting PCOS in them.
I check DHEAS, which can go up.
We call it adrenal PCOS and everyone's stressed out in LA where I live.
So adrenal PCOS is a real condition where they start secreting androgens and they have symptoms very similar to PCOS.
So I screen for DHEAS in their blood and I check testosterone free in total and I do a full STD panel.
But the most important thing I do in a 35 year old, I also check her egg count.
So that egg count is very important for me.
Once I do all of this, then I tell her to go get pregnant.
How do they try for pregnancy?
Basically, I recommend having them start prenatal vitamins, usually three months prior.
If they have a progesterone IUD, because they've been my patient, I pull that IUD.
If they have PCOS, I treat them with every single thing we talked about before they start trying, because metformin, the OV supplement, these things help with the ovulation and lowers their inflammation.
I encourage a healthy diet, a good exercise, stopping smoking, stopping alcohol.
And then I tell them to go try to have sex three to four times.
For patients younger than 35, I usually give them a year to try.
For patients who are older, 35 and older, I tell them go try for six months and come back.
I screen for their partner's health.
I ask the age.
I ask if they use any drugs, if they smoke weed, if they've had any fertility issues, if there's any concern.
I sometimes get a semen analysis because I don't want my patients to try at 35 for six months and then find out that the semen is not bad.
And 30% of fertility issues are male related.
And then, you know, I have them try for pregnancy.
One thing I don't have them do is check their ovulation, check their temperature, get an ovu kit, because the more you think about it and the more you stress, the more cortisol you release and your hormones go off balance.
So I tell them, go try for six months, go try for a year.
And if you're not pregnant, come back.
But one thing that I do in my office, I've already done 90% of the screening for that patient.
So it's rare for me to have a patient show up to my office under my care that she's tried for a year and she's not getting pregnant.
If they're under my care, I've already ruled out everything.
And if they've had PCOS, I've addressed it.
If they've had endometriosis, I've addressed it.
If they've had autoimmune, I've already addressed it.
If they've had a septum, I've resected it.
If they've had polyps, I've dealt with it.
Do you know what I'm saying?
So when I let them go, I maximize that time.
This is not being done.
One thing I want to do for women in the healthcare system I want to make pelvic ultrasounds mandatory at a well-woman exam.
Just by doing it by manual exam, you can't screen for these things.
If you come to my office and you tell me you can't do a pelvic ultrasound, then I will tell you to leave, probably because it's just like taking someone's glasses away and telling them to read.
I see so much with my ultrasound.
I can't even imagine women going once a year to their doctor and not having an ultrasound.
I think for a long time at least, these things weren't talked about.
And so people thought having kids was just like, you turn up, you have kids and things work out.
And I think everyone realizes all of a sudden, like I was saying, you start talking to all your friends and like hey, I had a miscarriage.
Hey, we've been trying for six months, nothing's happened.
Now we're gonna go get checked.
And so it's fascinating that this wasn't talked about for so long, that now, when people are finally coming to the point of wanting to conceive wherever they are in their life, They think that there's something wrong with them, or they think there's something that's not working out, or now they're figuring out a health issue because of the reactive approach as opposed to.
Hey, having a kid's not easy, no matter what age you are, because it could be a million different things going on, as we've discussed today.
And so, whether you're in your 20s and you don't want to have a kid till your 30s, there's still things you can do.
There's still steps you can take now that are probably going to help you, even if it's that far away.
If you've tried for a year and you've had sex three to four times every week and you haven't gotten pregnant at the end of the year, here's what you can do.
Number one, bucket is the female factor, right?
It's the woman.
Check your hormones.
I listed those hormones thyroid panel prolactin testosterone, free testosterone, dheas.
Make sure those are normal.
Do an std check, check for gonorrhea, chlamydia.
Check your amh.
Anti-malarian hormone is egg count.
Basically it tells us what that ovarian reserve is for the woman.
That's number one.
So that's female factor.
Second, you want to make sure the egg count is good and the hormones are good.
Second bucket is the male factor.
Make sure the semen analysis is normal.
Have your partner go to any fertility clinic, do a semen analysis.
It takes two minutes to do that.
Number three I call it the anatomy bucket, right?
Get a pelvic ultrasound because doctors are not doing it.
Make sure you don't have fibroids.
Make sure in the lining of the cavity you don't have any polyps.
Make sure you don't have any septum.
Ask your doctor for an hsg.
Histosalpingogram is a very simple procedure done by radiologists.
They basically inject dye into the uterus and they flush the tubes.
Not only it flushes the tubes and helps you get pregnant, it tells us whether or not there's any blockage of the tubes.
A lot of patients with endometriosis, with scar tissue, can have blocked tubes and that's why they're not getting pregnant.
So that's the third bucket.
My fourth bucket is the bucket of endometriosis.
Have you had painful periods?
Do you have painful sex?
Do you get really bloated?
Have you had recurrent bladder infections with negative culture?
Is bowel movements painful?
If you think you have endometriosis, endometriosis can cause infertility in several ways.
A.
That inflammatory environment that we talked about destroys the egg, doesn't let the egg go to the tube.
The tubes are scarred.
Even when you make an embryo and the embryo wants to implant into the uterus.
A lot of these patients have adenomyosis, which we didn't talk about.
It's a sister diagnosis to endometriosis.
A lot of times they go hand in hand when the walls of the uterus are so glandular.
And when you have that, your risk of miscarriage goes up.
So this bucket is an extreme extremely important bucket.
And if you think you have endometriosis and your doctor is telling you you don't have it, go find another doctor, go find an endometriosis specialist.
You have to be your own health advocate in this specific bucket because it will get dismissed.
Okay, and the next bucket is the bucket of pcos, which we spent all this time.
If you have irregular periods, if you have acne, hair loss, facial hair, body hair, if you have gain, if you gain weight and you can't lose it, if you've struggled with weight most of your life, if you're anxious, depressed history of eating disorder, these are all telltale signs of a PCOS issue.
And PCOS patients when they want to get pregnant.
I would a million percent.
I swear, not because it's my supplement, because it works.
Take the OV supplement.
Ask your doctor for metformin.
Believe it or not, women in this bucket who are lean and they go to the doctor and the doctor says well, your hemoglobin A1C is normal.
You don't have insulin resistance.
That lean woman also has insulin resistance at his tissue level.
You can't see it in the blood, but she has it at her tissue level.
And putting them on the supplement and giving them metformin will help them ovulate and get pregnant.
That's how you pull these patients out of the hands of the fertility doctors.
So that's my, what are we, fifth bucket?
And my sixth bucket is my autoimmune bucket.
This bucket is always also dismissed in women.
This is your friend with the autoimmune condition.
These are patients that when you have an autoimmune let's say, if you have psoriasis yeah, psoriasis doesn't affect your fertility, but if you have psoriasis you might have another autoimmune condition that does affect your fertility.
Why am I saying this?
Let's take antiphospholipid syndrome.
These are patients who might not have any symptoms, right?
But in their labs, their antiphospholipid syndrome is positive.
These patients may clot easily in pregnancy.
Pregnancy is a hypercoagulable state.
And patients in this bucket, when they get pregnant, they make blood clots in their placenta.
They get recurrent miscarriages.
Sometimes I have my medical assistant present a patient to me.
We have a new patient.
She's had five miscarriages.
She's seen all these doctors.
She's pregnant right now.
She's five weeks.
Even before going in, I'm like, give her blood thinners.
I don't even need to see the patient.
I can tell you she needs blood thinners because she's in this dismissed sixth bucket.
For me in my practice it's extremely rare, extremely rare that I find someone unexplained infertility.
Do you know that if you look at the literature, They say 30 of infertility is female-related, 30 is male-related and 30 is unexplained or mixed like?
No one knows?
Really?
I know.
You know why?
Because those are my poor endometriosis and PCOS women, the autoimmune women, that no one is addressing them.
I always say, if you send every 20 year old to my office once, actually if I could take him, I would probably take him at 18, every 18 year old to my office once.
I would shut down a lot of these fertility centers because I would not dismiss a woman with endometriosis.
I would not dismiss a woman with PCOS.
Now that you learned all this, I want you to imagine this patient, and I've seen thousands of them.
Imagine a 34-year-old girl who's had irregular period, who's overweight.
Since she was in high school she had an eating disorder because her sister was very thin, her mom was very thin.
And at a very young age, her mom kept telling her, honey, why are you?
You're probably eating unhealthy, that's why you're overweight, eat less.
She gets anxiety.
She gets depression.
By the time she's 16, she has an eating disorder.
She has acne.
Her mom takes her to the dermatologist.
They start her on Accutane.
She is very depressed.
She goes to a psychiatrist.
They put her on an antidepressant.
She bounces from psychiatry office to psychiatry office.
She's doubled over in pain.
When she's at school, the nurse calls for her mom to come and pick her up.
She goes to 10, 20, 50 doctors from state to state, country to country.
And everyone tells her that she needs to eat less, exercise more, that she's stressed out that she was born anxious and depressed, that her medications need to be changed.
And by the time she gets to me, she's 34 years old, I do her AMH and she has no eggs left.
Yeah.
This is my broken heart.
This is my trauma.
This is every single patient I see in my office.
Do you understand?
And I don't take insurance.
My office is expensive, not because I want to torture patients, because I just can't see patients anymore.
I've done this 30 years and their trauma is my trauma.
And that's why I started my podcast, my SheMD podcast.
I literally take these, we don't talk about men, men are not allowed.
It's a safe place for women.
And I literally take every single condition, endo, PCOS, fibroids, STDs, one by one.
I teach them, I empower them to become their own health advocate.
So if you're 25 and you go to an office and you're being dismissed, that needs to stop.
I'm here today because I want to change this healthcare system.
I swear to God, I feel like this is my calling.
I feel like I was placed on this planet to change this.
I feel like I got breast cancer because I was, you know.
Do you know how many people called me crazy with my breast cancer journey?
And if, as a woman's health advocate, people call me crazy?
Do you think women have a chance in this healthcare system?
It's so painful and tragic to hear.
It's so painful.
You don't understand the depth of this pain that these women go through.
You don't understand it.
The gaslighting is toxic.
I want to scream.
That's why i say i want the president of united states to give me the mic.
People grab that mic for nonsense.
Give me that mic for 20 minutes only.
Let me tell women what they deserve to know.
You don't have to be 35 years old to find out you don't have any eggs left.
You don't have to be 35 to learn that you have giant fibroids, that you have endometriosis, that you have PCOS, that you have an autoimmune condition, that your lifetime risk of breast cancer is high and no one diagnosed it.
And now you have stage four breast cancer.
Enough.
Enough is enough.
That's it.
I can talk for another ten hours.
Dr Ray, I wanna thank you for showing up and to have such a clear conscious, powerful message delivered, that emphatically by you to everyone who's listening right now.
Everyone who's listening or watching right now, please go and subscribe to SheMD.
It's free, it's a podcast by Dr. A, where you can get deeper insights.
You can get the extra 10 hours of conversations around any of these areas you're struggling with.
And of course, pass this episode on to a friend.
I think there's going to be someone in your life who you know struggling silently, who you know suffering in the background, who you know is not aware of what they're going through.
I hope you'll share this episode with them as a way of sparking a conversation and starting their journey and empowering yourself through your health journey.
Dr, thank you for enlightening us, inspiring us and giving us such a they're so sweet powerful message.
Truly, i i learned so much today, more than i ever have, truly on this subject, and even more than that.
I appreciate your directness, just your conviction in how important this is, because you're absolutely right.
I mean, women's health has been ignored for a long time.
It's been deprioritized for a long time.
It is at the core of how we exist as humans.
So for us to not understand it is there is no excuse for it.
There's no excuse and i'm just really thankful that you came on today and shared so much light on it, so i'm very grateful.
You're so sweet.
Thank you for giving me this mic.
Yeah, I mean it.
Well, hopefully you get the president's mic too.
Thank you for your time and energy.
Thank you.
Thank you for having me.
If you enjoyed this podcast, you're going to love my conversation with Michelle Obama, where she opens up on how to stay with your partner when they're changing.
If you're going through something right now with your partner, this is the episode for you.
The world won't always like you, but you can't count on the world to like you.
