Ep 30: PCOS with Dr. Kimberley Thornton
Fertility Forward Episode 30:
PCOS or polycystic ovarian syndrome, is a common diagnosis that affects a lot of women, especially when they’re trying to conceive, and unfortunately, most of us don’t know too much about it. What does it look like? How does it affect our bodies? What causes it? Or how can we manage it with lifestyle changes and medications? This topic we are discussing today is near and dear to all of our hearts. Our guest today, Dr. Kimberely Thornton, is an RMA physician, a board-certified reproductive endocrinologist, infertility specialist, and a board-certified obstetrician and gynaecologist, and has served as a faculty member at Mount Sinai Medical Center.
Rena: Hi everyone! We are Rena and Dara and welcome to Fertility Forward. We are part of the wellness team at RMA of New York, a fertility clinic affiliated with Mount Sinai Hospital in New York City. Our Fertility Forward podcast brings together advice for medical professionals, mental health specialists, wellness experts, and patients because knowledge is power and you are your own best advocate.
Dara: Dr. Kimberly Thornton, an RMA physician, is a board certified reproductive endocrinologist and infertility specialist, and a board certified obstetrician and gynecologist and serves as a faculty member at Mount Sinai Medical Center. Dr. Thornton completed a research fellowship from the Howard Hughes Medical Institute at Florida State University, where she graduated cum laude with honors. She went on to earn her medical degree at FSU. And while in medical school, she was elected by her peers into the Gold Humanism Honor Society in recognition of her services to others, as well as professional virtues of compassion, integrity, and relationships with patients. Dr. Thornton completed her residency in obstetrics and gynecology at Albert Einstein College of Medicine Montefiore Medical Center, where she also served as the administrative chief resident. Her subspecialty training in reproductive endocrinology and infertility was also completed at Albert Einstein College of Medicine Montefiore Medical Center.
Dara: Welcome to this podcast, Dr. Thorton. Nice to have you.
Thornton: Thank you for having me. I'm excited to join.
Rena: We're so excited to have you and talk about a topic that I think is near and dear to probably all of our hearts, although I don't know near and dear is the right language, but PCOS, something that affects so many people. I myself was diagnosed with PCOS.
Dara: Ditto. Myself as well.
Thornton: Me too. So we all three have that.
Rena: I mean, that's kind of crazy. So we have three women here, all with a PCOS diagnosis, and I think it's so common, but something a lot of people don't know about or they hear it and they have no idea.So let's kind of dive right in and help people sort of understand and shed some light on what PCOS means.
Thornton: Sure. So PCOS, you know, stands for polycystic ovarian syndrome for people who don't know. In general, I feel like it's a really bad name because it causes a lot of confusion with patients. Patients will come to me panicked and they're like, I’m having trouble. My periods are irregular because I have all these cysts. And PCOS isn’t really that there's all these pathological cysts on the ovaries. It's really that women have a lot of what we call follicles, which are these kind of fluid cavities where eggs grow in that normally come to the surface each month. But it's really more of a metabolic dysfunction where kind of the eggs start to grow and you see these follicles are quote unquote cysts and then one isn't really getting released or ovulating on a regular basis so there's other sequel, like people often will have elevated androgens or male hormones, or they'll complain of acne or hair growth and usually irregular cycles. And I see a lot of those people because sometimes they'll have trouble getting pregnant and so a majority of the ones I see, but also sometimes people will just come in for an evaluation who aren't even trying to get pregnant because they notice their cycles are very, very irregular. So I don't know if you want me to kind of jump in more in the like medical, the diagnosis, or if you had specific questions or where, where you guys want to go.
Dara: I know you'd mentioned before that it's, it's a strange name and I'm with you. I feel like it could be quite a confusing name and maybe this could be something that you could speak upon. I believe for a diagnosis you have to have two of the symptoms that you had mentioned prior: the androgenism and the potential, the fluids. So not necessarily cysts on your ovaries, but there's a bunch of symptoms and it's not necessarily the cysts on the ovaries. So the name I'm assuming it's probably, it should be called something else perhaps, but how do you diagnose it? What do you need to have?
Thornton: That's a really good question. So what most OB GYNs view as the diagnostic criteria for PCOS is something called the Rotterdam criteria. Now the Rotterdam criteria consists of three things and you have to test positive for two of those three things. The first one is irregular menstrual cycles, which can be very irregular. Some people will say they never get a period, or they go multiple months without a menstrual cycles, or some women it's just that their cycles are maybe a little bit longer, or maybe they're a month and a half. In general we talk about the definition being that they typically have less than eight menstrual cycles within a calendar year, but there is some variability on that. The second symptom is what we call signs of elevated androgens. Androgens are basically male hormones, things like testosterone, DHEAS, and so symptoms of that can either be clinical meaning sometimes one of them will say, well, I have hair growth on my lip or on my belly. I'm always waxing or doing electrolysis. Some people will complain of alot of acne or sometimes it can be hair loss or like balding around, you know, the hair line. Some women don't have any of those symptoms, but you can check their blood and they may have elevated testosterone or DHEAS levels. So you don't actually have to have both to meet the criteria, just either the blood or the clinicals. Some people do have both but you don't have to have both. And then the third criteria is what we call polycystic-looking ovaries on ultrasound. And so that's where we get back to kind of those follicles or those potential eggs. They look like little black circles. And if you have 12 or more on one ovary, that meets the criteria or else also the ovaries are often a little bit bigger. So what we call 10 cubed centimeters. If it's that size or larger also meets the criteria for PCOS. Polycystic ovarian ovaries have a very distinct, I guess, look on ultrasound. Sometimes people also say like a string of Pearl signs, meaning that we see all those little follicles or potential eggs really at the periphery of the ovary. Now PCOS is also a diagnosis of exclusion. Meaning you may have two out of those three categories and meet that Rotterdam criteria, but we have to rule out any other potential causes of irregular menstrual cycles or of those elevated androgen symptoms. So things like your thyroid, prolactin, it's a milk hormone. If it's elevated sometimes causes you regular menses. We want to check and make sure that the level of the androgens aren't high, what we’re their concerning for like a tumor level, all other things that could potentially mimic PCOS but may not be PCOS.
Dara: It's something that's hereditary?
Thornton: So that is a very good question. We actually do not know what causes PCOS. For all of our fancy science and research, it's really the, one of the most common gynecological disorders and we actually do not know what causes it. To date, it has not been linked with like any sort of gene that we can test for. And there is no screening recommended genetic wise for this. Although there often is a family history. So it doesn't mean that there will be if you don't have one, it doesn't mean you don't have it. But I have a lot of patients that have a mother, sisters with all very, very similar backgrounds. So that would be a genetic component to it.
Dara: In terms of PCOS also, do you typically see patients that struggle with their weight or perhaps gain weight more easily?
Thornton: Yes. It kind of goes back to the metabolic dysfunction of this disorder, especially obesity in the abdominal or truncal area. Women with PCOS have a harder time losing weight often, and they tend to gain weight specifically in that area. A lot of women with PCOS have something called insulin resistance, which means we have a lot of this insulin hormone, which normally tells our cells to kind of pick up glucose and to use glucose. And so our cells aren't as reactive to it. And so that also kind of goes along with people are more likely to be obese when they have this. If someone is obese, though, it does not mean that they have PCOS. It's about 20% of women with PCOS are actually not overweight and are a normal weight. So it's not diagnostic. It doesn't mean you have to be overweight to have it, but there are, there are all aspects of it.
Rena: So if you had a diagnosis of PCOS does that automatically mean you're going to need assistance to conceive? That you want to go to conceive naturally?
Thornton: No, it doesn't. So people with PCOS often do have a harder time getting pregnant. So the main thing that happens that makes pregnancy harder, our pituitary each month normally, let's say if you're having a natural cycle, releases hormones called FSH and LH to tell our ovary to kind of start to grow an egg. And we usually start to grow this whole group that comes to the surface because as women we're born with every egg we're ever going to have and then they're kind of sleeping, they’re dormant or what we call immature in our ovaries. And then normally this group grows and our body's kind of like, I like to say, we're not puppies. We're not kittens. It doesn't want the whole group to grow. So naturally it usually selects one egg to continue to grow and get released. With PCOS those eggs start to come to the surface, but then it stalls there and the one doesn't take off and get released. And so that is why menstrual cycles are often really irregular. If your menstrual cycles are irregular it's almost always a sign that you're not ovulating on a regular basis. Ovulation typically have causes what called your progesterone hormones, right to be elevated. And then you either get pregnant and it's going to stay elevated and you're not going to get a period. Or if you don't get pregnant, that hormone falling down is what brings on your menstrual cycle each month. And so people with PCOS often do ovulate. It doesn't mean that they don't ever. There's some severe cases in the sense where people may go months and months and months without a period. But often people will, at some point, it's just that ovulation doesn't happen on that regular, they don't usually have their 28, 30 day cycles where that mid-ovulation happens, mid-cycle day 14, 15. And so it can line up and somebody may get pregnant and ovulate. So if you have PCOS and you don't want to be pregnant, you shouldn't think, okay, I don't need any sort of birth control or contraception. You should be very mindful of that, but it can make it harder to get pregnant. I like to say, well, if you're ovulating every month, that's what 12 opportunities a year to get pregnant? You're only going to get pregnant a few months, you know, the few days of the month eggs are being released. And so if that starts to space out over much less time frames in the year that's a) less opportunities and b) it's really hard to time intercourse to know to line things up for pregnancy. So while it doesn't mean that someone definitely is going to have trouble, they often do have a little bit more difficult time because of that ovulation being very irregular.
Dara: It's interesting. A lot of the patients that I see who have been diagnosed when they're much younger before they're thinking of starting a family, they get diagnosed as teenagers and they get put on the birth control. So the birth control helps regulate their period. And then they decided they want to get pregnant, get off birth control. And like don't even realize that their, their ovulation again, sometimes can not be as constant. And then I always wonder why a lot of times the doctors don't always speak about it way back when, when they're teenagers. And unfortunately, a lot of times it happens when they're trying that they end up going back, whether to see a reproductive endocrinologist or to their GP. And they're like, what's going on with me?
Thornton: Yeah. I think in general, there's just not a lot of good education. And probably in the medical field is don't do enough awareness about PCOS. I think that that happens to me all the time. I see a patient who was like, well, my periods were always irregular when I was younger. So I was put on the pill and now I went off of it and they're still, I thought it was going to fix it. They were regular all those years. And now it's not. And birth control pills are not bad. They are actually really helpful if you don't want to get pregnant with PCOS because they increase something called sex hormone binding globulin, which is basically what binds your free androgens or your testosterone. And so it drives down and it helps get rid of those acne, hirsutism-type of symptoms and it helps regulate your menstrual cycles. You're not ovulating when you're on the birth control pill so that period is not like, I guess a true period per se, like when you're not on the pill, but it makes you have a withdrawal need because it has progesterone hormone in it. And you worry, if you go too long without having a period over years and years, it's not good for that lining of the uterus not to shed. It can predispose people to endometrial cancer. So birth control pills are a great fix for people with PCOS, who don't want to get pregnant, but sometimes people are not educated well enough to, well, what's going to happen when I go off the pill? What do I need to be thinking about in the future? In most people, some people’s cycles will be a little irregular when they first go off the pill, but in general, most people within about three months, their cycles really will come back. And so if it hasn’t at that point, it's really time to see a fertility specialist. And that's how I actually do a lot of young women with PCOS who really aren't even thinking of pregnancy. Some people are really great. They have a really good OB GYN. It's like, Hey, just go see someone to talk about down the future so that they know the things to kind of look out for. But I would say, that's something, I see. A classic story I hear all day long. And that's actually what happened to me. I was on, I never even knew until I was a fellow in reproductive endocrinology. You know I was a doctor and OB GYN and I didn't even know something was wrong with me. So I totally understand how that can happen to so many other people.
Rena: Yeah. It’s so crazy. I remember I was in college at the GYN. She said, Oh, it looks like you have PCOS. And like, that was it. End of sentence. End of story. I didn't know what that meant. And then it wasn't until years later when I was trying to get pregnant and had to go through IVF and I understood more of what that meant, but it was like, Oh yeah, you have PCOS, like that's it, no information. And it's only been through my own research to figure out how to manage it through diet and exercise and kind of, for me, what works is a combo of Eastern and Western medicine to manage it. But there, I find there's such conflicting information and I think people should be so much more prepared.
Dara: I'm with you. Rena. I have had a similar experience where they diagnosed me, but didn't really tell me so much about it and how it could be potentially managed through diet and exercise. And also they had mentioned that I had something called mild or slim PCOS, and that's still something that's a little bit confusing to me. Is there anything that you'd like to speak on, Dr. Thorton about that?
Thornton: Yeah. I think a lot of people have this misconception that if somebody is thin that they don't have PCOS and like I mentioned, there's a huge chunk, almost a quarter of people are not overweight. And I think we know that diet, obviously you're really the expert on this, Dara, but diet and lifestyle modifications can help improve PCOS.There unfortunately is no cure. Nothing's going to ever make it go away, but there are things you can do to make it better or things that you could do to make it worse and worse is going to be carbohydrates or eating a lot of desserts and sugar and all of those things. And so at the core of it, somebody can be thin and still have insulin resistance or still have elevated androgens and have those components. And I don't know if it's really a mild or slim version in the sense that you have it or you don't have it, but some people are able to manage it better. And I find that I actually encounter some patients that I feel like I've almost self, managed them, themselves. They're like I always gaining weight. They don't even realize I was doing all this exercise. I was cutting back carbohydrates. And sometimes it, people have just kind of self treated themselves and those aspects. And then of course there's some people who will diet, exercise, do all the right things and still maybe have higher PCOS is associated with more likely develop prediabetes or elevated sugars or still have those irregularities. So at the core of it, it's not just like lifestyle helps, but it's not that people have this misconception that I was, you’re overweight so you have this. No, this was there, obesity may be aggravating it, making it worse, but it was always there at the core, I guess, if that makes sense.
Dara: It definitely makes sense. And it's interesting because I also feel at least with my patients who are coming in and struggling with losing weight and they come to me and they say that I'm really dieting and I'm working out a lot and I'm still not seeing the weight loss results, but it's interesting, I've noticed and I, it would be interesting to do more research on it and I've seen some research on it, but in terms of sometimes that heavy, very intense high impact exercise, I don't always see as much success with my patients. And I wonder if that may be can create more inflammation in their system? And also I see lot of my patients who do a lot of low fat foods or fat free dairy, often struggle more with weight loss. And when they ask me and I know I've spoken to you, Dr. Thorton, when you are pregnant in terms of going for a fuller fat dairy, which has less of the testosterone or the androgens in the fuller fat dairy that sometimes patients can see more of a relief. And also when they do a lighter type of workout that is not so high intensity.
Rena: Yeah I think, Dara, you touched on something, the inflammation, and I know myself the past few months just in sort of like the lifestyle change in the pandemic, prompted me to start researching for myself and then it sort of track what's going on in my patients and I'm lucky sometimes in that my personal and professional life can bleed together. And so I started really delving into research about inflammation and stress and all that to better serve my patients. And then I uncovered a lot of information about how PCOS plays a role in all of that and everything I've uncovered basically says as much as we love cardio for the stress relief, it's really not serving us in terms of any sort of weight management and strength training is really the way to go in terms of losing weight. But of course you, don't, it's harder to get this sort of endorphins from strength training. So I think probably if you're someone who copes with a lot of cardio is to get that balance. But I think it's contrary to what I think a lot of people do, which is they try to starve themselves and then do a ton of cardio. But that's really the worst thing you can do.
Dara: For sure. I agree with Rena. But it's interesting because I think, and I'm sure you, both of you guys have seen this, that just like anything, every patient, every person is different and everyone's needs are different, their diet, their exercise or lifestyle. I'm sure their medication could be a good segue in terms of how do we manage PCOS? And I know we mentioned the exercise and the diet but, Dr. Thorton, is there a typical protocol that you take?
Thornton: Yeah, so I think we touched a little bit on, well, I kind of put people into categories: trying to conceive or not trying to conceive. Really first line therapy for like we talked about for people not trying to get pregnant really is birth control pills. And if the hirsutism symptoms are really not controlled with birth control pills, some days we think of adding other medications, something called like spironolactone that really drive down those androgen levels. Those medicines cause birth defects. We can not be having somebody on them who wants to get pregnant and birth control pills themselves are really counterproductive to people who want to get pregnant. So that's really for know that circumstance. When someone's ready to try to conceive, we usually have, obviously, lifestyle management is important as well, but a lot of people, their cycles are still going to be irregular, even with lifestyle modifications. And so really after that, we start to think about what we call ovulation induction. That first line medication for PCOS is something called Letrozole which is an aromatase inhibitor, which basically means this medicine actually kind of temporarily lowers the estrogen level in our blood. And so estrogen comes from our ovaries and our eggs and it basically tricks the brain into thinking kind of like, well, our ovaries are not working. And so then it gives a booster of those natural FSH, LH hormones. And so we usually can kind of overcome that dysfunction of that group of eggs started to grow, but stalled and get that one to grow and release. There is another pill medicine called Clomid. I actually find most people are more familiar with Clomid than Letrozole cause it's one of the oldest fertility drugs and it's been around a lot longer. It works very similar to Letrozole, but most of the new studies have shown for PCOS, letrozole is considered superior. It has been shown to have higher birth rates and ovulation rates per cycle. Of course, though, sometimes somebody doesn't do well, has side effects. We can always switch out one versus the other, but really let's letrozole, if I know someone has PCOS is the first medication I'm going to put them on and kind of go from there. Hopefully a lot of women will conceive after regular ovulation, but if it's a period of time and we're tracking, we know ovulation’s happening, the pill is working, then sometimes you do have to think of more aggressive options. There's what we call gonadotrophins or injection medicines that we typically reserve for IVF because we do grow quite large groups of eggs. Some women will take that just to have intercourse, but the risk of multiples is really pretty high. So it's usually very hard to control. These days we really encourage using those for IVF and that's really our kind of most aggressive treatment option in the fertility world.
Dara: Letrozole. I was going to talk about Letrozole. That it's interesting how letrozole sounds like a, a much newer... I know Clomid was something that I was put on initially before I went to RMA as a patient. Is it because it has less side effects that it's something that we typically use more now or is it because we've just seen more success?
Thornton: The main reason we're seeing it more is the studies show that there's just been more success.
Dara: That's great.
Thornton: The side effects are pretty similar between the two of them. People get hot flashes. You feel like warm the five days you're taking it. So it was a way some people do feel mood fluctuations from the kind of spike in hormones. And there is, there is still an increased twin rate with these pill medications because sometimes it's the egg to grow, but sometimes the second one makes it in there and usually not much more than 7 to 10% risk of multiples, but that's still much higher than if you weren't taking the medication. So there is still some risks with it.
Rena: And what about Metformin? Because I know recently they've been saying Metformin, you can take, I was put on Metformin when I was trying to conceive, but I know with PCOS you can just sort of take it continuously to manage it if you're not trying to conceive.
Thornton: So Metformin is actually a diabetes medication and it actually makes the cells more sensitive to insulin. So it really helps with that insulin resistance. I don't routinely put everybody with PCOS on Metformin, but there's definitely a group of women who really do benefit from it. So anybody with PCOS, I guess, to back it up a little bit, you are more likely to develop prediabetes, diabetes down the road. Also other health things that people should be aware of - you’re at higher risk for developing cardiovascular disease or endometrial cancer, kind of like we talked about earlier from the long periods of anovulation. But it kind of on this insulin resistance and potential prediabetes/diabetes era, it's really recommended that somebody with PCOS has some sort of screening for their sugars or for diabetes, whether it’s with a hemoglobin A1C, which is a blood test that kind of gives your three months sugar average or with a what we call a glucose tolerance test where you kind of drink a sugary liquid and they check your blood every two hours after. It really should be screened for that. If there's any signs of, especially pre-diabetes, then it's really indicated to start that Metformin. It's not standard that to check insulin levels, but if that were checked and even if someone's not in the prediabetic range and there's concerns there, it's also very much indicated to start Metformin. So those are the circumstances where I would say it's always a definite to add. As far as for fertility itself in like making someone ovulate, the studies really have looked at just taking Metformin or taking Clomid or taking Letrozole and, and really Clomid and Letrozole are both superior as far as getting ovulation and for pregnancy rates over Metformin. But there is some evidence that Metformin can make people a little bit more sensitive to medicines. It may, that it has a benefit over doing nothing. And especially for those insulin issues, it can be really, really beneficial in helping with that aspect of it. We know that insulin resistance is really what helps drive up those androgens. And so if we can help lower that we can help lower the androgens which can overall just help improve PCOS. Unlike other diabetes medicines, one of the great things about Metformin is it's not like insulin where either taking injections where we worry about people getting hypoglycemia, low sugars, you know, getting cheeky or passing out, Metformin does not cause that. So that's a really nice thing about that medicine. It does cause GI upset though.
Dara: People do talk to me about that, but I think Metformin can be great in combination with changing one's diet to make sure that their carbohydrate intake is not in excess, that you're choosing the right quality carbohydrates, higher fiber. And what I always mentioned to my patients is making sure that there's always a source of carbohydrate or healthy fat when the carbohydrate is consumed also to help prevent that blood sugar spike or to help make sure that the increase of blood sugars isn't as fast. So quality, quantity, timing of day, and the pairing of it with a source of protein in conjunction with the medication.
Thornton: And in general, I don't usually just put someone on metformin if they're trying to get pregnant and nothing else, but it's often a good thing to add into the mix
Rena: So that’s really a lot to think about. I think, you know, we sort of touched on, it really is individual. There's no sort of black and white treatment for PCOS and each person is different and it's really important to speak with your healthcare provider and figure out what's the best case management, course of management for you.
Thornton: Of course it’s such a ride. The definition of PCOS includes such a large group of women that there are almost different subtypes it seems lof PCOS within the diagnosis. And so yeah, in certain sense it does need to be tailored and based on an individual.
Dara: That's wonderful. Well, we got a lot of information from you today. We really appreciate that. I feel a lot more confident now with the subject as I'm sure Rina has as well. How we like to end our sessions is to discuss gratitude, what we're grateful for today. So Dr. Thornton, what are you grateful for right at this moment?
Thornton: I would say at this moment in time, I am very grateful for health and would say in the middle of the pandemic that’s something that I've been healthy and my family's been healthy and just grateful for the little bit of warmer weather. Well, today is a little extreme warm but nice summer weather. It's been a little nice.
Rena: Oh that’s wonderful. Dara, what about you?
Dara: I'm just grateful to talk about PCOS. It's something that I've known that I've had for quite some time, but it's always great to be reminded about what we can do and as much as I wish I had known all this information way back when it's great to keep on top of it, keep abreast with all the information so we can better help the people that we come across in our clinic. Rena, what about you?
Rena: I agree. I think one of those things of gratitude sort of from this pandemic is almost is, like found time, you know, and I’ve the past months been filling up with a lot of extra time to do research, to figure out how to better serve my patients and those around me. And I've really uncovered a lot of data and information about PCOS that's been really helpful to me individually and then sort of ripple effect to my patients in terms of PCOS or stress management, everything like that. So grateful for the found time for extra research. So thank you so much. This is definitely something, you know, we can do part one part two part three, it's a really big subject and you know, a lot more to discuss. There's a lot of information out there, but always remember - make sure you, you know, you trust your doctor, you go to them for advice because there's certainly a lot on the internet and you want to make sure that you're really understanding what's best for you individually.
Dara: And also if there's any questions about PCOS, you can always find us on Instagram at fertility forward and DM us with any of those questions, which can be very helpful for part two with Dr. Thorton hopefully.
Thornton: I was going to say I can do a whole episode about what to eat with PCOS. It's one of the most common questions I get and I know that's your up your alley, Dara.
Dara: For sure. Well, thanks for being on today and for giving us time out of your busy schedule. Thank you so much.
Dara: Thank you so much for listening today. And always remember, practice gratitude. Give a little love to someone else and yourself. And remember, you are not alone. Find us on Instagram @fertility_forward. And if you're looking for more support, visit us at www.rmany.com and tune in next week for more Fertility Forward.