Dr. Thaïs Aliabadi on Huberman Lab: Why PCOS goes undetected

PCOS is the most common hormone disorder in reproductive-age women (≈15–20%) yet >70–90% are undiagnosed. Diagnosis requires 2 of 3: (1) clinical signs of high androgens (facial/body hair, acne, oily skin, male-pattern hair thinning), (2) ovulatory dysfunction (irregular cycles, >35-day cycles, <8 periods/year), and/or (3) PCOS-like ovaries or high AMH. A normal blood testosterone or normal-weight body does NOT rule out PCOS, and there are at least four phenotypes, some lean, some with regular cycles, some with normal-appearing ovaries.

Aliabadi argues AMH testing and screening for PCOS/endometriosis should be routine from late teens onward. AMH is a simple blood test; roughly 0.1 AMH ≈ one follicle (e.g., AMH 1 ≈ ~10 follicles). High AMH is not always good: in PCOS, AMH can be high but egg quality poor. Endometriosis can destroy egg count and quality even in teens—she treats 13–14‑year‑olds with ovarian reserve of a 40‑year‑old and sometimes freezes eggs by 16. Waiting until the mid‑30s to first assess fertility can be catastrophic for women with silent PCOS or endometriosis.

In PCOS, GnRH firing, LH/FSH imbalance, and androgen excess disrupt ovulation, but insulin resistance amplifies everything: high insulin drives more ovarian androgens, suppresses sex hormone binding globulin (raising free testosterone), and pushes excess glucose into visceral fat, which releases inflammatory cytokines. This creates a vicious loop that worsens symptoms and long-term metabolic risk. Action steps: low‑inflammatory, lower‑refined‑carb diet; walking after meals; resistance and aerobic exercise; optimizing sleep and stress; inositol, vitamin D, and other insulin-sensitizing supplements (e.g., in Aliabadi’s Ovii formula); then metformin (often 750–1000 mg twice daily, not 500 mg once), and, if needed and appropriate, GLP‑1 agonists.

Endometriosis affects at least 10–20% of women (Aliabadi believes >20%) and is the leading cause of chronic pelvic pain and a top cause of infertility. The hallmark is tissue similar to uterine lining growing outside the uterus (ovaries, pelvis, bowel, bladder) that bleeds internally with each cycle, driving inflammation, scarring, nerve growth, bloating, and pain. It typically takes 9–11 years and 5–10 doctors for diagnosis; many women are told it’s stress, anxiety, or IBS, put on opioids, or misrouted into GI or urology workups. Any period pain that disrupts life (missing school/work, ER visits), deep-penetration pain, severe bloating, painful bowel movements, or recurrent negative-culture UTIs should be considered endometriosis until proven otherwise.

Gold standard diagnosis and treatment is laparoscopic excision, not just burning lesions. But only about 1 in 100 gynecologists are properly trained to do advanced endometriosis surgery, and many will perform a brief laparoscopy, fail to recognize subtle stromal endometriosis (fine fibrous bands without typical dark “powder-burn” spots), and wrongly tell patients they don’t have it. Aliabadi emphasizes: excision + long-term hormonal suppression are needed, especially for higher stages, often with a progestin IUD (Mirena/Kyleena) and sometimes GnRH antagonists (e.g., Orilissa/Myrfembree) up to two years. Stage has no consistent relationship with pain severity; mild disease can cause incapacitating pain, and severe disease can be relatively quiet.