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

Insulin resistance disrupts the brain-ovary axis to drive PCOS; AMH testing and Tyrer-Cuzick scoring give women early answers on fertility and cancer risk.

Dr. Thaïs AliabadiguestAndrew Hubermanhost
Nov 24, 20253h 7mWatch on YouTube ↗

EVERY SPOKEN WORD

  1. 0:00 – 2:56

    Thaïs Aliabadi

    1. TA

      Every single ophthalmologist knows about cataract.

    2. AH

      Yes.

    3. TA

      They will not-

    4. AH

      Most common form of, of, of blindness.

    5. TA

      So, it would be rare for you to go to an ophthalmologist with cataract and not get diagnosed, correct?

    6. AH

      Correct.

    7. TA

      So, why is it that the leading cause of infertility on this planet, 90% of women are not diagnosed? Women's health is very different than other fields of medicine. It's very... It's a different monster. It's that cataract patient that goes to 20 ophthalmologists and she keeps saying, "I can't see," and the ophthalmologist says, "You're crazy. There's nothing wrong with you."

    8. AH

      (upbeat music) Welcome to the Huberman Lab Podcast, where we discuss science and science-based tools for everyday life. I'm Andrew Huberman, and I'm a professor of neurobiology and ophthalmology at Stanford School of Medicine. My guest today is Dr. Thais Aliabadi, an obstetrician, gynecologist, and surgeon, and one of the most sought after experts and trusted voices in women's health. Today, we discuss crucial topics in women's reproductive and general health, including PCOS, endometriosis, breast cancer, perimenopause, and menopause. Dr. Aliabadi explains why so many cases of PCOS and endometriosis go undiagnosed and how many physicians unfortunately write off things like pain, hair thinning, mood changes, and other symptoms as normal, when in fact they reflect larger underlying issues that can impair fertility and lead to body-wide health complications. And she explains the key things to do to diagnose and treat PCOS and endometriosis, everything from how to adjust insulin sensitivity to hormone replacement, over-the-counter and prescription-based protocols. As you'll soon hear, Dr. Aliabadi is incredibly passionate about women's health and has developed various zero-cost online tools that women of any age can use to assess their risk for things like breast cancer, PCOS, and endometriosis. I should also emphasize that today's discussion is relevant to women of all ages. Many of the conditions we discuss are starting to show up in women even in their mid teens and 20s and can carry serious health risks. Dr. Aliabadi makes very clear that often these issues can be resolved, but that it requires knowing the telltale signs and taking the appropriate steps. She explains that, alas, many doctors and even OBGYNs are unaware of those telltale markers. So, what you're about to hear is an extremely eye-opening conversation that, thanks to Dr. Aliabadi's passion for and expertise in women's health, could very well save someone's mental and physical health, their fertility, and in the case of breast cancer screening, even their life. Before we begin, I'd like to emphasize that this podcast is separate from my teaching and research roles at Stanford. It is however part of my desire and effort to bring zero-cost-to-consumer information about science and science-related tools to the general public. In keeping with that theme, today's episode does include sponsors. And now for my discussion with Dr. Thais Aliabadi. Dr.

  2. 2:56 – 8:16

    Why Endometriosis & Polycystic Ovary Syndrome (PCOS) Go Undiagnosed

    1. AH

      Thais Aliabadi, welcome.

    2. TA

      Thank you for having me.

    3. AH

      Super excited to talk about today's topics, and there are a lot of them, because I think these days we hear a tremendous amount about how fertility rates are dropping, we hear that sperm counts are dropping, we hear that things like PCOS, which you'll explain to us, are on the rise. I'm curious if they're on the rise or they're just being detected or not detected as much. Let's start off quite simply and just bracket for people what the sort of standard trajectory of fertility looks like, uh, for the, quote-unquote, "average woman." I realize there's no such thing as an average woman, but I think we hear so much these days about people are waiting to have kids, some people are freezing eggs early, all this. If we were to just march through and say, you know, um, what fraction of healthy women are fertile in their, say, 20 to 25, 25 to 30, and march that forward just to give people a sense of what the data and your experience really tell us.

    4. TA

      First of all, before I go there, I want to tell you something. I want to tell you how excited I am to be here today, and I'll tell you why. Because I've been in women's health for 30 years, and one thing I learned is that women's symptoms get dismissed, minimized or completely ignored, right? It's normalized. These women, every time they complain they say, "It's in your head, you're anxious, you're stressed." Um, you know, "It's, it's normal. It's part of being w- a woman." And behind these dismissals are millions and millions of women suffering undiagnosed PCOS, endometriosis, chronic pelvic pain, infertility, which we're going to cover right now, and so many other issues because no one takes the time to listen to them. And, um, uh, the reason I'm so excited to be on this podcast is I want to shed light on these topics, especially endometriosis and PCOS, because they're the top leading causes of infertility on this planet. Majority of these patients are never diagnosed. Majority. And that's why I'm so excited to be here, and I love talking about fertility because the reason these women end up in a fertility clinic in the first place, majority of them have undiagnosed PCOS and endometriosis. So, we are born with certain number of eggs, millions of them, and we don't make more eggs after we're born. And as we go through life, we start losing these eggs until at about menopause, we have about 1,000 of them left. So, as we get older, the number goes down, but the quality also declines. The issue is PCOS and endometriosis d- affect your egg count and your egg quality. So, because 90% of these patients are never diagnosed, what happens is they start losing their eggs. Let's say an e- take an endometriosis patients, which we're going to get into it.... but they start losing these eggs, the quality starts shooting down. Some of 'em by age 30, they have zero eggs left, and these are patients who bounce from doctor to doctor, and their symptoms are dismissed, they're being told that their painful period is normal, that their painful sex is in their head, that they're exaggerating their pain, and meanwhile, their ov- ovarian reserve is completely depleting and no one is addressing that. Andrew, I've always said this, and I really mean it, if every 20-year-old in this country would go through my office once at age 20, I would shut down these fertility clinics because where do these patients end up? In fertility clinics. That's why these doctors are so busy and that's why these patients go bankrupt selling their homes, selling everything they have to pay for an IVF cycle that could've been completely blocked had they been diagnosed correctly and treated at a very young age. And I'm talking, sometimes I treat 13-year-olds with endometriosis. I have, right now in my practice, a girl at 14 with endometriosis whose egg count is the egg count of a 40-year-old. That's why you can't, I can't sit here and generalize that if you're in your 20s, you're gonna be fine. It's not true. You need to know at a very young age, every girl on this planet needs to be screened for endometriosis, for PCOS, and they need to know their egg count. Egg count, AMH, anti-Müllerian hormone, is a simple blood test. It's covered by most insurances. It needs to be offered. If you don't want to offer it to your young patients, because, you know, teenagers are tricky because they have so many eggs, but if they're complaining of severe pain, if they're missing school, if you're, uh, ha- if y- as a parent, you have to go pick 'em up from school, the nurse is calling you, they don't want to take their test because they're rolled up in bed from pain, that patient, even at 14, deserves an egg count check because for these patients, sometimes by age 16, I freeze their eggs.

  3. 8:16 – 10:54

    Infertility, Tool: Early Screening

    1. TA

    2. AH

      Incredible. So, then I'm going to reframe my question on the basis of what you just said, um, and ask, is the typical plot that we see of, you know, this, uh, X number of, uh, or X percentage of, of women of a given age bracket are, uh, this fertile or not fertile, meaning how many trials, uh, or times it would take in order to successfully, um-

    3. TA

      Get pregnant.

    4. AH

      ... car- get pregnant, carry a baby to term. Should we either discard or think differently about the data that we see plotted out? Like if I were to go into one of the AI platforms and ask, uh, I'm sure it would generate a plot for me. What I'm hearing from you is that because PCOS and endometriosis are not taken into account, the textbook picture is a false picture-

    5. TA

      Correct.

    6. AH

      ... of fertility as a function of age.

    7. TA

      Correct. And that's why, I have a patient who came to me, she was 24, severe pain. She said, "I listened to your podcast. I went to my doctor and I asked her, my gynecologist, and I said, 'I have really bad painful periods and I think I have endometriosis. Can you check my egg count?'" You know what the doctor told her, her gynecologist? "You're too young. It would be malpractice for me to check your egg count because at 24, you should not have any issues and you have no problems getting pregnant." I operate on stage four endometriosis patients at age 18. That's why I'm here. That's why I want to grab this mic and that's why I want to just focus first on PCOS and then focus on endometriosis, 'cause these two conditions you don't need a doctor to diagnose you. If you listen to this podcast, by the time you and I are done, whoever's listening, if it's a parent, if it's your sister, if it's yourself, if it's your daughter, you're gonna be able to diagnose these conditions. The leading causes of infertility on this planet. It can be diagnosed. By the time we're done, you're gonna walk on the street and you're gonna say, "I think that woman has PCOS." I'm serious. That my patients are so smart, they literally send their friends, they're like, "I'm sending you my cousin because she has endometriosis." Patients are diagnosing when doctors are not.

    8. AH

      Incredible.

    9. TA

      That's why I'm looking forward to these robotic doctors. I read that China has this robotic hospital. I'm like, praise the Lord. These robots are not gonna dismiss women. If you tell a robot, "Sex hurts. I stay in bed. I end up in the emergency room every time I have my period," the robot will not call you crazy. The robot will say, "You probably have endometriosis, but let's work it up."

  4. 10:54 – 14:07

    Sponsors: Lingo & Our Place

    1. AH

      Glucose is a key player in how our body functions, not just in the long term, but in every moment of our lives. That's because it is the major fuel for our cells, especially our brain cells. Glucose directly impacts our brain function, mood, and energy levels, and it may even affect our levels of tenacity and willpower. This is why I use the continuous glucose monitor from Lingo. I absolutely love it and I'm thrilled to have them as a sponsor of the podcast. Lingo helps me track my glucose in real time to see how the foods I eat and the actions I take impact my glucose. When glucose in your body spikes or crashes, your cognitive and physical performance do too. In fact, large glucose peaks and valleys lead to brain fog, fatigue, irritability, and hunger. What you eat, of course, plays a major role in your glucose. Some foods cause sharp spikes and big crashes, and others do not, but not everyone is the same in terms of how they respond to particular foods. Seeing your glucose in real time helps you build eating and other habits that support metabolic health, mental clarity, and sustained energy. Lingo has helped me to better understand what foods to eat, when to eat, and how things like a brief walk after a meal can help keep my glucose stable, and much more. If you'd like to try Lingo, Lingo is offering Huberman Podcast listeners in the US 10% off a four-week Lingo plan. Terms and conditions apply. Visit hellolingo.com/huberman for more information. Today's episode is also brought to us by Our Place. Our Place makes my favorite pots, pans, and other cookware. Surprisingly, toxic compounds such as PFASs, or forever chemicals, are still found in 80% of non-stick pans, as well as utensils, appliances, and countless other kitchen products. As I've discussed before on this podcast, these PFASs, or forever chemicals, like Teflon, have been linked to major health issues such as hormone disruption, gut microbiome disruption, fertility issues, and many other health problems. So, it's very important to avoid them. This is why I'm a huge fan of Our Place. Our Place products are made with the highest quality materials and are all PFAS and toxin-free. I particularly love their Titanium Always Pan Pro. It's the first non-stick pan made with zero chemicals and zero coating. Instead, it uses pure titanium. This means it has no harmful forever chemicals and does not degrade or lose its non-stick effect over time. It's also beautiful to look at. I cook eggs in my Titanium Always Pan Pro almost every morning. The design allows for the eggs to cook perfectly without sticking to the pan. I also cook burgers and steaks in it, and it always puts a really nice sear on the meat. But again, nothing sticks to it, so it's really easy to clean and it's even dishwasher-safe. I love it and I use it constantly. Our Place now has a full line of Titanium Pro cookware that uses the first-of-its-kind titanium non-stick technology. So, if you're looking for non-toxic, long-lasting pots and pans, go to fromourplace.com/huberman and use the code Huberman. Right now, Our Place is having their biggest sale of the year. You can get up to 35% off all products now through January 12th, 2026. With a 100-day risk-free trial, free shipping, and free returns, you can try Our Place with zero risk and you can see why more than one million people have made the switch to Our Place kitchenware. Again, that's fromourplace.com/huberman to get up to 35% off.

  5. 14:07 – 15:24

    Women’s Health Education Gap

    1. AH

      Well, clearly, you're on an important mission, and clearly, it's good that we reframe the question that I initially asked-

    2. TA

      (laughs) Yeah.

    3. AH

      ... and start with PCOS and then-

    4. TA

      Yes.

    5. AH

      ... endometriosis. But before I do that, I just want to, um, just give a reflection, which is, uh, m- one of the takeaways from what you just said, and just one, there are many, but one of them is that most young women learn about the menstrual cycle. I think they also make an attempt to t- teach boys about the menstrual cycle.

    6. TA

      Yes.

    7. AH

      When we were in high school, they d- they tried to teach everybody. Whether or not it sinks into, to the males' brains is, is a question of debate. But most every woman learns at some point about the menstrual cycle. It sounds to me like female health education should also include education about PCOS and endometriosis at a very young age.

    8. TA

      Mandatory. It should be mandatory.

    9. AH

      And currently, I... it's not. In fact, many, um, female listeners of this podcast, I believe, um, either suffer from or know somebody who suffers from PCOS or endometriosis. I know this 'cause I get asked a lot, uh, to cover these topics, which is one of the reasons you're here. And the other thing is that I'm, I'm certain that many do not. That many do not, because they came up through an education system where that just didn't happen.

  6. 15:24 – 21:28

    PCOS Overview: Symptoms, Diagnosis, AMH, Disordered Eating

    1. AH

      So, we can start this important initiative now. Um, what is PCOS?

    2. TA

      Very good question. So, PCOS is the most common hormone disorder in women in their reproductive age. The most common. So, we're not talking about some rare diagnosis, number one. It affects 15% of women in this country. If you go to Middle Eastern countries, that number can go north of 20%. Studies show that 70% of these patients are never diagnosed. I tell you today that that number is over 90%. Majority of these patients are never diagnosed, or even when they're diagnosed, they're not being treated correctly. I listen to podcasts on PCOS where doctors come and, uh, you know, whoever's interviewing them asks them, "So, what do we do for PCOS?" And the answer is, "We give birth control." That's not true. Birth control is just one tiny little aspect of the entire treatment plan, and that's why patients get frustrated. So, when it comes to diagnosing PCOS, right, you need to meet two out of three criteria. The first one being symptoms of high testosterone or high androgens. What are those? Facial hair, body hair, the most common, acne, oily skin, or male pattern hair thinning, which a lot of women complain of. Number two is basically...... uh, ovulation dysfunction. These are women with irregular periods. They get their periods, um, over like, you know, 35 days, it's not regular 28 days, or they get about eight periods per year. These are patients who usually come to the doctor and when you ask them how your periods are, they can't really tell. They tell you, "It's irregular. I can't quite pinpoint when I'm gonna get my period." And number three is PCOS-looking ovaries on ultrasound. Polycystic ovary syndrome does not mean cyst. That's a bad name.

    3. AH

      Mm-hmm.

    4. TA

      It's this very specific finding on ultrasound when you see almost, like, 20-plus follicles in the ovary, and these are follicles. They look like string of pearl. It's very specific to PCOS. The issue is doctors don't recognize it. They dismiss it, and they look at the ovary and they, like, they say, "Oh, you have so many eggs. You have no issues with fertility." So PCOS-looking ovaries on ultrasound does not mean cyst. To this day, doctors tell patients, "I don't see a cyst on your ovaries, so you don't have PCOS." So PCOS is an ultrasound finding. However, in 2023, they added another criteria to this third, um, criteria, which is elevated egg count or elevated AMH. So women who have very high AMH, that is a telltale sign for PCOS, and that's what we were talking about before this podcast.

    5. AH

      Yeah, because so many women who are interested in and concerned about their fertility will go in and get their AMH measured and so many just have in mind to d- that you just want the higher numbers. Uh, higher is better, right?

    6. TA

      The higher is better, but in case of PCOS, higher does not mean good-quality eggs.

    7. AH

      I see.

    8. TA

      We're gonna talk about that. So you need to meet two of these three criteria.

    9. AH

      Only two of the three? You don't need all three.

    10. TA

      Two of the three. No. So if you have irregular periods, right, and you have, uh, PCOS-looking ovaries on ultrasound, you meet the criteria. If you have, uh, e- ir- irregular periods and you have symptoms of high testosterone, you qualify. Now, let me tell you. You do not need to have a high testosterone in the blood to get the diagnosis of PCOS. If you do, great, then you qualify for that high testosterone symptom or in blood, but you do not need to have a high testosterone in your blood. And that's why a lot of doctors tell their patients, "Well, I checked your hormones and your testosterone's normal." That's not one of the diagnostic criteria. So if you're sitting at home, if you have irregular period, if you have a daughter who gets laser of, you know, constantly is lasering her face, she has acne, she's on spironolactone, she takes Accutane, these are criteria. She meets the criteria of PCOS. PCOS patients have mood disorder. If you listen to them, they struggle from, with anxiety, depression. They're moody people. Uh, 75% of them gain weight. 25% of them are very lean. I see a lot of eating disorder or disordered eating in my PCOS patients. I would literally tell you that 60, 70% of my PCOS patients have disordered eating. You want to find PCOS patients? Go knock on the doors of these eating disorder centers. They're sitting behind those doors, undiagnosed, and it's the leading cause of infertility. So this is the big picture of PCOS. So imagine these women who are walking around, they're gaining weight, they can't lose it, they're anxious, they can't get pregnant, they have acne, hair loss, facial hair, body hair, their periods are irregular. They go to the doctor and what do they hear? "There's nothing wrong with you. Eat less. You probably need to exercise more." That's all they hear. What do they do? They put them in eating disorder centers when they're a teenager, and they feed them pizza, and they say, "If you don't eat this pizza, that means your eating disorder is not better." I did a podcast with a patient of mine, Phoebe. She said in this eating disorder center, every day, they would put pizza in front of her and she would say, "I- I- I'll eat this pizza, but when I eat it, I get sick. I can't... I feel awful when I have this pizza." You know what they would tell her? "See, you have an eating disorder. You're not ready to go." No, she had PCOS. But at least if you diagnose and validate them, you can start helping them better.

  7. 21:28 – 24:36

    Irregular Periods, Teenage PCOS Diagnosis

    1. TA

    2. AH

      I have several questions. Um, you mentioned irregular periods, and, um, I think to most people that means that whatever cycle length they are accustomed to, 28 days or 30 days or even, you know, 22 days, that it's regular, um, and that if it changes by, you know, plus or minus five days or so for, uh, you know, more than-

    3. TA

      Yes.

    4. AH

      ... two or three months out of the year, then you would s- call that irregular. Okay, but if a y- given how young you're s- uh, seeing PCOS in your clinic and given that women start menstruating at, l- let's say, in the- in their- in their mid-teens, early teens... I mean, I know the age is getting pushed back and it... but it's gonna vary, but I could imagine, I- I've only lived as a male, so I'm- I'm really, uh, truly imagining here, but I could only imagine that for a lot of women, cycle regularity is something that they're still figuring out at the stage when they could already have PCOS. Maybe not full-blown PCOS but m- milder forms of PCOS. And so this notion of regular periods versus irregular periods, uh, could be, uh, quite confusing for someone to figure out, um, i- if it's happening on a backdrop of PCOS, uh, and then that, of course, leaves aside all the, you know, stress and food-induced, uh, r- regulation of- of menstrual cycle length, et cetera. So, it seems like a very difficult thing to identify.

    5. TA

      So that's... Actually, you brought up a very good point, and I want to make that very clear. For teenagers, you have to be very careful, very cautious diagnosing them with PCOS. Why? As you said, when you s- first start having your periods, your periods are irregular.... and if you do an ultrasound, these young ovaries have tons of follicles. So actually, the PCOS, uh, uh, um, uh, PCOS morphology does... Is not used for teenagers. For teenagers to get the diagnosis of PCOS, they need to have criteria one, which is the irregular period, and criteria two, which is the high androgen symptoms. You do not use the AMH or PCOS morphology on ultrasound as a diagnostic criteria, number one. Number two, you want to be very careful diagnosing these patients because you don't want to label them at a very young age. So what I do with these patients, I do a hormone panel and these are patients who usually at a very young age, they end up on Accutane for their acne. You give them spironolactone, it's not working. They complain of hair loss, they're gaining weight, they're showing signs of an eating disorder, they're anxious, they're not feeling well, they have really bad... I see a lot of PMDD with my PCOS patients. So you look at the big picture and I tend to not label them, but I will treat them. And, uh, you know, in, uh, um, 2014, I started using GLP-1s on my patients for weight loss for PCOS. 2014.

    6. AH

      Yeah.

    7. TA

      11 years ago.

    8. AH

      I think most people don't realize that these peptides were out there, they weren't as commonly discussed. They were sort of considered a little bit niche, a little bit... You know, it was certainly cutting edge. Incredible.

  8. 24:36 – 27:49

    Diagnosis, Pelvic Ultrasound; PCOS Naming

    1. AH

      Okay, a question that I just, um, have to ask is because PCOS is diagnosed, if it's diagnosed properly, by this kind of amalgam of different features, and, and you mentioned by ultrasound, this kind of characteristic lining up of, of the follicles, I have to ask what might sound like a politically incorrect question, but I'm gonna ask it anyway. Do you think that male OB-GYNs more often make this mistake than female OB-GYNs or is this an equally distributed problem in the OB-GYN community?

    2. TA

      Equal. 90% of these patients, let me tell you, are never diagnosed. A, a lot of gynecologists don't do a pelvic ultrasound, which I wanna change that in this country. It needs to be part of a well woman exam.

    3. AH

      They don't do a pelvic ultrasound?

    4. TA

      No.

    5. AH

      Is there a... Uh, I'm b- I'm baffled. What, what is the reason for not doing it?

    6. TA

      They're not trained to do it or they have to hire a ultrasound tech to their office to do it. Uh, or they... But for me, in my office, if you come to my office and you say you can't do an ultrasound, it's just like me grabbing your glasses right now and say, "Read." How can I... How can I diagnose you? Pelvic ultrasound should be mandatory, but that's another topic I want to cover with what well woman exam should look like (laughs) -

    7. AH

      Mm-hmm.

    8. TA

      ... versus what women get when they go to their doctor's office. So one of the issues is because women don't get a pelvic ultrasound, no one knows, one. Two, a lot of doctors don't even know what a PCOS-looking ovary looks like. They think p- polycystic ovary syndrome means cysts on the ovary.

    9. AH

      Yeah. The naming is really a problem. And, and this is true in science and very clearly true in medicine as well, that what things are named can be, uh... It can be very useful, but it can also really limit understanding.

    10. TA

      Confusing.

    11. AH

      Yeah. Uh, if anything, um, today's discussion hopefully will re- maybe even remove or put an asterisk next to the C in, in PCOS.

    12. TA

      You know, they want to change the name, but I personally am against it-

    13. AH

      Mm-hmm.

    14. TA

      ... because I've spent (laughs) -

    15. AH

      (laughs)

    16. TA

      ... 25 years saying PCOS, PCOS, PCOS, PCOS, and I feel like just in the past few years more and more people... You know, like, people didn't talk about menopause, now everyone's talking about, uh, menopause. I feel like PCOS is the next topic hopefully, and if you go and change the name, then I feel like I have to start all over again.

    17. AH

      No, but you make a very good point. Uh, we, we don't want that to have to happen, and I agree that there-

    18. TA

      But they're trying to do it. (laughs)

    19. AH

      There's this... There's a, uh, strange thing in public health where there needs to be a ton of hydraulic pressure over time. Like, you know, I guess today is my day to be only slightly politically incorrect. You know, five years ago, if you said the word obese or you said, "This person has health issues because they're obese," it was considered... I mean, people were losing jobs for, for making statements like that. Now, we understand obesity-

    20. TA

      It's a... Oh, my God.

    21. AH

      ... can be a serious risk to brain and body health.

    22. TA

      Yes.

    23. AH

      It's a medical condition. I think the GLPs have kind of helped shift the view now because there's a medical treatment, but it was always true that obesity was dangerous for people, but now you can say it. So I do think that there needs to be a lot of hydraulic pressure behind that, and now, um, you're, uh, doing the same for PCOS.

  9. 27:49 – 35:54

    Thinning Hair & Acne; 4 PCOS Phenotypes; Mood & Treatment

    1. AH

      So, uh, I have a couple of questions about the thinning of, of hair, acne, and so forth. I could imagine that a number of women listening to this are thinking, "Well, you know, I've got a little bit of acne. My hair is thinner than it was five years ago, but, you know, is this mild PCOS? Is this indicative of PCOS?" I mean, everyone knows that... Hopefully knows their body best, but how bad does the acne or the hair thinning have to be? How rapid before you might say, "You know, it, it's maybe just, you know, the, the hairs seem thinner. Um, there's a little bit more acne. It's back acne, but..." And is it throughout the cycle?

    2. TA

      Yes, it's throughout the cycle and these are patients who usually come to the office asking for help. They say, "I can't get rid of my acne." I always say, "If you're 20... Older than 25 and you're struggling with acne and you come to my office and you're asking for spironolactone and Accutane, something's not right." Right? If you have hair thinning, like you brush your hair and you lose tons of hair, I mean, these are patients you look at... You could look at their scalp and you know they're losing hair. I'm not talking about the hair loss that you get postpartum. Do you know? That's transitional and it recovers in like 9 to 12 months. These are symptoms that persist and as they get... These patients get older, it becomes more and more and more significant. But the reason I give that big picture is I always look at other factors. Are they having a hard time losing weight? Do they have mood disorder? Do they have any history of eating disorder? Have they been on Accutane? Do they go and laser their hair like twice a year because they can't get rid of it? It's a pattern that you will know. It's not a little bit of this and... These are patients, patients who are listening right now to me, they're gonna say, "Yes, I have this."

    3. AH

      Okay.

    4. TA

      "I have every symptom," and I put a-... check in front of it. The problem with PCOS is there are four different phenotypes of PCOS. That's why it's so confusing for doctors to diagnose PCOS. The most common, classic phenotype is a patient that has all three. PCOS-looking ovaries on ultrasound, elevated testosterone symptoms or high testosterone or androgens in the blood, or, uh, a- and irregular period, and irregular period. The second, type B patients have the high androgen symptoms. They do have, um, dysfunctional ovulation with irregular periods, but these patients have normal ovaries on ultrasound. So you can't... In this group of patients, you can't do an ultrasound and say, "Your ovaries are not PCOS-looking, so you don't have it." Then the third phenotype is the ovulatory PCOS. It gets very confusing. This group of, uh, PCOS patients actually ovulate at least sometimes because, you know, 70 to 80% of PCOS patients don't ovulate.

    5. AH

      70-

    6. TA

      To 80% do not ovulate, even when they have regular cycles. So of the 20, 30% who ovulate, you need to ovulate to get pregnant, this C phenotype, these patients are ovulating sometimes with regular cycles. So these are PCOS patients who go to the doctor, they have PCOS-looking ovaries on ultrasound, they have acne, hair loss, facial hair, body hair, mood, all of that, but their periods are regular. Even these patients, a lot of times, are not ovulating. That regular cycle that you're seeing is estrogen withdrawal. It's not from the progesterone of ovulation, and we're gonna get into all that if you want to. And the fourth category, these are patients who, um, basically don't have any, uh, elevated testosterone or androgen symptoms. They don't have acne, hair loss, facial hair, body hair. They just don't ovulate regularly and they have PCOS-looking ovaries on ultrasound. So imagine these four phenotypes, right? And imagine all the insulin resistance and all these other underlying conditions. It makes the big picture, the image of these patients so different. They all present differently to the office. That's why doctors scratch their heads. That's why doctors don't want to diagnose PCOS, because they really don't understand all these phenotypes. They don't understand that you can be completely thin and have PCOS, that not all PCOS patients need to have weight issues, that you don't have to have acne, hair loss, facial hair, body hair, that in some phenotypes you don't need to have a PCOS-looking ovaries. There's some that have regular cycles. So that's why it gets so confusing.

    7. AH

      It is, uh, confusing and yet I think when one hears that there- there are different, um, indicators obviously, and it sounds like a- a skilled practitioner like yourself can- can see the contour of which ones fit together. I mean, it's patter- pattern recognition.

    8. TA

      Yes.

    9. AH

      Clinical pattern recognition.

    10. TA

      Yes.

    11. AH

      Which is very difficult to do from an AI search or from a... It's impossible really. I mean, I think, um... I have a couple of questions. Uh, one is, just leap to mind as it relates to the mood disorders. Um, I could imagine that some of these disorders are treated or they attempt to treat them through, uh, antidepressants, SSRIs and things of that sort. Is there any indication that the drug treatments for these mood disorders interact with the hormones that we're talking about in a way that exacerbates the PCOS? I mean, we know that serotonin and dopamine, all these things have feedback and interaction with these hormones. Or do you think that, um, that's se- a separate thing entirely?

    12. TA

      In order to answer that, I think it's better for me to tell you the underlying drivers of the symptoms of PCOS and how those can affect the mood. And by treating the underlying conditions, sometimes you can address mood changes without having to give them-

    13. AH

      Mm-hmm.

    14. TA

      ... a Zoloft or a Lexapro. You might have to, right?

    15. AH

      But there's no evidence, uh, from what I understand, that those drugs are actually causing PCOS?

    16. TA

      No. No.

    17. AH

      Okay. I just wanted to e- essentially rule that out.

    18. TA

      Right.

    19. AH

      Okay, good. I'm relieved to hear that because those drugs are commonly prescribed-

    20. TA

      At least not to my knowledge.

    21. AH

      Yeah.

    22. TA

      I've never experienced that.

    23. AH

      I- I- my- my, you know, n- not so cursory, uh, web search on this in- uh, said no, but I- I want to verify with you. So, um, so what is the cause of the mood disorders? You're talking slightly elevated testosterone, so all the ma- all the males listening are like, "Ooh, sounds great." And of course, um, supplementing with testosterone, um, in women in menopause has now become kind of a trendy thing.

    24. TA

      And you can absolutely do that with PCOS patients. We can get to that.

    25. AH

      Mm-hmm.

    26. TA

      But I... Is it okay if I discuss the underlying pillars because it's very important and I think that's what people don't understand, and I think that's what I've observed in my practice at least over the past 25 years. And it's so important to understand it because if you don't understand it, then you don't know how to treat PCOS. Then you don't just throw birth control pill at it, and that's why these patients don't feel better. So there are underlying pillars that drive the symptoms of PCOS. The number one issue is the brain-pituitary-ovary axis, which I'm sure you know it by heart, but as you know, our hypothalamus releases a hormone called GNRH that stimulates in a, uh... It fires in a pulsatile fashion, and basically it stimulates the pituitary gland to release this hormone called FSH which stimulates the follicles in the ovaries. As the follicles, uh, one follicle per month, as the follicle gets stimulated and starts growing, it starts releasing estrogen. When the estrogen peaks really high for 48 hours, it stimulates that same pituitary gland to release a hormone called LH, and LH is responsible for ovulation. It comes, it basically weakens the wall of the follicle. It causes inflammation, it

  10. 35:54 – 40:30

    Underlying Pillars of PCOS; HPA Axis, Androgens, Menstruation & Ovulation

    1. TA

      causes vascular changes.... all of that, so the egg gets released. Once the egg gets released, whatever's left of that follicle is the corpus luteum cyst which starts releasing progesterone to basically, uh, support implantation. This is what's supposed to happen, and that's how people get pregnant.

    2. AH

      It's such a beautiful mechanism, right?

    3. TA

      It's so beautiful.

    4. AH

      The, the very cells that are stimulated by FSH produce a hormone which feeds back to shut down the production of FSH and bring in the LH. I mean, it's a, I mean, it's a beautiful, uh-

    5. TA

      It's beautiful.

    6. AH

      ... molecular set of gears, basically.

    7. TA

      It's beautiful.

    8. AH

      I mean, not to make it too reductionist, but it's, it's truly incredible when one thinks about it, and as you mentioned, that it spans from the brain all the way to the ovary. It's, I-

    9. TA

      To the uterus, right?

    10. AH

      Yeah, it's a, it's a, uh, it's a spectacular set of, of interactions, really.

    11. TA

      And you know that estrogen that the follicle is, uh, stimulating gets the lining of the uterus nice and juicy, ready for pregnancy, and then when the egg ovulates and now the progesterone comes, the progesterone stabilizes that lining so the embryo can go and implant and turn into a beautiful baby. And usually that cyst, the corpus luteum cyst during the first 12 weeks of pregnancy is helping release the progesterone to help the pregnancy really stick to that wall of the uterus, in simple terms.

    12. AH

      Nothing wasted.

    13. TA

      Nothing. But women are incredible. Aren't we incredible?

    14. AH

      It's amazing. I mean, it's, it, it, indeed, indeed they are. It's, it's like nothing's wasted. The, the portion of the follicle that-

    15. TA

      Nothing.

    16. AH

      ... that would otherwise be quote unquote discarded is actually a source of critical hormones. It's incredible.

    17. TA

      It's incredible.

    18. AH

      It's incredible.

    19. TA

      But let me tell you what happens in a poor PCOS patient. That's the problem. The GnRH, remember, that secretes from the hypothalamus, it starts pulsating super fast. By doing that, it shifts the FSH/LH balance. So FSH goes down and LH goes up. LH stimulates the cells in the ovary, I don't know if you remember, the theca cells in the ovary, and they start pumping androgens out, right? And it, when you have a lot of androgens in the ovaries, the androgens block the growth of that beautiful follicle that's growing to ovulate, so it freezes the follicle and it prevents it from ovulating. The follicle is still secreting the estrogen, but it never gets to that peak high, right? And it's still stimulating the lining of the uterus, but the ovulation doesn't happen. So when the ovulation doesn't happen, polycystic ovary syndrome. You start seeing these follicles in the ovary.

    20. AH

      So is it, um, lack of sufficient LH?

    21. TA

      It's too much LH.

    22. AH

      Too much LH.

    23. TA

      So in PCOS, the LH/FSH ratio flips, so the LH is twice as much as the FSH. So you have this constant secretion of LH that stimulates these theca cells to just pump androgens out, right? So the follicle freezes, doesn't ovulate. The follicle stays in the ovary, and one thing that they've noticed with PCOS patients, for whatever reason, their ovary is super sensitive to the LH. It's like adding fuel to the fire.

    24. AH

      It's like a positive feedback. The reason I ask if it's, if it's, um, how LH is adjusted is, the, the LH surge is what triggers ovulation normally.

    25. TA

      Right.

    26. AH

      Correct?

    27. TA

      But there is no LH surge.

    28. AH

      What I'm getting a kind of mental visual of is that, um, the strong pull of the levers is, is, it's just a bunch of smaller levers being pulled repeatedly, but, but there's still shedding of the uterine lining, right? There's still menses, so-

    29. TA

      So it can be.

    30. AH

      So that's why it's probably very misleading for people who don't have extreme symptoms of PCOS, 'cause they think, "Well, if they're menstruating-"

  11. 40:30 – 46:30

    Insulin Resistance & PCOS, Visceral Fat & Inflammation

    1. TA

    2. AH

      What is thought to disrupt the hypothalamic, uh, GnRH neurons?

    3. TA

      It could be everything. It could, it comes to all the other pillars.

    4. AH

      It could be the feedback.

    5. TA

      Because they're all ... Yes.

    6. AH

      But, but is there any evidence, um, I mean, we don't wanna attribute everything to psychological stress, but the more I learn about the brain and body and their interactions over the years, the more I'm convinced that psychological state does impact hormones and brain function. There's, uh, anyone listening will say, "Well, of course it does," but 10 years ago, there was this notion of psychosomatic illness. People would say, "Oh, it's ..." They would say, "It's all in your head." We now know that, um, that stress is a, is a powerful modulator of hypothalamic function, and it actually comes from the hypothalamus in part. So i- is there evidence that this is, you know-

    7. TA

      Partially, it can-

    8. AH

      ... preceded by stress or trauma, things of that sort?

    9. TA

      No.

    10. AH

      It just sort of comes about?

    11. TA

      It partially, it c- yes. It's genetic, and that's why I wanna talk about it. This is just the first pillar. You saw like just the first driving force is this brain/pituitary/ovary pathway that's completely disrupted, that some, most patients, 70 to 80% don't even ovulate, and of the ones who ovulate, the environment is not really good for the embryo. So that's just the first pillar. But at its core, PCOS has insulin resistance, and I'm sure you know all about insulin resistance, but I wanna explain it to your-

    12. AH

      And please remind our audience-

    13. TA

      Yes.

    14. AH

      ... 'cause I, you know, we, we have newcomers to the conversation, and I don't think we could hear enough about insulin resistance.

    15. TA

      Insulin resistance.

    16. AH

      Yeah.

    17. TA

      And as a gynecologist, I'll explain insulin resistance, so I'm sure you've had, uh-... you know, physicians, uh, who will probably explain it better. But I'm going to simplify it because it's one of the biggest drivers of PCOS symptom and it's extremely common. Even lean PCOS patients can have insulin resistance. So, what is insulin resistance? The simple way of explaining it is when we eat carbohydrates and our body breaks it down into glucose, glucose stimulates our pancreas to release a hormone called insulin. The job of insulin is, it goes to the cells in our muscle, in our liver, and it opens up the channels on these cells and pushes sugar into the cell where it can turn into energy. So basically, insulin takes the sugar from the blood, pushes into the cell, and turns it into energy. PCOS patients, 80% of them have insulin resistance. It's not their fault. They're born that way. What does insulin resistant do? When they eat carbohydrate and their body breaks it down into glucose, glucose stimulates their pancreas to release insulin, but their cells are resistant, and I'll tell you why. Remember that androgen that I was talking to you about that gets secreted from their ovaries because of the first pillar makes women more insulin resistant, so their cells don't respond well. I know, it's like... Let me get there. It's-

    18. AH

      Do an- uh, the, the question I was gonna ask was gonna be a facetious one. I was gonna say, do androgens do anything good? No, of course they do, but-

    19. TA

      Not for women. No, they do.

    20. AH

      But, well-

    21. TA

      They do.

    22. AH

      Uh, women need androgens, but they don't need-

    23. TA

      Yes.

    24. AH

      ... this many-

    25. TA

      Too much of it.

    26. AH

      ... androgens coming from the thecal cells.

    27. TA

      Right.

    28. AH

      Right.

    29. TA

      So when their cells can't uptake this glucose, glucose bounces in the blood. Well, you can't have blood stay in, I mean, glucose stay in your blood. You have to clear it. So as glucose goes up, it pushes our insulin to go up. What does insulin do to PCOS patients? Number one, when insulin goes up, insulin stimulates our ovaries to push more androgens out. How about that? And it blocks the ovulation. It freezes that follicle, right? And it causes acne, hair loss, facial hair, body hair, irregular periods, all of that. The other thing insulin does, it blocks the liver from secreting sex hormone binding globulin. If you do a blood test on a PCOS patient, a lot of them, the sex hormone binding globulin is low. Sex hormone binding globulin is a protein in the blood that grabs free testosterone from our blood, right? When the levels go down because of high insulin, our free androgens and testosterone go up. So more acne, hair loss, facial hair, body hair, all those symptoms.

    30. AH

      I see.

  12. 46:30 – 49:10

    Sponsors: AGZ by AG1 & Joovv

    1. TA

      that inflammation.

    2. AH

      We've known for a long time that there are things that we can do to improve our sleep, and that includes things that we can take, things like magnesium threonate, theanine, chamomile extract, and glycine, along with lesser known things like saffron and valerian root. These are all clinically supported ingredients that can help you fall asleep, stay asleep, and wake up feeling more refreshed. I'm excited to share that our longtime sponsor, AG1, just created a new product called AGZ, a nightly drink designed to help you get better sleep and have you wake up feeling super refreshed. Over the past few years, I've worked with the team at AG1 to help create this new AGZ formula. It has the best sleep-supporting compounds in exactly the right ratios in one easy-to-drink mix. This removes all the complexity of trying to forage the vast landscape of supplements focused on sleep and figuring out the right dosages and which ones to take for you. AGZ is, to my knowledge, the most comprehensive sleep supplement on the market. I take it 30 to 60 minutes before sleep. It's delicious, by the way. And it dramatically increases both the quality and the depth of my sleep. I know that both from my subjective experience of my sleep and because I track my sleep. I'm excited for everyone to try this new AGZ formulation and to enjoy the benefits of better sleep. AGZ is available in chocolate, chocolate mint, and mixed berry flavors. And as I mentioned before, they're all extremely delicious. My favorite of the three has to be, I think, chocolate mint, but I really like them all. If you'd like to try AGZ, go to drinkagz.com/huberman to get a special offer. Again, that's drinkagz.com/huberman.Today's episode is also brought to us by Joovv. Joovv makes medical grade red light therapy devices. Now, if there's one thing that I have consistently emphasized on this podcast, it is the incredible impact that light can have on our biology. Now, in addition to sunlight, red light and near infrared light sources have been shown to have positive effects on improving numerous aspects of cellular and organ health, including faster muscle recovery, improved skin health and wound healing, improvements in acne, reduced pain and inflammation, even mitochondrial function, and improving vision itself. What sets Joovv lights apart and why they're my preferred red light therapy device is that they use clinically proven wavelengths, meaning specific wavelengths of red light and near-infrared light in combination to trigger the optimal cellar adaptations. Personally, I use the Joovv whole body panel about three to four times a week, and I use the Joovv handheld light both at home and when I travel. Right now, Joovv is having their biggest sale of the year. From now through December 1st, 2025, you can save up to $1,000 on select Joovv devices during their Black Friday sale. Just go to joovv.com/huberman. That's J-O-O-V-V .com/huberman. Some

  13. 49:10 – 52:31

    PCOS, Chronic Inflammation, Genetics & Lifestyle; Mood

    1. AH

      exclusions apply.

    2. TA

      So the next pillar is chronic inflammation. That's why PCOS patients have this chronic inflammation that they complain about. And this chronic inflammation basically stimulates their ovaries to release more androgens. This chronic inflammation makes their insulin resistance worse. This chronic inflammation can affect their gut. That's why PCOS patients come and say, "I don't feel good. I have food sensitivities. I feel bloated." Because these hormonal shifts and these inflammations do affect our gut. Then we go to the next pillar, which is genetics. If you look in PCOS families, there's someone who's either diabetic, pre-diabetic, had gestational diabetes, is overweight. There's some form of insulin resistance. A lot of times you see these patients and their dad is diabetic, so you don't have to look in your mom's side (laughs) of the family.

    3. AH

      This is a very important point.

    4. TA

      It's both sides.

    5. AH

      A lot of people just do the direct one-to-one and they assume, "Well, if my mother had no fertility issues and she wasn't overweight and wasn't diabetic, didn't seem to have type 2 diabetes, then it's not an issue." But yeah, dad's genetics are, are critical as well.

    6. TA

      Huge. And then the last, uh, pillar is epigenetics, which I know you talk a lot about it, but it's our stress. How much are we sleeping? What kind of food are we eating? Right? Someone said this to me, and I love this saying. They said, "Your genes load the gun, your environment pulls the trigger." Andrew Huberman: Mm-hmm. And I love that because even if you're loaded with insulin resistance, all of that, you can suppress these symptoms. But if you start eating unhealthy, if you're stressed out, if you're not sleeping, if you're just not exercising, right, you're pulling that trigger. And that's why, Andrew, all these pillars work together, and that's why these patients present so many different ways, right? And when you were talking about mood, why does someone feel bad? Why does a PCOS... First of all, the androgens do affect, disrupt the dopamine and serotonin in their brain. That's a fact. But put yourself in the shoes of a PCOS young girl who lives at home with a thin, beautiful mom, or a thin, beautiful older sister. She's overweight. She doesn't eat anything. She's exercising every day. She's already a little anxious. She has acne. Her mom takes her and they put her on Accutane. She's constantly lasering her hair. Her periods are completely unpredictable. She's starting to have an eating disorder because nothing she does is working for her, right? And then you take this patient with everything I told you, with all these underlying pillars not working in her, you take her to the doctor and she gets dismissed. That's why I'm here to speak for them. I feel like over the past 25 years, their trauma has become my trauma. I literally can cry right now.

    7. AH

      That's clear how much you care about your patients and the ones that are not even your patients, just the women out there that are suffering

  14. 52:31 – 58:34

    PCOS, Fertility, Freezing Eggs, Tool: Egg Count & AMH Range By Age

    1. AH

      in this way. I, uh, perhaps, um, could we explore the possibility of a different, uh, if I say phenotype, it make... it sounds so clinical, uh, but, but a different person who, um, perhaps is only experiencing a subset of those symptoms-

    2. TA

      Yes.

    3. AH

      ... that you just described. Um, and, and on that note, I'm struck by the fact that, you know, what we know from male pattern baldness and female pattern baldness is that when androgens get too high, it miniaturizes the hair follicle. It's kind of interesting that when androgens get too high in the ovary, they miniaturize the follicle there too. It seems like t- that basically e- excessive androgens are bad for follicle development.

    4. TA

      Stunts it.

    5. AH

      Yeah. So two parallel pathways operating in the exact same way. Um, it sounds like we're trying to make, uh, high testosterone the issue, but in some sense, unless we think back to the, the GnRH neurons firing too much, the elevated androgens really seem to be the, the kind of tip of the spear in this whole thing. Not what initially sets off the cascade, but in terms of, of tractable things that m- good medications and good practices might be able to take hold of.

    6. TA

      Correct.

    7. AH

      Is that right? And, and certainly insulin sensitivity as well. But, um, so I'm imagining, uh, you know, a bunch of different, uh, patient profiles here, but I can imagine women in their 20s, in their 30s, who have been told by society, "Okay, you're still fertile. You're good. You're, you're gonna be fine." These are the women that are showing up in clinics in their late 30s and 40s and saying, you know, "Why is it that, you know, my egg count is so low?" Or, "Why is it that I can't conceive?"

    8. TA

      So PCOS patients, their egg count is falsely high because of that...... you know, the, these tiny follicles that are frozen in the ovaries that never got to ovulate, they do secrete AMH. So these patients, that's why in 2023, they changed that second criteria, the PCOS ovaries to elevated or elevated AMH.

    9. AH

      How high for, for AMH? I mean-

    10. TA

      Sometimes I, like a norm, let's say a young-

    11. AH

      What's a typical value for someone in their 20s and 30s?

    12. TA

      Uh, so I would say up to six is normal.

    13. AH

      And, and in, and people in their 40s?

    14. TA

      Less than one. 0.5-

    15. AH

      It drops precipitously?

    16. TA

      Oh, yes.

    17. AH

      But where is the, the, the, I don't want to say cliff 'cause maybe it's more gradual than that.

    18. TA

      After probably late 20s, it starts declining.

    19. AH

      Okay.

    20. TA

      That's why I always tell patients, especially PCOS patients, to freeze by 28 to 30, even though they have tons of eggs. Listen, I get patients, they come to my office, they're like, "Doctor," new patient, "I went to my fertility doctor. He doesn't know what he's doing." "Why?" "40, 41 year old, I put out 30 eggs and he couldn't make a single embryo." Well-

    21. AH

      Through IVF, yeah.

    22. TA

      Through IVF. You shouldn't put out s- s- 30 eggs at age 40. That's PCOS. (laughs)

    23. AH

      This is so important for people to hear because I think egg count and elevated, uh, or high enough AMH is, is sort of touted as the thing that people go and look at. It makes sense, right? I mean, they'll do an ultrasound, count, count follicles, they'll-

    24. TA

      It's great as long as you're not missing PCOS. Because if you're, if it's PCOS, then the quality of the embryo is bad, then the ovulation is suboptimal, the environment is suboptimal, and everything else needs to be fixed.

    25. AH

      And this is perhaps why some people go in in their, their 30s, they might be doing IVF or something like that, and they actually have relatively low egg count. They'll get, you know, maybe, I don't want to... it's always tricky-

    26. TA

      Yeah.

    27. AH

      ... what, what low corresponds to what, you know, three and-

    28. TA

      Yeah.

    29. AH

      ... and two, wh- you know, three on one side, two on the other, but then the IVF works because it, you're, you don't necessarily need-

    30. TA

      The quality (overlapping) .

  15. 58:34 – 1:01:20

    Women’s Health Education, AI, Clinicians; Cataracts Analogy

    1. TA

      And let me tell you, 50% of counties in this country don't have an OB-GYN.

    2. AH

      50%?

    3. TA

      50% of counties. M- a lot of these women have to drive two to four hours to see their OB-GYN.

    4. AH

      That's crazy.

    5. TA

      That's why these podcasts are a game changer because if they don't have access, that's why artificial intelligence, AI, these robotic chatbots that hopefully can someday diagnose these patients and treat them, you know, from home without having them have to drive, I don't know, four hours to see an OB-GYN who will then also dismiss their symptoms.

    6. AH

      Yeah. Like you said, in some cases, technology may be better than certain physicians. I don't disagree with you there. Although g-

    7. TA

      By the end of this podcast, you'll believe in the robots treating o- (laughs)

    8. AH

      Well, I'll believe in, in, in robots and technologies perhaps doing better than some clinicians-

    9. TA

      Yes.

    10. AH

      ... and scientists, to be fair.

    11. TA

      Yes.

    12. AH

      But I do think that spectacularly good clinicians like yourself and in other fields, I mean, I know people in different fields of medicine, I'm fortunate enough, blessed to know people in different fields of medicine for whom you-

    13. TA

      Incredible.

    14. AH

      ... can truly say that there's n- no world where a robot or even 15 doctors can compare because there's something about, you know, knowing the principles of something, knowing the principles below the principles, the principles below that, and then being a long time practitioner in a given field.

    15. TA

      Yeah.

    16. AH

      You know, the, like, true e- what we call true expertise, deep expertise and lateral expertise. So-

    17. TA

      No, I was gonna say, you know, most fields of medicine, let's take ophthalmology, right?

    18. AH

      Mm-hmm.

    19. TA

      Every single ophthalmologist knows about cataract.

    20. AH

      ... yes. Most common-

    21. TA

      They will not-

    22. AH

      ... form of, of, of blindness.

    23. TA

      Thank you. M- so it would be rare for you to go to an ophthalmologist with cataract and not get diagnosed, correct?

    24. AH

      Correct.

    25. TA

      So why is it that the leading cause of infertility on this planet, 90% of women are not diagnosed? Women's health is very different than other fields of medicine. It's very- it's a different monster. It's that cataract patient that goes to 20 ophthalmologists and she keeps saying, "I can't see," and the ophthalmologist says, "You're crazy. There's nothing wrong with you."

    26. AH

      That's an excellent analogy. Not, not just 'cause it's vision, and that's my home area of science, but because I think, uh, humans are so, uh, dependent on vision and just the idea of losing vision is, uh, for people who are sighted is, uh, so challenging. Oh, I, I mean, the number of, of incredibly elegant feedback loops and the way the whole thing works, like a beautiful symphony when it works, also indicates that, like small disruptions in these things are- can cause, um, really downstream consequences.

  16. 1:01:20 – 1:06:44

    Stress; PCOS Treatment, Birth Control, Insulin Resistance & Metformin

    1. AH

      I'm curious, why so much more PCOS? Or is it like so many areas of medicine where it probably was around a long time, but, uh, we just weren't aware? And, you know, I can point to the insulin resistance, maybe it's how people are eating-

    2. TA

      Yeah.

    3. AH

      ... and the, the downstream chronic inflammation from the visceral fat. Maybe it's the neuroscientist in me, I keep thinking of these GnRH neurons in the brain that are s- suddenly start-

    4. TA

      Firing.

    5. AH

      ... firing abnormally. You know, I have all sorts of pet theories as to why that could be the case, but of course I don't have any, any data.

    6. TA

      Stress affects it, for sure.

    7. AH

      Disrupted sleep wake cycles? I always sort of default-

    8. TA

      Yes, but then-

    9. AH

      ... to that.

    10. TA

      But then you see these young girls who grow up in amazing, loving families, they've never had any stress, they're n- you know, they didn't have any trauma-

    11. AH

      They're sleeping well, they're eating well-

    12. TA

      And they're sleeping well, they're eat-

    13. AH

      ... great nutrition.

    14. TA

      Yeah, but they, they start having these symptoms. The reason I'm saying this, I don't want, um, people to get this message that stress is starting all this, because they really- it's a, it's a multi-system dysfunction. It's an immune system dysfunction, it's a insulin resistant dysfunction, it's a brain-pituitary-ovary dysfunction. It's- has a genetic factor, it has an epigenetic, and that's why the treatment plan is so important. That's why you can't throw birth control at all these pillars and say, "All right, see you later."

    15. AH

      Also, birth control means many, many things, right?

    16. TA

      Yes.

    17. AH

      I mean there's the estrogen-based-

    18. TA

      And I love birth control-

    19. AH

      Yeah.

    20. TA

      ... but m- you know?

    21. AH

      Well nowadays there's a bit of a pushback, I notice, at least in- on Instagram, for what it's worth. (laughs) Um, sometimes we think Instagram's the whole world and I'll tell you everyone, it's not the whole world. There are a lot of people who are not on Instagram all the time but many are. Um, and there seems to be a bit of a pushback against, um, i- uh, certainly hormone-based contraception. A lot of women, um, I, I hear from are convinced that it somehow, they believe it damaged them. And, and I believe them.

    22. TA

      That's when the topic of endometriosis will come up, and I would love to talk about that, but the reason birth control pills work for PCOS patients, it's one of the aspects, I don't like birth control pills for PCOS patients. Remember I told you they're moody patients, they're- they have an- anxiety, they're depressed, um, it's hard for them to take birth control pills. In my opinion, a lot of times they complain of, "I'm eating more," or, "I don't feel well," or, "I'm more depressed," or ... so I- it's not my first go-to treatment, but I will tell you why it works. Remember I told you the ovaries are, um, the sex hormone binding globulin goes down because of that high insulin? Birth control pills stimulate that sex hormone binding globulin that starts grabbing the testosterone and helps with their symptoms. That's why, if you go to the doctor and you say, "I have acne," they're like, "Birth control." "I have hair loss." "Birth control." "My periods are irregular." "Birth control." We use it for all- everything, right? But it does work to treat the symptoms of PCOS. It makes the periods regular, it helps with the skin, it helps with the hair loss, it helps with e- all of that.

    23. AH

      This is estrogen-based or progestin-based birth control?

    24. TA

      Uh, you can do both.

    25. AH

      Uh-huh.

    26. TA

      Estrogen and progesterone, or there's a progesterone-only birth control pill now called Slend that helps with, um, uh, it's very anti-androgenic, that I try for PCOS patients who don't want to, you know, need a method of birth control. But y- when it comes to treatment, you have to hit the underlying, um, pillars, right? So we talked about the epigenetics, I always start with there- with that. Exercise, walking after each meal, you know walk for 10, 15 minutes. Make sure you're sleeping well, make sure your diet is healthy, you're not eating inflammatory foods, you're avoiding, you know, uh, processed foods. Um, so lower your stress. So you deal with that, but that doesn't work for these patients. That's why you need to address everything else. Insulin resistance is one of the main pillars that needs to be addressed. You have to lower that insulin, because if you lower that insulin, you're lowering visceral fat, you're lowering inflammation, you're lowering the ovaries from secreting androgens, right? So m- that insulin needs to be lowered. That's why a lot of PCOS patients get prescribed Metformin, right? What does Metformin do? Metformin basically makes us more insulin sensitive. It's opening these channels so sugar clears the blood and goes into the cells where it turns into energy.

    27. AH

      Is it high dose Metformin or sort of l-

    28. TA

      No, high dose. High dose, I mean, I start patients on 750 twice a day, but you have to start slow because, uh, PCOS patients, especially the ones with insulin resistance, which is, uh, n- 80% of them, (laughs) um, I start with 750 because it can cause sometimes GI symptoms like diarrhea and it can also cause nausea, so I start with 750 at night, then if they tolerate it, I, um, add the 750 in the morning. And for patients who, um-... are tolerating it and they still are not ovulating, their periods are still not regulating and they still have symptoms, I might up it to a thousand twice a day. But you see these patients who come in on 500 milligram of PC- uh, of metformin once a day, that's not gonna touch these patients. So metformin is

  17. 1:06:44 – 1:12:32

    PCOS Risk Calculator, Supplements, Lifestyle Factors; GLP-1s

    1. TA

      one. But before metformin, and I don't know if you know this, because of my passion for PCOS, I actually developed a calculator. It's called, it's a platform called Ovii. Women can go on it. Obviously, I can't diagnose on the, on any website, but I can tell them that, ask them... It's my algorithm that I've developed over the past 25 years, and I can tell them very closely whether or not they have the likelihood of having PCOS.

    2. AH

      Hmm.

    3. TA

      So that, it's there, it's ovii.com, O-V-I-I .com. It's free.

    4. AH

      They answer some questions?

    5. TA

      Questions, and I tell them whether they have the likelihood or, uh, y- you know, if they're less likely to have PCOS. And if they do, PCOS is one of the very few conditions in medicine where supplements make a huge difference, and these are for patients who don't have access to the doctor, and these are patients who basically go to the doctor and they're not being, they're being dismissed. These supplements work amazingly well. Why? Because, um, th- the Ovii supplement I created, I literally did it, "Here, diagnose yourself, and if you're being dismissed, start with this supplement." They make a huge difference for these patients. Why? Because they address the insulin sensitivity. I'm sure you've heard of inositol, different forms of inositol, that work, um, to s- uh, to increase sensitivity to insulin, and that's why these patients, when they take it, they say, "Oh, my periods became regular," or, "I took it and I got pregnant," because it does address that. When it comes to this insulin resistance, they can either do the metformin, but what I like to do, I like to start them on supplements that has inositol in it and sup- vitamin D. Did you know that low vitamin D makes you insulin resistant?

    6. AH

      Well, I'm convinced that I'd- I was aware, but I think it's, it can't be stated enough or emphatically enough.

    7. TA

      (laughs)

    8. AH

      Because, you know, I know I'm alway- I'm really bullish about this sunlight thing, I'm always talking about sunlight. I don't want people to get sunburned. That's not what I'm talking about. But we spend so much more time indoors now under artificial lighting, where the short wavelength lighting-

    9. TA

      Everyone's low.

    10. AH

      ... it really disrupts how the mitochondria process energy and the long wavelength light from sunlight, that so-called red and infrared light, serves as a protective feature against the short wavelength light. So, we're not getting enough vitamin D and we need that. That comes from the short wavelength light. I do have a question about inositol. Um, there are a couple different forms.

    11. TA

      Yes.

    12. AH

      Uh, there's myo-

    13. TA

      Myo, yes.

    14. AH

      Right? Um, and, and we can explore those in more depth. Um, but, um, uh, it is a well-known, uh, regulator, and, and can improve, um, insulin, uh, sensitivity, which is what you want. Sometimes people hear insulin sensitivity and they think that's the bad thing. You want your insulin to be sensitive.

    15. TA

      You don't want it to be resistant.

    16. AH

      Right. Right.

    17. TA

      Anything that will make you more insulin sensitive will help with symptoms of PCOS. So, you want to bring down these pillars, right? Without even thinking about birth control pill, you want to lower your insulin resistance. So whether it's metformin or supplements or exercise or low carbohydrate diet or lowering your stress and lowering your cortisol, all of that, all of this system, that's why I wanted to explain all this, because they all work together.

    18. AH

      Mm-hmm.

    19. TA

      Then you want to bring your inflammation down. You wanna bring that visceral fat down. So you have to... That's why, I don't know if you heard this, but, you know, in 2014, back then, I had Trulicity as GLP-1, and that's what I used to use for my PCOS patients, and they would lose 50, 60, 80, 100 pounds, and this is 2014.

    20. AH

      What did your colleagues think at that time that you were injecting patients with GLP-1?

    21. TA

      Um, I actually learned it from a cardiologist who I used to work with, Dr. Khorsandi, and I used to send... Because I would screen for lipid panel on these PCOS patients, and they were all, you know, w- they had high triglycerides and they were overweight, so I would s- keep sending them, send my patients to him, and one day he called me, he's like, "Listen, Thais, there's this medication called Trulicity. Do not, stop sending your (laughs) patients to me. Treat them with this medication. They will lose weight and their cholesterol, everything will get better." So in 2014, I started putting these patients on Trulicity, and one thing I realized is their periods were getting, starting to get regular. Their symptoms of PCOS would get better, and the first thing they would come and tell me is, "Doctor, I feel less inflamed." "Why do you think?" Because you put them on these medications... First of all, PCOS patients chronically, they have this insulin firing, right? And that's why this cascade starts. What GLP-1s do, bas- uh, people think it's an appetite suppressant and that's how it works. Well, that's, that's a side effect of it, but what it does, it actually regulates that insulin, so when you eat, it spikes your insulin up and clears that sugar out of your blood, right?

    22. AH

      It's like a scavenger, glucose scavenger.

    23. TA

      Right, and it also makes you insulin sensitive, so again, clearing it, which is oxygen really for these PCOS patients. That's why I get so upset when patients comment about these GLP-1s, because in this subgroup of patients with insulin resistance who are overweight, who are not ovulating, and who have all these symptoms, these medications since 2014 have changed their lives in my practice.

    24. AH

      The pushback on GLP-1s is of, there are a variety of reasons, um, probably a discussion for another time, but they've clearly helped many, many people. Uh, as long as people still engage in the right behaviors-

    25. TA

      And it's not for an eating disorder, yes. (laughs)

    26. AH

      ... maintaining muscle through resistance training, and people still need to take great care of themselves-

    27. TA

      Yes.

    28. AH

      ... eat properly, exercise, sleep,

  18. 1:12:32 – 1:19:13

    Berberine, Metformin; GLP-1s, Food Anxiety & Alcohol

    1. AH

      et cetera. You mentioned, uh, metformin several times. I'm aware of a, um-... of an over-the-counter version called berberine, which I believe comes from a tree bark, um, which is supposed to be a pretty potent glucose scavenger as well. Uh, is there any reason why berberine is not advised?

    2. TA

      So, I think there are some studies that say long-term berberine is not, uh, advised. The problem with PCOS is, it's not something y- it doesn't have a cure. You can't cure it. It's an ongoing issue. That's why you need to b- uh, be on supplements that long term you can stay on. And, you know, like you mentioned, vitamin D, uh, curcumin, uh, chromium, uh, um, inositol. There are so many things we can do to increase that insulin sensitivity, lower the inflammation in the body. I don't usually give berberine long term, but it definitely short term, you can use it as pulse, uh-

    3. AH

      Mm-hmm.

    4. TA

      ... treatment for these patients.

    5. AH

      And metformin, it sounds like, is a relatively safe drug. Is that right?

    6. TA

      It's very safe. Uh, you know, um, even for my patients who are not PCOS, um, I recommend, um, metformin. Let's say perimenopausal women with hemoglobin A1Cs in the borderline range, you know, 5.7, you fall into the pre-diabetic range. Um, you know, I'm very lean. I've never been overweight, you know, but I have a long family history of diabetes. And, uh, my hemoglobin A1C was, um, 5.6 a few years ago, and I started taking metformin and now I'm at 4.8.

    7. AH

      W- what, um, dosages for people who are relatively lean or, or lean?

    8. TA

      I start with like 500 at night.

    9. AH

      Okay.

    10. TA

      Just to see how they do. Metformin does have side effects and-

    11. AH

      Drops your blood sugar, right?

    12. TA

      ... an- and, no, it's mostly like the nausea and some people-

    13. AH

      Mm-hmm.

    14. TA

      ... really get really bad diarrhea with it.

    15. AH

      Mm-hmm.

    16. TA

      That's why, you know, um, you can s- I start them on the supplements. If it doesn't work, I go to metformin. If that doesn't work, then I offer them GLP-1s.

    17. AH

      I see.

    18. TA

      But you can abs... And I always ask, patients ask me, "Can I be on the supplement, on, uh, metformin, and on the GLP-1?" Yes. You just don't want to start the GLP-1s with the metformin because they both cause nausea-

    19. AH

      (laughs)

    20. TA

      ... and you don't know which one's causing what. So, if someone's morbidly obese and they really want to lose weight, I, I start with the GLP-1s and usually in about four months... My average since 2014, I can tell you, four months of GLP-1s done correctly, patients lose 24 pounds. That's my, that's my, uh, that's my curve at my office. (laughs)

    21. AH

      Of body fat and muscle or-

    22. TA

      Probably of muscle too, but these patients are m- a lot of them are like-

    23. AH

      They need to lose weight.

    24. TA

      ... 300 pounds.

    25. AH

      Yeah, they do.

    26. TA

      So, it's hard to even assess that. But you know what? As they start losing weight, they become more motivated because it's the first time in their life that something actually works for them because you're actually regulating that insulin, this function that they have. And by supporting that, they become more active, they, their self-esteem gets better. I had a 26-year-old in my office who I've been treating for many years for PCOS and these GLP-1s, and she came into my office a few months ago and when I walked in, she was videotaping me 'cause she looked so good, she was so confident. Her hair was done, she had a mini skirt with these boots and she was always like, you know, very shy and she wouldn't talk. She was, is a different person that walked into my office. And I started hugging her and she started crying and she looked at me, she said, "Dr. A, this is the first time in my life I know what it means to be happy."

    27. AH

      Wow. Yeah, I mean, it's very clear that these GLP-1s can help a lot of people. It's interesting the, the pushback on GLP-1s now is changing a bit because, um, a number of compounding pharmacies make them now. So, you know, people t- tacked the GLP-1s to, quote-unquote, "big pharma." You know, it was kind of a-

    28. TA

      Yeah. Yeah.

    29. AH

      Um, and I understand people's gripes with big pharma insurance and things. It's, you know, if, if everyone has been, you know, boxed out of, of access to a drug or something like that and ins- had insurance issues, it can be very, very frustrating, even deadly. I mean, there's a whole discussion about this recently around cancer and cancer drugs. But to stay on point, I think now that some of these GLP-1 peptides are available through compounding pharmacies, prices have come down. The big pharmaceutical companies don't like that, but it's also the case that people are m- are, quote-unquote, "microdosing them." They're taking the GLP-1s that-

    30. TA

      I love that.

  19. 1:19:13 – 1:21:56

    PCOS Prescriptions & Fertility; PCOS Co-Occurrence with Endometriosis

    1. TA

      need to be addressed.

    2. AH

      And for people that want to get pregnant and treat their PCOS, uh, what are the success rates that you observed in your clinic?

    3. TA

      Very good question. So as, I'm not a fertility doctor, but I'm trying to take these patients out of the hands of the fertility doctors. So one thing I do, I put them on the supplements, uh, on my OV supplement. I give them metformin and I, uh, have them try and I try to see if I can regulate their period. Two things you can do easily and doctors can do it in their office. One is a medication called Letrozole and the other one is Clomid. Both of those basically, um, uh, regulate that hypothalamus, pituitary, ovarian axis and pushes these patients to ovulate. With Letrozole, 60, 70% of them, I think, ovulate and with Clomid it's a little bit less. So you can try those in the office for someone who wants to get pregnant. What I usually do, I have them try on their own for six months to a year depending on their age. If they're above 35, I say six months. If they're less than that and they're not in a hurry and their egg count is good and I've regu- and I know I've dealt with their PCOS and their inflammation and their insulin resistance, then I have them try for a year, right? Because if you take, um, 100 couples regardless of age, um, and you have them have sex, I don't know, three times, uh, three to four times a week, 50% of them get pregnant in the first six months and 90% of them get pregnant in the first year. But for patients with endometriosis or PCOS, I usually have them try for, like, about six months and then check back in with me. You know, if Letrozole, Clomid, uh, trying on their own, everything fails, then you can send them to fertility doctors. Uh, one thing that I want to bring up here, which is my observation, and it's nowhere in the literature but I'm saying it today and I know it's going to be published some day, I strongly believe that over 50% of PCOS patients also have endometriosis. Over 50%. And I've always said this. If you have a patient with PCOS, think about it, PCOS is already one of the leading causes of infertility and in my opinion, 50% of them, because I, I've seen it in my office, have endometriosis. And I have a path report and I've done laparoscopic surgery to prove it. If you only address PCOS and you're dismissing their painful period, then they're not getting pregnant. That's why you have to make sure you put a check in front of all these underlying

  20. 1:21:56 – 1:23:16

    Sponsor: LMNT

    1. TA

      conditions.

    2. AH

      I'd like to take a quick break and acknowledge one of our sponsors, LMNT. LMNT is an electrolyte drink that has everything you need and nothing you don't. That means the electrolytes sodium, magnesium, and potassium all in the correct ratios, but no sugar. Proper hydration is critical for brain and body function. Even a slight degree of dehydration can diminish your cognitive and physical performance. It's also important that you get adequate electrolytes. The electrolytes sodium, magnesium, and potassium are vital for the functioning of all cells in your body, especially your neurons or your nerve cells. Drinking LMNT makes it very easy to ensure that you're getting adequate hydration and adequate electrolytes. My days tend to start really fast, meaning I have to jump right into work or right into exercise. So to make sure that I'm hydrated and I have sufficient electrolytes, when I first wake up in the morning, I drink 16 to 32 ounces of water with an LMNT packet dissolved in it. I also drink LMNT dissolved in water during any kind of physical exercise that I'm doing, especially on hot days when I'm sweating a lot and losing water and electrolytes. LMNT has a bunch of great-tasting flavors. In fact, I love them all. I love the watermelon, the raspberry, the citrus, and I really love the lemonade flavor. So if you'd like to try LMNT, you can go to drinklmnt.com/huberman to claim a free LMNT sample pack with any purchase. Again, that's drinklmnt.com/huberman

  21. 1:23:16 – 1:32:02

    PCOS Treatment, Freezing Eggs, Egg Quality; Advocate For Your Health

    1. AH

      to claim a free sample pack. I definitely want to talk about endometriosis. Um, before we move to that, it sounds like going after the insulin resistance first with metformin, inositol, the other things in, uh, OV... Well, first people should go to the, uh, OVII site.

    2. TA

      Take the quiz.

    3. AH

      And we can put it in the show notes. Take the quiz, uh, as it's a zero-cost platform. You get some feedback there about what might be happening, what's likely happening. Um, and then sh- take care of the insulin resistance, which presumably also includes things, uh, you mentioned trying to get best possible sleep, limit stress, exercise.

    4. TA

      Yes. And start with supplements first if your symptoms are not bad. You know, I've had, like, 50-some patients get off OV because they got pregnant. All you're doing is addressing their hormone and metabolic health. That's all we're doing with it. But if it doesn't work, ask for metformin. If it doesn't work and you're, you're having a hard time losing weight, uh, ask for GLP-1s. Ask your doctor for Clomid if you're trying to get pregnant. Ask your doctor for Letrozole. Letrozole first, Clomid second. And if all that fails, go see a fertility doctor. But before that, even if you're single and you don't have a partner and you're in your late 20s and you have no one, uh, and, you know, having a baby is something that will probably happen a few years down the line, consider freezing eggs. Not because of the count, because of the quality of the eggs. Because PCOS patients, again, have tons of eggs-... but the quality is not that good. Endometriosis is opposite. Endometriosis destroys your egg count and quality.

    5. AH

      I've seen a few papers, um, that suggest that coenzyme Q10 and L-carnitine might be beneficial for egg quality-

    6. TA

      Yes.

    7. AH

      ... and in males, sperm quality, but we're talking about eggs here. Um, do you include that?

    8. TA

      Yes, and I would say it's probably because of inflammation, right?

    9. AH

      We don't really have great tests for inflammation yet. Like, the number of tests, you know, that are coming online for, um, evaluating biomarkers is, is quite, quite impressive. But we don't really have a good test for inflammation.

Episode duration: 3:07:27

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