I’m excited to be interviewing one of the world’s experts in PCOS. Dr. Mira Aubuchon’s clinic MCRM fertility is located in a suburb of St. Louis, Missouri. We will be talking about everything you need to know about PCOS.
Dr. Aimee: Welcome, Mira! Why don’t you start off and let our audience members know where you’re from, where you went to school, and I’m certainly going to have a lot more questions for you.
Dr. Mira Aubuchon: Thank you for having me! I grew up in Wisconsin and went to Northwestern University for medical school in Chicago. Then I came to St. Louis to do my OBGYN residency. Then I went to Albert Einstein College of Medicine in New York to do my reproductive medicine fellowship.
Dr. Aimee: What made you go into medicine, and specifically fertility medicine?
Dr. Mira Aubuchon: I think that I was just drawn to medicine from childhood. I can’t remember a time not wanting to be a doctor. Then I went to medical school, I really thought that I was going to go into psychiatry. Then I did my OBGYN rotation and fell in love with the patients. Then I did my reproductive medicine rotation, and this was back in the 1990s when IVF was very new in this country, and I just thought it was the most fantastic thing I had ever seen. The ball went rolling from there.
Dr. Aimee: I’m glad you have just about as much passion as I’ve seen in anybody. You and I share that. I too wanted to be a fertility doctor from the womb, so I can relate to that passion.
The subject of today’s show is everything you need to know about PCOS from the expert. I just want to start off with some of our questions.
What do you think is the biggest misconception about PCOS that patients have?
Dr. Mira Aubuchon: I have a few. One of them is that it only happens to people that weigh more. Really, PCOS can be present regardless of body weight. That’s one thing I hear a lot.
Another thing that I hear a lot is sometimes patients will experience pelvic pain and they’re told on an ultrasound that they have very large cysts on their ovaries, and then they’re labeled as having PCOS after that. That’s not necessarily the case.
Finally, I get told a lot that pregnancy just won’t happen if you have PCOS. That is a very sad myth, because so many patients can have families.
Dr. Aimee: It’s hard. They’re sometimes told that when they’re young, like 10, 11, and 12 years old. It’s heartbreaking to see patients who are now 30 who feel like they’ve been told they can never have kids for 20 years, until they meet us and we’re like that’s a myth.
What are some of the causes of PCOS?
Dr. Mira Aubuchon: Multiple factors. They include genetic factors, which don’t always run in families the way certain genetic diseases do. Cystic Fibrosis, for example, you can almost do the math and figure out who is going to have Cystic Fibrosis in a family. PCOS is different in that there are genes that cause it, but it’s a wide variety of genes and it may be different, depending on ethnic background. Still, PCOS runs a lot in families.
It also has to do with the hormones. Even when a woman is a baby inside of her own mother’s womb, the hormones that she experiences there play a role in whether she’ll actually have the symptoms later in her life.
Finally, there’s environmental, the air we breathe, the water we drink. Also, body weight and lifestyle.
All of those factors come together. Some people may have some of those factors and never have the condition at all. Other people might really encounter all of them. We see a wide variety.
Dr. Aimee: What do you think is the most helpful way to get an accurate diagnosis?
Dr. Mira Aubuchon: The first step is just visiting the doctor and just talking about the symptoms. Sometimes the symptoms really point to make the diagnosis pretty obvious. Then to flush out that that may in fact be the case, we do some very simple blood tests.
If the patient can tolerate it, an abdominal ultrasound, which is an ultrasound on the tummy with the bladder being full. Or if the patient is of an age where this is appropriate, then an ultrasound in the vagina, a very simple ultrasound to take a look at the ovaries. Some combination of those can reach the diagnosis very quickly or rule it out.
Dr. Aimee: Talk us through treatment. How would you treat someone who is not trying to get pregnant with PCOS who has problems with hair growth or irregular periods?
Dr. Mira Aubuchon: With the irregular periods and the hair, a very simple treatment to start with, if the patient is agreeable, is to just try a simple birth control pill. These are very inexpensive and most of them work very similarly to reduce the symptoms of hair and to give people more regular cycles. After a few months, if that isn’t working, then we can add in medications on top of that.
Dr. Aimee: What are some of the medications you would add in, for example?
Dr. Mira Aubuchon: An example would be spironolactone or Aldactone. This is used to treat blood pressure. It’s very inexpensive. It’s not specifically used per the Food and Drug Administration to treat these types of symptoms, but it has been used for many years very effectively, so we use it very commonly.
We start out with a fairly low dose and make sure that the patient can tolerate the side effects. Usually patients tolerate it really well, but they just have to be watchful that they don’t get too dehydrated. Every few weeks, two months, we just do simple blood tests to check the electrolyte balance in the blood and make sure that looks okay.
Dr. Aimee: Great. Let’s say you have a patient with PCOS who is now trying to get pregnant and her cycles are really irregular. She is trying to get pregnant. What would your approach be?
Dr. Mira Aubuchon: Okay. With irregular cycles, I get a sense for the patient’s circumstances. She’s relatively young, meaning I would say if she’s in her early 20s, mid 20s, she has not been trying for very long, and she has some characteristics where if we just did some simple types of treatments that may work.
It may be as simple as just a little bit of body weight loss. Even a 5% loss of body weight may be enough to jump start somebody’s menstrual cycle.
For people where maybe that’s a hard thing to do, and if they’ve tried that and maybe they’re not having much luck or maybe they did and their cycles are still irregular, then there are medications available by prescription. The treatment that I like to use as a first line therapy is called Letrozole.
This is also used in what we call off label, meaning that it’s actually used to treat breast cancer, but it has been used for many years to treat people with PCOS to help their cycles become more regular and to help their bodies do something called ovulation, which is where they release an egg. It’s a pill that they take for five days and then that can be very helpful to help them ovulate. I like to start with that.
Sometimes I’ll add in some medications with that. Such as diabetes drugs, like metformin. I don’t give those to everybody, but some people may benefit from using that.
Dr. Aimee: What kind of side effects do you see with the metformin? Do you have, with all your experience, any tricks for people who are listening to deal with the side effects so that they’re not as bad?
Dr. Mira Aubuchon: In terms of the side effects for the metformin, the main side effect is tummy upset, so queasy stomach, nausea, diarrhea, very bad diarrhea sometimes. Obviously, it’s very unpleasant and many people just are not able to tolerate it.
In the past five to eight years, metformin has been formulated to be available in what’s called an extended release form, so it gets absorbed through the body slower. So slowly that sometimes the patient passes the capsule in their bowel movement. It’s still getting into the patient, but it’s just passing through slower. Many patients find that much easier to tolerate.
Other things that I tell people to do are to take it with a meal, which can be helpful. I have them play around with the dosing to either take it just at night, or take it in the morning, or space it out. Every scenario is a little bit different for how people tolerate it. Most of the time, people tolerate it okay. Every once in a while, no matter what we do, it’s just not a good fit for the situation and we just have to think about something else.
Dr. Aimee: Okay. Are there any specific supplements that you put your PCOS patients on?
Dr. Mira Aubuchon: Especially when they’re not able to tolerate metformin and I think that they might benefit from using something similar to metformin, I like a product called myo-inositol. It’s often combined with D-chiro-inositol. It’s in this 40–1 ratio. The myo-inositol comes as a powder and it can be taken once a day or twice a day. The D-chiro-inositol sometimes comes with it or separately. I let the patient know specifics of how I want them to take it.
This has been found to give some similar benefits in terms of if people have some difficulties with their insulin or diabetes control, and in terms of ovulation it may be helpful, but it’s not all that helpful as a standalone treatment, so I usually use it in conjunction with other treatments. I don’t usually give it plus metformin together, I’ll pick one or the other.
Dr. Aimee: What about diet? I’m sure your patients ask you a lot about the best diets that they should follow, especially when they have PCOS. What is your advice?
Dr. Mira Aubuchon: I have looked at so many diets. I’ve written some research papers on certain diets, but honestly, I don’t really have a set diet. It seems like the best diet that is helpful is the one that the patient can stick to. Typically, that’s a diet lower in calories, but oftentimes it’s just simply a diet that they can follow without feeling so deprived that they overeat and that minuses out all of the benefits that they had originally.
The diet I’ve been recommending lately is what’s known to many people as more of a Mediterranean style diet. This can come in many forms. There’s not just one set Mediterranean diet. The one that I like to recommend allows plant based type of beans, lentils, chickpeas, that type of thing, along with poultry and other meat, if people eat those things, and then fish or fish oil, antioxidant rich fruits and vegetables.
Antioxidants are compounds and nutrients that we can take in through our food that help our bodies be healthier, it helps our bodies fight off infection, it helps with inflammation. Inflammation is a big part of PCOS, so that can be very helpful.
I also tell patients to try to decrease sweets that can sometimes be hidden. In your coffee and tea, for example. Not to say they shouldn’t ever do that, but just to be mindful of what they’re eating and drinking, and to try to reduce some of their sugar intake. PCOS, even when people’s weight is normal, they can still be very sensitive for inflammation when they eat meals that are high in sugar. That’s something that they can start to reduce.
Whole grains are very good. Plant based oils, olive oils, have also been found to be very beneficial. I try to recommend diets that I would myself eat. I figure if it doesn’t taste good, there’s not much motivation to stay on it long term.
Dr. Aimee: That’s true. What about this question, do you think PCOS is treatable? No one wants to be labeled as having something. I think it’s hard for a lot of people to hear it. I think it’s important, because knowledge is power. Once you know what your diagnosis is, then you can build a team around you to support you and get the care that you need.
Do you think that there is a way to actually treat it and be cured?
Dr. Mira Aubuchon: I think that is one of the myths and misconceptions about PCOS is that it can be cured. Unfortunately, it can’t. This is going to be something that people are born with. It’s a condition that is present even before birth. Even though the word ovary is in the name, it really is affecting just about every organ in the whole body. Unfortunately, there’s not a way to make it go away.
Out of all of the reproductive conditions to have, this is a condition where we have multiple ways to control the symptoms and to help the person with their goals. If those goals are fertility, we can help with that. In very rare cases is this just an issue that is beyond help. Usually we can treat the hair, we can treat the fertility, we can treat the menstrual cycles.
It used to be just it was a condition that we had nothing to offer. Now it’s more like we can easily treat those conditions. Now it’s more like how do we help patients live as long and healthy lives as possible, even when fertility is behind them. Now they’re in their older age, we want them to live healthy lives just the same as everybody else.
I feel like that this is the point that we’re in now with PCOS, that patients now live the same long life that everybody else does. I think we’ve come a really long way.
Dr. Aimee: That’s very true. Let’s say in pregnancy, what particular risks does a patient with PCOS have in pregnancy compared to someone that doesn’t have PCOS? Is her pregnancy higher risk? Should her OBGYN know that she got pregnant and she had PCOS before, would it change her pregnancy management at all?
Dr. Mira Aubuchon: I think that PCOS patients do have higher pregnancy risks, but overall I think we have to be not unnecessarily alarmist. I think most people with PCOS who are pregnant do fine.
There are somewhat increased risks of things like diabetes during a pregnancy, so the OBGYN would be told, I would tell them about the PCOS diagnosis, so that they can be screened early on for diabetes.
Blood pressure issues can also come about during pregnancy, like preeclampsia, which is a condition that involves high blood pressure during pregnancy. Sometimes patients have to have special care during their pregnancy to help with that.
There might be a somewhat increased risk of miscarriages with PCOS, but that is a bit more nebulous in terms of pointing to PCOS as a cause for most of those.
I wouldn’t necessarily tell somebody that just because they are pregnant with PCOS that they automatically need to see a high risk OB doctor. I would think that the vast majority of generalist OBGYNs would be able to care for them well.
Dr. Aimee: That’s very reassuring. Based on the fact that you’re on the cutting edge, you have the pulse on everything PCOS because of all the research and all the articles that you’ve done, do you predict any future treatments out there that women with PCOS should know about?
Dr. Mira Aubuchon: I think the most exciting thing that I’m waiting for more data to come out is the whole issue of the bacteria in our gut. This is really exciting, because it’s being looked at for just about every disease you can imagine, not just related to the reproductive system, but to even our brain health and our heart health, and so many things in terms of weight and weight loss.
I feel like some of my patients that have PCOS, some of the myths and misconceptions that they come in with that they’re being told is that it’s their fault somehow, that if they just did XYZ with their diet, they would lose weight and everything would be fine. What this research is finding out is that some of this is so beyond our control. It even comes down to the bacteria in our intestines that are also controlling our appetite and controlling our hormones.
I think that a lot of exciting things are going to come out of research being able to pinpoint which bacteria do certain things. If we know that, then we can take probiotics and tailor them for particular health issues. That’s one of the things that I’m really watching closely.
Dr. Aimee: If you had an audience full of just PCOS patients, what is the one thing you would want them to know?
Dr. Mira Aubuchon: You are not alone. Even though from my perspective I feel like I see so many PCOS patients, they feel like they’re the only ones that have this, they feel so isolated, they feel like these symptoms are so unusual, nobody else in their circle has these. I would tell them this is so common. It may not be as talked about and as public as some other types of conditions are, but it is very common.
Things have gotten to the point medicine wise and science wise where it is now possible for people to live normal lives and have this condition with not too much that they have to do to control it. Even though they may be scared, we’re now at a point where we can help them live their best lives healthfully and give them the families that they desire. It shouldn’t be something where they lose hope.
Dr. Aimee: Thank you, Mira. Thank you again for answering all my questions. If you’re interested in working with Dr. Aubuchon, the best way to find her is through her website: www.MCRMfertility.com.
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