The Food Medic - S10 EP6 The truth about balancing your hormones.

Episode Date: November 6, 2023

Dr Hazel is joined by Dr Anjali Amin, a Consultant in Diabetes & Endocrinology and Honorary Clinical Senior Lecturer at Imperial College London. This epsiode covers: What are hormones? The truth about “hormone balancing” recipes At home Hormone testing kits Is adrenal fatigue a medical diagnosis? Why women experience more thyroid issues than men Should you worry about glucose spikes? PCOS and insulin resistance Interested in more content like this? Check out @thefoodmedic on instagram Hosted on Acast. See acast.com/privacy for more information. Learn more about your ad choices. Visit podcastchoices.com/adchoices

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exclusions and terms apply. Instacart, groceries that over-deliver. Hello and a big welcome back to the podcast. I'm your host, as always, Dr. Hazel. Right now, there's lots of interest or chat about hormone imbalances or balancing hormones with various recipes and supplements which can be found on social media so I just wanted to ask an actual hormone expert her thoughts. Today I'm joined by Dr Anjali Amin who is a consultant in diabetes and endocrinology which is a doctor that treats diseases related to problems with hormones. She's also an honorary clinical senior lecturer at Imperial College London and completed a PhD in 2018 looking at the effect of dietary factors on appetite. Here's Anjali. Anjali, welcome to the Food Medic podcast. Thank you, lovely to be here.

Yeah, it's so nice to have you here and chat all about hormones. For those listening at home, you are a consultant of endocrinology, which is a doctor of hormones, essentially. And I think it would be really great to just start there. What exactly is a hormone and what does it do? So hormones are chemical messengers so they're produced from specialist glands in the body endocrine glands and they send signals to other parts of the body where they have effects on things like growth metabolism reproduction all of those things that are essential for life essentially. Yeah and I think you know right now there's a lot of chat around hormones and I don't think people fully realize

how many hormones there are in the body and how many different processes they have an impact on and you hear a lot about like hormone balancing and hormone imbalances and it's a very vague and non-specific term and I mean even if you on TikTok, there'll be recipes to balance your hormones. As an endocrinologist, is this something that we can do? Do you think this is really the right phrase we should be using? It's really interesting. So the endocrine system is really clever and essentially it regulates itself. So most of the time in most people that are inverted commas normal the endocrine system balances all of the hormones naturally so it is there are very little influences through things like diet environment that impact your hormones on a day-to-day basis that's not to say

that things like diet don't influence hormones but they don't balance your hormones as such. Your body does such a good, has such a good role in doing that naturally that you can't really force the body into balancing itself through diet, through smoothies, through teas. I mean, social media is a minefield. If you just look up hormones, you will get so much unsolicited advice on how to balance your hormones naturally. And really much of it just simply isn't true. And I'm not saying don't have a green smoothie, because, of course, there's lots of good things about green smoothies, but they aren't going to naturally force your hormones to balance themselves so I think it's really misleading to assume that you can do that through things like particular

recipes or buying into a specific product or vitamin or supplement yeah there's I mean there's a lot of that going on right now and I think people are very interested in just doing various tests on their body to understand their hormones and other levels in their blood and I guess that's because we have those tests more available to us you no longer have to go to the GP you can just do a test through the post and you know there's a lot of female hormone testing kits, but there's also other hormone testing kits that you can do. How do you feel about these? Do you think they're a good thing, a positive thing? Or do you think there's risks associated? In all honesty, I think there are lots of risks associated with do your own hormone testing, because the thing about having hospital labs, clinic labs, etc., is that the actual platforms on which these tests are run are regularly checked.

There's a lot of quality control that goes into running these assays and you don't have any level of regulation with DIY hormone kits. So you don't even know that if you get a positive test, is it actually real? You know, creating a huge amount of anxiety, worry that could be completely unnecessary. And the thing is, once you've got, let's say, a positive test through your DIY hormone test, what do you do with that result? You know, how do you interpret it? And, you know, studying endocrinology is a long process and understanding all the nuances with testing, for for example should it have been fasting what time of day was it taken all of these things might even affect the way that you know the result

comes out and what you do with that test so I think I would be very cautious about doing a DIY test because you just don't know whether it's being quality controlled and also what you do with the result. Yeah, I agree with you. I think people probably feel more empowered being able to do these tests. But as you said, if you don't have someone there to consult with you on these results, be that positive or negative, then what do you do with that information? But I guess hormone imbalances is not the right term for us to be using, but there are a number of problems that can go wrong with your hormones and lead to a number of conditions where maybe the hormones are too high or too low, like hypothyroidism, for example. What are some of the common conditions that you would see in your clinic?

So I see a huge variety of conditions. So you've mentioned thyroid problems, so underactive hypothyroidism and overactive thyroid hyperthyroidism, but also, you know, all sorts of other conditions affecting the other endocrine glands, the pituitary gland, so the gland, the sort of master gland, if you like, within the brain, things go wrong with pituitary gland, the reproductive hormones. So I see a lot of PCOS, hypothalamic amenorrhoea, you know, male hormone problems, adrenal issues. So I see a huge variety and not just those hormones, but also diabetes. I do a lot of work in type 2 diabetes, which obviously many think of as a sort of lifestyle, a genetic slash lifestyle disease. So a massive variety of endocrine

conditions that I come across on a day to day basis. Yeah, it's so fascinating. I think, you know, when I was studying endocrinology as a student, I found it really interesting, but also really logical following the feedback pathways. And then once you get it, once you understand it, it is a really incredible system of hormones. But I'd love to just discuss a few of those conditions that you mentioned there. One of the glands that you mentioned was the adrenals. And this is something that is also very much talked about on social media is adrenal fatigue and issues with the adrenals. Now, to my understanding, adrenal fatigue is not like a recognised medical condition.

Certainly when I was at medical school, it wasn't something that we learnt about. Is this something that you're seeing in clinic or people are asking you about? Yeah, it's interesting. So as you say, it's not a recognised medical condition. Now, that's not to say the people that believe they have it don't have real symptoms. They do often, you know, symptoms of tiredness, lethargy, extreme fatigue. Now, the theory behind adrenal fatigue is that chronic stress levels have caused their adrenal glands to give up and stop producing enough hormone. Now, when we measure these people's hormones, they are actually

normal. And therefore, per se, they don't have adrenal failure, which is a recognised condition, something called Addison's disease or adrenal insufficiency. And so adrenal fatigue, as such, has a huge, the symptoms associated with adrenal fatigue, have a huge overlap with other conditions, depression, anxiety, fibromyalgia. So although I do have patients that ask about it, it isn't a recognised medical condition, but I do believe the patients really do have very real symptoms, but they can't be explained by adrenal failure as far as we know with the test that we can do. And for people who maybe have thought that adrenal fatigue is what's causing their symptoms what would you recommend that they do in order to kind of go and seek help and rule out other conditions? I think the first

in the first instance they should consult their GP their own family doctor to get advice on, you know, what other things might be causing this. Because as I said, there is a huge overlap, you know, even long COVID, for example, has so many other symptoms that could be associated with those that they have then associated with adrenal fatigue. And of course, it's quite straightforward to test people for adrenal insufficiency. Well, when I say straightforward, no endocrine testing is straightforward. But, you know, if somebody really believes that they have adrenal failure, then, of course, they can be referred to an endocrinologist for further evaluation of that.

And that's quite straightforward for us to rule out. That's something I remember doing in the hospital is a testing for that and the morning blood tests as a junior doctor would be because you'd have to do it at a certain time. The other endocrine gland that's often discussed is the thyroid gland. And thyroid problems are more common in women. I actually don't know the stat. Is it like eight times more common in women or something? Do we know why that is? It is so interesting. It's something I'm absolutely fascinated about. the stat is it like eight times more common in women or something do we know why that is it is

so interesting it's something i'm absolutely fascinated about um and i have real interest in female sort of endocrine conditions and it's one of those things that remains really poorly understood despite the number of years that we have understood issues to do with the thyroid we still don't fully understand why is it that women are more predisposed to it. Now, most thyroid issues tend to be autoimmune, and we know certain autoimmune conditions are more common in women. Why is that? Well, one of the theories surrounding it is that the X chromosome is the chromosome that has more of the genes associated with the immune system on it. And because we as females have two x chromosomes and males have one x chromosome we the theory is that we are naturally

more predisposed to things going wrong because we have those two x chromosomes so i think that's really fascinating the other thing that um people think might be the cause of, you know, thyroid problems being more common in women, is that our immune systems have naturally adapted compared to men in order to carry a fetus. So you adapt your immune system, you dampen down your immune system when you're pregnant to allow you to carry a baby. And for that reason, it's thought that your immune system is naturally more predisposed to autoimmune thyroid disease, for example, because of the effect of, you know, evolutionary effect of having to carry a baby. And in fact, it's really interesting because some thyroid problems like an overactive thyroid, for example, actually get better in pregnancy. Oh really? So the immune system itself during pregnancy clearly is dampening down in order for you to carry the baby at the same time actually treating your endocrine disease. It's absolutely fascinating. And thyroid issues can also manifest in kind of menstrual cycle symptoms and also

fertility. What are some of the symptoms or some of the ways that it can manifest kind of related to the menstrual cycle? So it's really interesting. So there can be all sorts of issues with the menstrual cycle. So irregularity. So often, you know, people will notice their periods just have become irregular over time. There are issues with ovulation as a result. And in pregnancy, higher risk of miscarriage with an overactive thyroid, risk of preterm labour. So there are, you know, real risks to female reproduction when things do go wrong with the thyroid. But the good news is, is that, you know, most thyroid conditions are really easily treatable under, you know, either your GP or a specialist endocrinologist. So it is interesting. And sometimes actually, the irregularity of the periods is one of the first things that people notice. And, you know,

I think most women tend to seek help when they notice a change in their periods, because it's something that's really quite unnatural for them. Yeah. And I think the more we kind of talk about menstrual cycles and what's normal and what's not raises that red flag when something goes wrong. We talk a lot about the menstrual cycle on the podcast and you know when things go wrong and are cause for concern and having a regular cycle if you were formerly regular is definitely a reason to see your doctor and having a thyroid issue is one of the main causes but PCOS is another major cause and this is a hormone slash reproductive condition that I would love to chat to you a bit more about in terms of how does it

manifest and what are some of the causes. So it's one of the commonest conditions reproductive conditions I actually see in clinic it tends to affect women in their 20s and their 30s. And as you say, it's a condition affecting the reproductive system and your reproductive hormones, resulting in problems with ovulation, irregularity of cycles. And, you know, the way that we diagnose PCOS is really difficult and sometimes is a diagnosis of exclusion. You've excluded other endocrine conditions, other gynae conditions that this could be and leaves you with the most likely diagnosis being PCOS. Now in order to diagnose it you need to have certain criteria so either an irregularity of your cycle so either no periods or irregular periods or you need to have symptoms associated with too much male hormones or too much testosterone and that often manifests with

excessive hair growth on the face on parts of the body where you wouldn't expect it or acne or you do an ultrasound of someone's ovaries and they have cysts, multiple cysts on their ovaries. And that's very characteristic. Now, interestingly, you don't have to have multiple cysts on the ovaries, as you would imagine, be it, you know, it's called polycystic ovarian syndrome, but you don't have to have those cysts on the ovaries. You can still have the syndrome without it. So you only have to have two of those sort of three criteria your cycles going irregular the excess male hormone and the polycystic ovaries so as long as you've got two of those three factors you can make a diagnosis of PCOS. And one of the things that is a huge risk in or is a huge driver, but also a risk factor in PCOS is insulin resistance.

And not all women with PCOS have insulin resistance, but majority do. How can we screen for those at risk because of the knock on effects of having insulin resistance? Of course, there's higher risk of cardiovascular disease and type two diabetes. So it's something that we should really identify. Yes insulin resistance is the driving factor in a lot of cases of PCOS but not all and PCOS tends to be more common in people that are overweight who tend to be insulin resistant naturally. It's difficult though because there are a subgroup of PCOS who are what we call lean PCOS who who have a normal BMI, which tends to be the most common way that we identify lean PCOS. Although there is some data suggesting actually people with lean PCOS tend to have a more severe form of insulin resistance.

Now, how do you screen people for insulin resistance it's really difficult so as you say you want to identify those people that are going to be at higher risk of cardiovascular disease type 2 diabetes and poor metabolic health essentially is what you're talking about and you know in women who we think have PCOS you can test them for type 2 diabetes which is often associated in women who are overweight with PCOS that's really quite straightforward to do you might want to know things like their lipid profile what what sort of what's their cholesterol for example you know all of these markers will help you identify those that are naturally more at risk of cardiovascular disease in the long run

I think it's such an interesting conversation because we don't really fully understand the kind of comorbidities associated with PCOS and we're only kind of collecting data now. From a treatment and like management point of view there's like a lifestyle component but also we've got medication as well that we can use. Can you talk us through the different options? So it's really interesting. So obviously dealing with the vast majority of patients that are overweight, the single most effective way of curing slash treating PCOS is weight loss. And it's really hard for women to lose weight. We know that it's difficult and it always feels slightly unsatisfactory to tell someone, you know, you need to lose weight and your PCOS will get better.

But actually, the evidence suggests if you do lose weight, your PCOS will get better. So, of course, diet is important. There is no one perfect diet for PCOS, regardless of what social media tells you and actually it is the actual weight loss effects that are probably more important than the actual what you're eating. So that's your sort of diet exercise of course hugely important in any conditions involving metabolic health so really important not just to focus on diet but exercise to be incorporated into someone's natural diet, but not just to treat the PCOS, but forever, you know, considering they are always going to be at risk of cardiovascular disease because of their metabolic health. And, you know, these are young people who will be at future risk of type two diabetes. So, you know, sorting their diet and lifestyle out early and

getting them to understand that actually, you know, eating well and exercising is normal and should be done forever is really important. So that's the lifestyle factors that we can really address. And then there are treatments, of course, and it depends on what what the patient wants at that particular moment in time. So if they want a pregnancy, they follow a different route and they see a fertility specialist or they see a reproductive endocrinologist. And there are lots of treatments that can be done that can be given to them to help them ovulate in order to get pregnant. And in those women, in the vast majority of women that I see that don't need pregnancy right now, there are tablets that you can take. So metformin is classically a drug that was given for type 2 diabetes, but has been shown to improve insulin

resistance in women with PCOS. And through doing that helps regulate cycles. Doesn't work in everyone, but it's definitely worth giving it a try. Doesn't really help you lose weight, but as I said, it improves the insulin resistance to their metabolic health in order to try and get the periods to regulate. Then if the cycles are really problematic or if people are worried about, you know, not having periods, of course, one of the options that we sometimes suggest is the oral contraceptive pill. Not for everyone. There are risks associated with it, but does help quite a number of people. Also helps with things like acne. And then finally, the cosmetic treatments. Now, this is probably the single most common symptom that people worry about in the clinic. Of course,

they're worried about their future fertility, but they're worried about the excess hair on their face. They're worried about acne, which I completely understand. You're a young woman in your 20s and 30s. Of course, you don't want to be shaving or plucking every single day. Unfortunately, the treatments for that are limited. And, you know, laser treatment is probably the most effective semi-permanent cure for that aspect and even things like the oral contraceptive pill which can help once you stop it the hair growth will come back so if people can afford it and it's not available on the NHS sadly laser treatment probably is the best way to address things like the excess hair growth

yeah it's so expensive um and for some people it is a really debilitating symptom there is also i think like a higher higher rates of poor body image in women with pcos and disordered eating because of this pressure to because of the symptoms but also the pressure to lose weight for a lot of women but as you said you know for some women they they're not in a position where they have any excess body weight to lose and it can almost feel a bit right what can I do to help myself um but I think what you've mentioned is really helpful we also had Claire who's a dietitian on the podcast discussing PCOS and diet before and we were discussing inositol is that something that

you ever recommend with you? I do so yeah I do recommend they try my own inositol and definitely there are studies showing that it improves insulin resistance so yes that would be something else that I would recommend you know it doesn't have much in the way of side effect profile so of course you know you've got to pay for it but it's worth giving it a go and as I said there is scientific evidence backing up its efficacy so definitely. One of the topics I'd love to discuss with you today as a diabetes consultant is the rise of monitoring glucose. Now we've talked about this briefly on the podcast before, but I'm seeing more and more kind of startup companies using it as a marker of health,

especially when it comes to diet. So checking how your body responds to different kind of foods when it comes to the glucose response. And incidentally, I was looking at papers related to how tracking our biomarkers or our health markers can lead to a lot of health anxiety. And one of the papers was discussing CGMs or glucose monitors. Are you seeing people coming to clinic that are concerned about findings that they're having or as a consultant yourself, witnessing this going on, do you think it's a positive thing for us to understand this? Or do you think this is something that we should only be looking at if we have the need to be checking our glucose?

I mean, it's so fascinating to see what's happened in the last couple of years. Of course, I think there is a real role for CGM, so continuous glucose monitoring or flash glucose monitoring, in people that have diabetes. So, of course, it is really important that those people, you know, understand what they're eating and what are happening with their blood sugars. Now, outside of that, we just don't have the evidence that tracking your glucose spikes is having any long-term benefit to you. Now, the worry with doing that, tracking what happens to your glucose, so we all know that carbohydrate equals glucose. So if you eat a bowl of pasta, you will get a spike in your glucose. Of course, that's normal because carbohydrate equals sugar. Now, in people who do not have diabetes, you have a functioning pancreas. So your pancreas will produce insulin, the insulin

will kick in and your blood sugar will come down. That's normal. So having a spike in your glucose is normal, but your insulin will counteract that and return it back to normal. So, you know, in somebody who doesn't have diabetes that realises, oh my goodness, that bowl of pasta put my glucose up, I'm never eating pasta again. To me, that sends a very, very poor message out there that will result in, as you say, health anxiety, disordered eating, orthorexia, all sorts of psychological issues around what they are eating. Now, what people might not realise is that if you had that same bowl of pasta tomorrow, when you slept a bit better, you were feeling a little bit less stressed out, for example, actually your blood sugar might be very different.

So there are so many other factors like your environment, your sleep, your mood, all of these things can have an impact on your blood sugars. So, you know, to think, to try and work out that, you know, to determine certain food groups that you then identify as being really bad for you, just sends the wrong message out altogether and I think it is going to provoke a lot of anxiety in people who will then start to restrict food and of course we you know I'd never want to advocate disordered eating or promote eating disorders in any way through these technologies and of course there are people making a lot of money through these technologies not And of course, there are people making a lot of money through these technologies, not realising the long term damaging effects that these might be

having on people without substantial scientific data to back up their, you know, their health benefits. So for me right now in 2023, actually, I would be very cautious about using flash glucose monitoring to monitor what you're eating I think it can have real you know detrimental effects on one's mental health and I would steer clear personally if you have diabetes I think that's a whole other matter and I think it plays a really important role yeah Yeah, absolutely. I mean, if you have diabetes, it's almost essential in that way. But are there any groups of people perhaps who are at risk, maybe in the kind of pre-diabetes space or perhaps PCOS, those who are at risk of insulin resistance, that there might be a place for these? Or do you think it's something that should really be regulated within a kind of more clinical environment? I think so, in all honesty.

I think if you start to really worry, because also the worry is that, let's say you're somebody at risk of diabetes, but you don't have it, like you say, somebody with PCOS, for example. We already know that these people do have, you know, worries about their body image and the way they look. And then if you add in the pressure of, you know, what they're actually eating and what their glucose is doing on a day-to-day, hour-to-hour basis, actually, I think it's going to create a huge amount of anxiety for them

as well. I'm not saying that we shouldn't educate those people on what's what's, you know, dietary factors they might want to consider changing in their diet, etc. But I don't think personally that it has a role just yet, because what will it do to those people, you know, we can tell them, actually, you know, if you reduce the amount can tell them actually you know if you reduce the amount of saturated fat that you have you reduce the you know amount of carbohydrate you take in or you would just reduce your calorie intake you will probably lose some weight so what extra evidence is flash glucose monitoring or continuous glucose monitoring going to give these people that's that's the bit that i don't know that we actually know you know what benefit will it have to them yeah i would agree with you there and i think looking at anything in isolation

can be a really slippery slope so if we're saying you know glucose is the harmful thing and yet then in order to avoid having a glucose spike you remove carbohydrates but then you increase saturated fats and other foods that maybe are not health promoting then are you really you know in a kind of a positive swing of the balance yeah absolutely and i think it's really interesting that you mentioned carbohydrate because often you know people do ask me about carbohydrate you know carbohydrates really bad at equal sugar but actually you know there are many good things about carbohydrates you know and that we shouldn't forget that so I'd never advocate completely removing one food group you know think about your gut microbiome for example you know without

certain carbohydrates it'd be really difficult to maintain a healthy gut so it it's interesting that you brought the carbohydrate up because I think people do worry about carbohydrate but if you don't have diabetes even if you have the carbohydrate your pancreas will will kick in and it will sort the glucose out for you by bringing the blood sugar down so actually what why do you need to know that information yeah i agree with you and i think because carbohydrates as a category are so huge and you know we can look at a spectrum of processed to unprocessed and and various different types of carbs but it's really reassuring for me to hear that because when i had my diagnosis of PCOS, my gynecology consultant said, so you don't need to lose weight because you're a normal BMI, just cut out the carbohydrates. And not once did he

ask me about my diet. I was doing my master's in nutrition at the time. So I was kind of like, okay, red flag, don't let that filter into your head or don't take it too seriously. But I think, you know, when it comes to insulin and glucose, if we don't fully understand that, sometimes it's very easy to just demonize carbohydrates as a whole, without fully understanding that, okay, potentially, we're reducing the amount of refined sugars in our diet. But carbohydrates also include fiber, and they've got lots of vitamins and minerals in it. And they also sustain us with energy. And I think those throwaway statements for some people, especially like a young girl who's just been newly diagnosed with PCOS like I was, that could be really problematic and then cause her to constantly avoid carbohydrates out of fear that it will make her infertile or make her symptoms worse.

Yeah, it can be really damaging. You know, it sounds like your experience was horrible. And if you didn't have the, you know, knowledge to sort of understand that actually I shouldn't listen, because of course, you know, people do have quite divergent views on diet. You know, you could have been in a very different place. and that's why i think going back to the glucose monitors if you then put on a glucose monitor thinking oh i must now restrict that because last week when i had x you know a piece of toast my blood sugar went up and so you know all of these factors can be really damaging and without understanding actually some of that is quite normal now just to go back to your lean PCOS, it's very difficult to manage these patients and I do look after a number of patients with lean PCOS

unlike the group where actually improving diet, getting them to exercise in the hope that some weight loss will improve either their cycles or their symptoms. The lean PCOS group is much more challenging. And we don't fully understand why people have PCOS and are lean and actually what we do with those people. Now, we know that any factors that will improve metabolic health may be beneficial in that subgroup of women. And it's not an insignificant number of women we're talking about. So probably between 10 and 20% of women with PCOS have a normal BMI. And there is some evidence to suggest, you know, things like time restricted eating,

you know, intermittent fasting, all of those things that won't make you lose weight, but might improve your overall metabolic health can be beneficial in some women yeah i think it's the overarching thing is that we we just simply don't have enough research like looking into these different phenotypes of pcos and any you know anyone i've spoken to who does research in the space is saying that we're only really understanding that kind of I guess the pathology behind lean PCOS and how it's different and how maybe our management would change but like you said it can be almost really tricky managing those people when there's no easy low-hanging fruit to you know you know jump for the weight loss or changing around their diet if

they're already doing those things but I'm really grateful to be able to have these conversations and and for women listening at home who potentially have PCOS and don't fit that particular phenotype feel like they're being listened to. Oh absolutely and I think it's really important to ensure those women also have had other diagnoses excluded so that they have had the test to exclude other conditions that this could be. Because in these women, lean PCOS needs to be a diagnosis of exclusion. They need to have had all the other tests to check that they don't have something else that could be causing their symptoms. Usually it tends to be irregular cycles that people present with. And there are lots of things that can cause irregular cycles, as you know. So I think that's important to know. Also, remember, there are drugs like metformin that can improve insulin resistance in those that are insulin

resistant. And many of these women are insulin resistant, even though they are lean. So there are medications that can help and there are things that can be done but as you say it really remains a poorly understood subset of women and it's a shame because you know more money is needed in female research female endocrine research because and I think you've probably alluded to this previously that a lot of scientific studies are based solely around men. And not just you, obviously we're talking about female health, but generally science as a whole is geared to looking at the male. And I just think that women, not just reproductive age, but menopausal age, just haven't got the scientific data out there so I do think that we need more to understand women with lean PCOS and PCOS in general which in all of the conditions that I see as an endocrinologist remains the one that I always feel least satisfied by as a doctor with a patient in front of me because

as you know as we know it's women in their 20s and 30s that you know are so disturbed by their appearance by their facial hair their weight you know their cycles their concerns about fertility and no one wants to be worrying about these things when you're 20 and in the prime of your life so I always feel really desperately sorry for these women and wish there was more science to understand the pathophysiology we just don't have that and so it's good to know that you know you've had conversations with others that working in the field and hopefully as time goes on more money will be put into scientific research around these sorts of conditions. Yeah I completely agree with you and I think you raised a really important point that I flagged to come back to and that was ensuring that perhaps lean PCOS is a

diagnosis of exclusion but one of the conditions that it has huge overlap with, and it would be a differential for it, is hypothalamic amenorrhea, which is also a diagnosis of exclusion. And I think from speaking to other practitioners who are working with women with PCOS or HA, oftentimes one will be misdiagnosed for the other. What will be the kind of core differences or key differences between the two interesting that you brought that up because yes there is a real overlap in terms of symptoms for example now with hypothalamic amenorrhea um as you know the issue lies within the hypothalamus so go to going back to a bit of physiology so we've got the pituitary gland within the brain which is your sort of master gland of the hormone controls most hormones within the body and the pituitary gland is regulated by the hypothalamus which sits literally just above it in the brain and when so from an evolutionary point of view, the hypothalamus is very much affected by

extreme stress. So if you had no food, starvation, for example. So what it does is it switches off all the unnecessary hormones that it feels you don't need. So if you were in a period of extreme stress, it would switch off your reproductive hormones because it would think, do you know what? I don't need to reproduce at this particular time. I need to just survive. And it would see reproduction as an unnecessary event at this point in time. So the hypothalamus switches off and therefore doesn't send the signals to the pituitary gland to release the hormones that control the ovaries that release your sex hormones. So in some ways, although there is an overlap, actually we can test the pituitary hormones, we can test your LH, we can test your FSH. Your LH particularly tends to be low with hypothalamic

amenorrhea. And that can be really quite different from PCOS, where you tend to have normal LH. So actually, we can differentiate in terms of biochemically, most of the time between hypothalamic amenorrhoea and PCOS not always but there are biochemical differences first of all between PCOS I think clinically it's very difficult if you met somebody in clinic it's very difficult to know which diagnosis you're dealing with based upon symptoms because often there is a huge overlap in terms of management with ha a lot of the times especially in my experience it's come through either excessive exercise restrictive eating often a combination of both and stress and if someone has been labeled with pcos and then they're going down the i need to be on this extremely healthy diet where i'm cutting out carbohydrates and whatnot,

you could actually make matters worse, which is why I wanted to bring it up, because I think it's really important for both practitioners, but also people listening to understand that there is an overlap and it's very easy to kind of misdiagnose one for the other. Definitely. And you picked up exactly the right point. So with HA HA obviously all those factors that you mentioned the excessive exercise eating disorders etc all are resulting in that extreme stress that switches off the hypothalamus and unfortunately the treatment for that is stop exercising as much. Obviously, get help for the eating disorder if you have one. And that is in complete contradiction to the treatment of PCOS.

So it is challenging. And I do think that there probably are people that have been mislabeled as one or the other. Or that they might have a combination of both. And that is the group that is extremely challenging again more research is needed there to understand like how we would manage those people i wanted to briefly go back to your phd which i only realized from your bio that you've done a phd in appetite and body weight and i think we don't often talk about how hormones are and how they influence our appetite and the hunger hormones in particular so I'd love to chat to you a bit

about that and how that works and how we can also how our environment would also influence those hormones like our sleep and our stress levels. So thank you I think back to my PhD now. So I did a PhD looking at the effect of diet, in particular protein, on appetite and gut hormones. So the gut is one of the glands, it's probably the biggest endocrine gland that releases hormones that control appetite. And I looked at trying to identify what it was about protein that makes people feel full. And we know that of the macronutrients, protein is the macronutrient that makes people feel the most full. And so my PhD was really set out to look at understanding why that was the case. And I looked at hormones such as GLP-1, which is probably the most well known of the gut hormones, although there are many gut hormones that do exist. And the reason that people know about GLP-1 is that it has been targeted by drug companies and used by celebrities, Kim Kardashian effect, to as probably the single most effective weight loss agent that we have out there at the moment.

So our GLP-1 analogs. And the reason those sorts of drugs work is that GLP-1 is one of your satiety hormones. So it makes people feel full. So by taking a synthetic version of it tricks your body into thinking it's full. And so it reduces your appetite. People eat less and they lose weight. And that's how the GLP-1 analogs work. But as you say, you know, the gut hormones are influenced by a huge number of other factors such as environment, stress levels, periods, menstrual cycle. And going back to what we talked about earlier, is that, you know, often when you do research studies, you do these studies

in men. And the reason for that is that you take out the sort of confounding factor of periods and the effect of the menstrual cycle and how your hormones will vary according to what time of the month it is on your gut hormones so a lot of the studies that do exist in the literature will be very much based on men because they wanted to remove the possibility that the menstrual cycle could be, you know, confounding their data. Yeah. Do we have any research in women in terms of like how hunger hormones like ghrelin and leptin would be affected related to the menstrual cycle? Yeah, I mean, I don't know very well, but I think there is definitely research that looks at those hormones. And we know, you know, just by symptoms, many women often feel those that huge amount of cravings but then

of course you know you have other hormones like progesterone that have impacts on your appetite on your mood etc just before your period for example so there are lots of hormones that all you know there's an interplay if you like of the various hormones so I don't think we fully understand which one it is that's causing it. And I think it probably is a combination of factors, to be honest. Yeah, yeah. Every time we kind of start scratching the surface of how the menstrual cycle and our physiology changes across the menstrual cycle, I think we realise there's so much to learn because we've excluded women from research for so long. This has been such a fascinating episode.

Before we finish, I've got three questions for you that we ask all our guests. And these have been sent in from the audience listening, so you can blame them if you don't like them. But the first question is, if you had an extra hour in the day, how would you spend it? Gosh, if I had an extra hour in the day, honestly, the thing that I miss, so I obviously I work as an endocrinologist, but I also teach students, medical students, and I have three children at home.

So I often feel that I would love an extra hour in my day. And I think if I really had an extra hour in my day, probably I'd spend it reading with a book in somewhere quiet maybe my garden a bit of me time me time I think so sounds really selfish but I think I'd probably take the time and read a book yeah no I think that's the perfect answer the next question well you would get some me time here if you're going to a desert island what would be three things that you take with you I can't live without coffee I'd have to take a coffee maker with me I assume I've got electricity um kindle to read um I don't know about the third one uh pillow yeah yeah it's not a pillow I feel like I'd need a pillow I feel like that's that they're like really good selections

we've had such an array of answers for this it's hilarious and finally what's one thing that you're grateful for today do you know funnily enough just coming into London when you have some sunshine it just makes you so grateful to live in the city of London I've lived here my whole life but seeing sunshine in September it really made my day this morning yeah it's so true how a sunny day in London can just change your mood. But give me a rainy day in London and all I want to do is be at home under the duvet. Amazing. Thank you so much for coming in today. You're also on Instagram. So for those who want to kind of find out more about the content that you're putting out and your work, remind us of your handle. Thank you. Thank you for having me. First of all,

it was really interesting discussion. If you want Thank you for having me, first of all. It was a really interesting discussion. If you want to follow me, Kitchen Doctor and Mum, healthy eating, family recipes, a bit of hormone chat. Lots of really lovely, yummy recipes. Thank you. Amazing. Thank you.

Thank you so much. That's all from me. But before you go, I've got a little favour to ask you, and that is to please leave us a review and rating and to share this episode with someone you know will love it too see you next time