WHOOP Podcast - How to Support Fertility with Dr. Natalie Crawford

Episode Date: September 24, 2025

On today’s episode, WHOOP SVP of Research, Algorithms, and Data, Emily Capodilupo, sits down with Dr. Natalie Crawford, OB-GYN and leading voice in fertility education, to unpack the science behind fertility, the menstrual cycle, contraception, and long-term health.Together, Emily and Dr. Crawford explore why fertility is more than just about having kids—it’s a vital sign for overall wellbeing. Dr. Crawford breaks down how hormonal birth control works, the misconceptions it often carries, and why advocating for yourself in the doctor’s office is so important. Emily and Dr. Crawford dive into endometriosis, PCOS, and other common, but often overlooked, hormonal conditions that impact fertility. Whether you’re actively thinking about family planning or simply want to better understand your body, this episode is full of empowering insights to help you take control of your hormonal health.(00:45) WHOOP Podcast Rapid Fire Q’s(01:46) When Does Fertility Matter?(03:56) Birth Control, Understanding Your Cycle, and Impact on Fertility(06:23) How Does Hormonal Birth Control Actually Work?(12:58) Advocating For Your Health: How To Talk To Your Doctor(19:26) Birth Control and Hormonal Health(24:19) Preventative Fertility Care: How Women Can Better Understand Their Body(39:41) Cycle Tracking: Hormonal Health Indicators To Look For(45:42) Endometriosis and Infertility Signs and Symptoms(59:11) Irregular Cycles and PCOS: The Rotterdam Criteria(01:05:02) Symptoms of PCOS and What To Look For(01:09:54) Lifestyle Changes To Aid Hormonal Health(01:12:55) Importance of Exercise and Movement (01:16:31) Your Fertility Isn’t Just Luck: What Needs To Change In Fertility TreatmentsDr. Natalie Crawford:WebsiteInstagramYouTubeLinkedInTikTokFacebookSupport the showFollow WHOOP: www.whoop.com Trial WHOOP for Free Instagram TikTok YouTube X Facebook LinkedIn Follow Will Ahmed: Instagram X LinkedIn Follow Kristen Holmes: Instagram LinkedIn Follow Emily Capodilupo: LinkedIn

I talk about these lifestyle changes and anti-inflammatory approach because it is what we can control. The idea that your fertility is just luck is really a false narrative because learning more about your body, getting a diagnosis earlier, knowing what's wrong so you can intervene and then taking control of what you can is really important. But there is for everybody a time period where no fertility treatment will work. And all of us, our eggs, our chromosomes in that nuclear side, they do accumulate damage with age. and at some point, we might be past the point of no return. If we could change that, that would really change how we view reproduction. And at least for my patients, it would change the trajectory of their fertility journey immensely.

Hey, everybody. I'm Emily Capital Lupo, Woop Senior Vice President of Research Algorithms and Data. And today I am joined by the incredible Dr. Natalie Crawford. Dr. Crawford, thank you so much for being here with me today. Emily, thank you so much for having me. I'm thrilled to be here. So we're going to jump in and start with a rapid fire round of questions. Oh, love it. So true or false.

You can have a regular period and still be hormonally imbalanced. True. True or false. Stress is one of the most common yet overlooked contributors to infertility. True. True or false. Hormonal birth control gives your body the same. kind of cycle it would have naturally.

False. True or false. Most women don't learn how fertility actually works until they're trying to get pregnant. True. True or false. Fertility doesn't really matter until you're trying to get pregnant. False. And then last one, true or false.

Coaches and trainers should understand their athlete's menstrual cycle. True. Now, let's use that as a bit of a jumping off point. So you rolled your eyes when I said that fertility doesn't matter until you're trying to get pregnant. I did. if you're not trying to get pregnant, who cares? That's a great question.

And I think it really is the opposite of how a lot of us who are my age maybe have gone through our life because truly, and I'll use myself as an example, I knew I wanted kids one day, but until I was ready to have them, I didn't think much about my fertility at all, right? I was preventing pregnancy and it wasn't until I was ready to get pregnant that I started to think about, will I be able to, are my cycles normal, when am I ovulating, do I have enough progesterone, all these questions that start coming in that I realized quickly that I never learned earlier. One thing that's really important is that your fertility is a sign of your hormonal health, but it's also a health marker for the future. And we know that women who have

infertility are at higher risk for other metabolic diseases, cardiovascular diseases, cancer, and even early death. And it's not that infertility is causing these things, but there's underlying factors that can contribute to infertility, things like insulin resistance and chronic inflammation, that predispose you to these other risks. And so how I like to think about it, infertility might be that first red flag for a woman who's relatively healthy, that something at its cellular level is not really working. But in order to pick up some of these clues, you really have to understand your body better at an earlier age.

And that's why I'm a huge advocate for trekking your cycle, really understanding your hormones, and having that fund of knowledge well before you want to conceive also because if inflammation's a big player, there's a lot that you can do to set yourself up for success later on down the road. So I love what you're saying. So if I can just parrot that back to you, you're saying that your menstrual cycle and fertility is a vital sign that has loads of valuable information, even if I don't care about having a baby now or ever. It's still something that I'd want to track. I have a toddler, so have lived the whole like you're on birth control. and everybody tells you to be on birth control, and then you stop birth control to get pregnant,

and you don't really think about fertility until you're sort of in that chapter of life. How should people think about birth control? Obviously, it serves an important purpose, but it also potentially masks this really important vital sign and signal. This is a fabulous question, and we live in very interesting times, and it goes on both ends. So number one, being able to prevent a pregnancy when you don't want a pregnancy, is extremely important. That being said, I think a lot of women don't understand how birth control works, and they are prescribed it sometimes even for a very valid medical reason, but it's not

explained to them. And then it is masking symptoms or masking their cycle, and they're losing years or decades of intervention opportunity or understanding their body. So a good example is the birth control pill, what most people think about when they talk about birth control. That is a synthetic type of estrogen and progesterum. And so this tells the brain not to say, send out any hormones to get you to ovulate. But essentially, the cycle that you're having on the pill obviously is just a hormonal cycle from the pill. It's not your natural cycle. And then when you stop the pill, your brain to ovaries have to kick back on and very complex hormonal system that I know we're going to dig into completely. But it'll take some time to see if that pattern

is regular to identify warning signs. So we have a generation of women who were started on the pill maybe for irregular cycles or acne or painful or heavy periods, very valid reasons. But they never had a workup done to figure out what was going on. They never were told. The pill may have been the right choice, but they didn't get that opportunity to say, hey, this might be PCOS. Here are other things you should do. You should know when you stop the pill, your cycles might go back like this.

So you should give yourself some time to figure that out, see a doctor earlier in your time to conceive journey. And I think this approach of not educating women earlier is really setting them up for a deficit. And then what we're seeing online is this entire social media campaign against birth control pills about how they cause infertility or how they cause your periods to be irregular. Or they cause acne. And I'm essentially an advocate for you making educated choices about your body with real information and real data. And so this online smear campaign against the birth control pill is also equally harmful because there are people who could benefit from them who now are afraid because of what they are seeing online. And I think this is just speaking to the complex

relationship of people not understanding how hormonal contraception works and what may or may not be the right choice for them. There's a lot of meaty stuff in there. I'd love it if you could spend a couple minutes explaining how it works, what it's actually doing to your body when you're on birth control pills or any kind of hormonal contraceptives. And then I want to get into from there, let's say I've made the choice, hopefully an educated one, that a hormonal contraceptive is right for me. What are the things that you might want somebody to do before they introduce these exogenous hormones to their body? And you mentioned like that work up to root cause some of the symptoms that they might be trying to mask. Anytime we want to talk about birth control or hormonal contraceptive, let's talk about the normal cycle really quickly.

Great. Because everything is manipulating the normal cycle. So menstrual cycle 101 in one to two minutes. I like to think about all the eggs you ever have kept in a vault inside your ovary, and every month you have a group of these eggs available to you. Each egg grows inside a small fluid-filled structure called a follicle. The brain is going to send out f-sh, follicle-stimulating hormone, so a well-named hormone, which gets a follicle to grow.

And as the follicle grows, the egg is maturing. It makes estrogen. Our bodies love that estrogen, but when estrogen levels are high enough for long enough, so 200 picograms for 50 hours, it's a very specific amount. then the brain knows there's a mature egg and it will send out a surge of a hormone called LH. LH then comes from the brain and allows the follicle to rupture the egg to be released and that's ovulation. But after ovulation, that same follicle reforms and now LH is released in pulses throughout the entire second half of the cycle. And this cysts that was the follicle

is now called a corpus luteum. And this corpus luteum is making progesterone in response to the LH pulses from the brain. Well, the corpus luteum can only live for about two weeks if you don't get pregnant. If you get pregnant, a pregnancy comes in, and the hormone from a pregnancy, HCG, actually binds to the LH receptor. So it keeps the corpus ludium alive, stimulating progesterone production. But assuming you don't get pregnant that month, your corpusoleum is going to die. Progesterone will drop, and you will get a period or a menstrual bleed, and then this process starts over again. But this progesterone timing is really important when it comes to getting pregnant because it opens and closes the

implantation window inside the uterus. And so when we step back and then we talk about hormonal contraception, there's a few different types that all get lumped in this bucket. The birth control pill, what we started talking about is a type of estrogen, ethanol estradiol and a type of progestin. And all the different brands of pills that exist all have different types of progestin, which is synthetic progesterone. These are very effective because they work at multiple layers. So they have the ethanol estradiol in them, binds to estrogen receptors in the brain, the brain says, we have estrogen. So I don't need to send out FSH or LH.

I already have an egg happening. So the brain thinks you're already in that state because it sees estrogen in the pill. So no FSAB being sent out, no egg growing, maturing, or ovulating. But the pill also has daily progesterone. That changes the uterine lining. So it sends out the uterine lining, changes its architecture. It also changes the cervical mucus. So you see a difficulty getting pregnant when you're on the pill purposefully because you're not ovulating.

you see a change to the lining and a change to the cervical mucus. So you really have multiple layers of protection if you're trying to prevent a pregnancy. So to summarize, two things are happening. The estrogen's telling your body you're already pregnant, so don't ovulate. An egg is already growing. Or an egg is already growing. And then the progesterone makes your uterus, like, less friendly for implantation. Exactly, to sperm and to implantation. Yeah, less of a hospitable environment. Okay. Exactly. So it's really working in twofold. And to answer the second part of your question before we do. Most of the other types of hormonal contraception only based. So you have things like progesterone IUD, which is working just at the uterine level.

So you get those progesterone effects at the uterus and at the cervical mucus. You also have progesterone when it comes to an arm implant or you could have a shot of progesterone. The implant in the shot are high enough progesterone dose to prevent ovulation completely. So you do get that multilayered approach, but they take longer to get out of your body. They're long acting. forms. The one in your uterus is a more local impact, but in some women, they won't ovulate, and some women they will. Often what happens is because the IUD is very long acting, you might not ovulate at the beginning. And then towards the end of your IUD, maybe if you're in years five to seven, I'll have women say, oh, I'm starting to get a little monthly spotting

again, right? They start to ovulate again, sometimes on the IUD. But it doesn't always prevent ovulation in everybody. And it doesn't matter because it's going to prevent the implantation. The suppression locally with a hormonal IUD is so profound that the lining becomes so thin, many women have amenorrhea or no bleeding altogether. So they all work slightly different, but in the same idea of manipulating that normal hormonal system so that you can prevent a pregnancy. What workup needs to be done before you start hormonal contraception? I think this really depends on why you're starting it. So if you have perfectly regular cycles, you just want an effective birth control option. Maybe you don't need much of a workup. You want to understand how it

works and you want to think about what this means when it comes to stopping it in regards to getting pregnant later. But if you are being prescribed because you have heavy bleeding that you're bleeding through your clothes or extremely painful periods or irregular cycles, these are circumstances where we have to think about do you have uterine fibroids or uterine polyp? Do you have endometriosis? do you have PCOS? And the workup for each of these is a little bit different. But what I always tell patients, or I mean, now it's I'm telling friends to tell their doctors for their daughters. And I say, hey, it's not that the pill may not be the right choice for this exact problem. But should we ask the question, well, hey, the periods are really heavy. Why is that? Have we looked for reasons? Can we try to find something? Because that might really change what happens down the road. I'll see patients come in for fertility treatments who have. have a bleeding disorder that makes their blood really thin. And they bleed really heavy. And they were on the pill for all these years. And as an adolescent, they had extremely heavy periods, never worked up. And now we are finding this out later on. So just one of those examples where

I don't think any doctor is trying to do the wrong thing. We know, there's a lot of issues in how the medical health system is structured when it comes to patient care. But it's essential that you're an advocate for your own health. So if you say, what I have this problem, what's going on, we should at least try to get to the answer with blood work or imaging, depending on what the exact problem may be. So this is such an important thing that you brought up, which is the need to be an advocate. And so I wonder if you can just speak to what is standard of care? So let's say in two different cases. So in one case, a patient or a patient's daughter comes to you. They're 18 years old and they just want birth control because they have a serious boyfriend and aren't ready to

be a parent, but otherwise a sort of healthy normal cycle. And then for the other patient, let's say they complain about uncomfortable symptoms, whether it's heavy bleeding or cramping or something like that, and they're not looking to get pregnant, and they just want those symptoms to go away, and they're looking to our hormonal contraceptive to make those go away. Is it correct that standard of care in both cases is here's your birth control go? And on the topic of being a great advocate for yourself, what should those patients be demanded? So I think standard of care is a hard word. I think common practice might be a better description of what is happening or what has been happening. Certainly, that's what we have seen. And we have

a generation of women who didn't have any workup or any discussion even, and we're just giving a prescription. We're definitely seeing a change towards more patient-centered care, but every physician, every provider is going to be different. And I certainly think in the two examples you gave, we could see that exact scenario playing out where these two patients are very difficult. different, and they have the exact same thing happen. We'll hear some birth control. That'll make it better. We'll see you back in six months. And no real discussion or work up if it's indicated. I think if you're a patient, it goes twofold. So what I recommend is, number one, knowing your symptoms and your story. And that sounds really simple, but it can be a lot when you sit in front of a doctor

and you've been waiting and you feel nervous. So take a moment to make sure you write things down and think about how long this has been happening, what's associated with it. And, you know, Maybe if it's a change from what you had before, that information's really important. Because as a physician, I can only work with the info you give me. So you've got to give me the best description of what's going on because that's going to allow me to start thinking, well, what test do I need to order? And don't downplay it. This is a relationship to be very honest. I see a lot of people like, oh, it must not be that bad or, oh, it's okay.

Just be really honest, this is bothering me. This is what's going on. This is what I'm concerned about. I also think it's important to schedule the right type of visit. A lot of people don't really understand that the different types of medical visits have different lengths of time. So at an annual visit, your doctor might have to go through your pap smear, your other screening, they have a whole checklist of things they have to get through in order for that visit to be successful. And now have 12 minutes to do it. Right. And they have no time. And they have this list of items. So I always say, hey, if you have a problem specific visit, you should call your doctor and say, I'd like a visit to discuss heavy periods, or I'd like a visit to discuss birth control options. And I see so many people who just wait for their annual, and they'll just bring it up when I'm there. That's me. I mean, I think so many of us are, but you're not going to get the best care that way.

That's not how the visit is structured. That's not the time that your doctor has allotted to go into that discussion. I think that's such an important tip because I think people go to their annual. They ask the question. They don't get a satisfying answer. And then they just go, like, well, my doctor was useless. Right. And instead, what you're saying is no, like, that's user error, maybe totally understandable user error, but user error.

And I should call my doctor and explicitly say, this is bothering me and ask for help with that thing. Exactly. A problem focus visit is typically 20 to 30 minutes. And an annual is 12. So you get a 20-minute visit. You can talk about your heavy periods, think about what's going on. they can get this history, explain the testing, explain the workup, the options. You're going to leave feeling like you got a lot better care than if you tried to say

before your doctor walks out the room after your pap smear, hey, but my periods have been really heavy. What should we do about it? And it's an understandable user error, but it is not how our current health system is meant to be. An annual is everything is rocking and rolling fine. It's a preventive care visit. So if you have any problems, you should schedule a separate visit to go talk

to your doctor about those, and then they have the right time to discuss them. And I think that's one of the biggest keys that I see people messing up on and then to your point getting really frustrated. I think that's just such an important tip and just in general, an important tip about understanding what your annual physical is and that you shouldn't just save your laundry list for that. Like that is about preventative stuff. Let that serve its purpose still go to your annual physical but any questions you have deserve their own visit and just really helpful to know that if I schedule it that way I'll get 20 to 30 minutes which is enough time to go through these things not 30 seconds tacked on to the end of the last piece of advice to this I always give

patients regardless of what you're doing is understand why you're doing the test you're doing what are we looking for and then understand what I call the next step so what do I as the patient need to do next. So I need to get my blood drawn. That's going to happen today. Then I need to call when my period starts to get this ultrasound scheduled or whatever your to do list is. Last minute of that appointment, clarify it so that you again understand, okay, these are the steps that I'm going to do. And then when the results come back, what's going to happen? Are you going to get a phone call, an email, a portal message? Are you going to have a follow-up visit? That's important, too, is setting the road for expectations. So I'm going to do these things. How am I going to get results?

What are we going to do next? And I think a lot of times as a physician, you feel like you covered it in the course of the visit. I told you all these things. And then I realized at the end, the patient's absorbing so much information during the visit. So it's really helpful. I like to just summarize it and say those things. But every doctor's different. So as a patient, you can say, all right, before we leave, let me make sure I understand. We're doing X, Y, Z. And when those results come back, we're going to have a virtual visit to follow up on them, whatever the case may be. I like that. It's a good also tip for patients to regurgitate back at the end of the visit, what they think we've agreed on, and to not leave until you feel like you know what next steps are.

Exactly. And to not just kind of have the visit be, you know, its own thing and then not know what's coming. I want it. And this is going back. a while, so maybe things have improved. But when I was in high school, a ton of my friends got prescribed birth control by dermatologists to treat acne. And you're an OBGYN. Like, is that something that people, and I guess specifically like maybe parents of teens, should be really careful about or how should we think about it? Because I think a lot of birth control is not getting prescribed by OBGYNs who are thinking about what I'm doing to your reproductive hormones,

but instead it's symptom management for other manifestations of these hormones. And if you're one of these people that, you know, this prescription is sort of being managed by a different specialist, how should they kind of bring that back into their primary care or something like that? That's a great question. You know, the birth control pill, because of how it works and decreasing the gannatotropins or F-S-H and LH from the brain, it's a potent decrease in your androgen production, but also because the birth control pill specifically increases something called sex hormone binding globulent in the liver. And the easiest way to think about this is it binds to free circulating hormones. And testosterone's a big one. So it binds to

testosterone, lowering the level of testosterone that could be active, meaning it's extremely effective for acne and those high androgen symptoms. And I see dermatologists prescribe this in twofold. to treat acne itself, and then also because some of the medications they want to use to treat acne work better in conjunction with the pill, or they're very teratogenic, meaning can cause birth defects, and they want to ensure that this young patient is on effective contraception. It's not wrong. It does change your hormonal profile. In this case, you're getting a huge symptom benefit. We know acne can be hugely impactful for everybody, but especially for teenagers or younger women. But it is impacting in your hormonal system. And so the same thing that I would say, health care is so fragmented,

but you have one body. So when you do go to your OBGYN, you need to make sure you say, hey, I was prescribed birth control by my dermatologist. I'm really happy on it. But is there anything I should know about this? And truly, the birth control pill is out of your system very, very quickly, right? So the half-life is 28 hours. There's this idea that the pill's going to linger you're around for months and you need birth control pill cleanses or to do something when you stop it. And none of that's true. It will take a while just based on the length of the time the menstrual cycle takes to see your cycle pattern. And if that's such an important vital sign like we started this discussion with, it will take you a while to see some of those red flags that

things are off. So you lose that opportunity. But it doesn't change the rate of decline of your eggs. You're losing eggs every single month, no matter if you ovulate or not. You actually lose the majority of your eggs before you ever have your first period. They are constantly coming out of that vault in the ovary. And until the brain matures in puberty, which is when it starts sending out FSAH, you're not going to ever ovulate. But you also lose eggs when you're pregnant, when you're breastfeeding, even though you're not ovulating in those times either. So the breath control pill is not changing the trajectory of egg loss. It is not inducing infertility or causing people to have a higher rate of infertility. But it is masking some other hormonal problems. And

problems, you're losing that vital sign. And that's part of why when we switch that conversation to say, when should we stop the pill, when we want to get pregnant, when you stop the pill, you could get pregnant immediately, right? That's an important idea. But in the perfect world, I love people to stop the pill three to six months before they want to get pregnant, not because it has to clear out of your body, not because you need to buy a birth control pill cleanse, but because it's going to take time for you to start seeing your cycle to learn how to track it and then say, oh, my gosh, maybe my cycle's really far apart and something else is going on. Or, hey, look, since I stopped the pill, I've been having this really heavy bleeding or my luteal phase is short. All these little

things your body's trying to tell you about your hormones, you've lost that indicator on hormonal contraception. And that's okay for certain phases of your life. That may be totally great. But we want to make sure that we stop that in time to then really get to know what's happening. What's up, folks, if you are enjoying this podcast or if you care about health, performance, fitness, you may really enjoy getting a whoop. That's right. You can check out whoop at whoop.com. It measures everything around sleep, recovery, strain, and you can now sign up for free for 30 days. So you'll literally get the high performance wearable in the mail for free. You get to try it for 30 days, see whether you want to be a member.

And that is just at whoop.com. Back to the guests. I want to shift gears a little bit because I think there's something that is so, so important for people to take away from this conversation, which is just everything that your cycle tells you about you that's useful to know inside and outside of any desire to get pregnant. And then the other piece that I would just kind of love to touch on is I have so many friends who sort of found out that they had endometriosis or PCOS or something because they struggle to get pregnant. And I'm under 35. And so guidance under 35 is that you have to like wait a year before a doctor will even

see you for anything related to infertility. And whenever I can sort of tell people that has to be the right kind of relationship, but it's like I wish at 25, you know, long. before you're thinking about kids, maybe even before you're married and, you know, ready for any of that, you just kind of know because it's so heartbreaking to deal with infertility. And so many of these issues are fixable, but they can take a year. And like in the context of now feeling the pressure of your, you know, ticking clock and all that kind of stuff, I think it's just we make it so much more painful than it needs to be.

And so two questions. what is important for people, even if they're completely confident that they never want to have kids? So it's not about preserving fertility for later, but just what is important for health. And then the other question is, let's say you're so not ready yet, but you want it eventually. What can you ask for years before that is just going to set you up to deal with any problem that might get in the way? so that when the time comes, it's just about having fun with your partner and not this horribly stressful thing. And when you really hit the nail on the head here, my big mission and passion is to completely

change how my field approaches infertility. So that's like some lofty goal, right? Right now, by definition, you have to fail at something to then get a workup, right? Which is horrible. It's horrible. You have to try for X amount of time. You have to have a current pregnancy loss. you have to have this failure, quote unquote, to then even get the definition that gets you

and to be seen to get this work up done. It's a completely reactive field. And I've been a huge advocate proponent that this should be much more preventive care. If we think about a correlation, I'll use myself. I wanted to be a doctor. I wanted to be a mom. Those are my two big life goals when I was in my early 20s. I did so many things to be a doctor, right? I went to math school. I studied for the MCAT. I did internships. I had all these things that I did and I prepared and I planned. And what did I do about the mom goal? Nothing. I didn't learn about my body. I didn't think about it. There was no tests that were run. It was nothing until it was time. And so those things are really in contrast. If we say for a large number of people having children is a life goal, yet we don't even talk about this till later. Or to your other point, fertility is a sign of your hormonal health, which is important in your longevity, in your future overall health risks. Understanding things earlier give you more opportunity and time to change the trajectory of your health and have a healthier, happier life. So it's this entire idea that we don't even learn about these things till later, which I hate. And it's why I

wrote the fertility formula in a book coming out because of this idea. So I'm going to try to summarize all of it much, much more quickly for you. This discussion is very nuanced. And I have to admit here that what I recommend is against what the American College of OBGYN recommends. So when it comes back to the idea of your fertility as you get older, let's say there's two main ideas for female infertility that start to contribute. So you run out of eggs. You also have a decrease in the quality of your eggs. And when we talk about the quality of your eggs, this is both the genetic normalcy, but also the metabolic competency, the ability of the mitochondria to do their job for that egg to divide normally. In fact, early embryo growth up until day

three, so an eggs have been fertilized by a sperm, that sperm's genome doesn't even kick on until day three. The egg has to carry it that entire first few days. So the egg health is so, so crucial. And this is why you get this double hit as you start to get older, because not only do you not have as many eggs to work with, you start to have a decrease in their ability to accept sperm fertilize normally, and then also an increase in the rate of chromosome abnormalities. And so this is really confusing. And the way I like to think about it is we can't check your egg quality. There's no test for this. I can't run a test to say how many of your egg chromosomes are genetically normal, is the DNA fragment. There's no test for that. So we assume egg quality based on age

right now, which I think is an oversimplification because that's one piece of the puzzle that doesn't take charge of this metabolic health. And in fact, there was a recent study done that's actually been misquoted online showing that the mitochondrial DNA doesn't have as many abnormalities as we age as the nuclear DNA does inside the eggs. And I think that's wonderful news. So online we see people saying, doctors have been lying to us. Our eggs are not aging. And that's not true. Nuclear DNA is still aging. We have an increase in chromosome abnormalities as we age. But if the mitochondrial DNA do not age at the same rate, we don't have as many genetic abnormalities, that means this metabolic. health idea can be preserved more as we age and gives us a little bit more control to say

how am I going to decrease inflammation and insulin resistance and things that do negatively impact egg health? Egg count though is separate and we do have tests for this. So the idea here is that if we go back to that analogy where there's a vault where all your eggs are kept, you're born with them all, you run out of them over time, every month a group of eggs comes out of them, we already established that. But what's really interesting is that when the vault is more full, more eggs come out every month. And as the vault starts to get emptier, fewer eggs come out every month.

And that's really fascinating. It's why you run out of more when there's more eggs in the vault. But that means we can check the eggs outside the vault. And that's a surrogate marker for how many you have inside. So there's two ways to do this. One is with an ultrasound where we count the small fluid-filled structures, those follicles. That's called an AFC antrothal follicle count. The others with a blood test called AMH, or anti-malarine hormone.

This is much simpler, right? A blood test that you can draw on any day of your cycle. AMH is made from the granulosis cells. These are cells that surround all the follicles. So to put it really simply, if you have more eggs remaining, more are going to come out of the vault, there's more granulosis cells, you're going to have a higher AMH. And it's not a perfect test. No test is because your vault's also not perfect.

If I said for your age, I would expect you to have 18 to 20 eggs outside the vault in a given month. you're not going to have 20 eggs every single month. It's going to vary some. So these hormones do vary, but the analogy I give to somebody who is aware of their health, because an antithalcal count might be like checking the glucose right now. Important and helpful, but not everything. Right, because you don't know what I ate in the last 24. Exactly. It's influenced by so many different variables, but it's still really important data. AAMH is maybe more like a hemoglobin A1C. It's in your bloodstream a little longer, giving me an average of what's been happening the past few months. But both of these things are influenced by the world around us to some degree. And that is true

in our ovaries as well. Well, right now, the American College of OBGYN or ACOG recommends that AMH is not test in women unless they have infertility. Okay. And the idea here is that low numbers will cause undue stress and are not correlated with infertility, which is a yes and a no answer. But they say, hey, that's going to cause too much stress, too much testing, they don't recommend it. And I am on the complete opposite end of the spectrum. I feel like that's a statement that reflects everything that's wrong in health care. Here's a data point where for a woman, if you found out that you might have lower ovarian reserve, would you make different choices? And I see patients every single day who might. Maybe they are in a relationship and they could start trying for their family

earlier. Maybe they would freeze eggs. Maybe they would change some lifestyle factors. Maybe they would say, I'm not going to do anything. But you know what? Then they were the one to make that decision and not time, which is going to make it for you. Right? For all of us, time will make the decision for you. And even on the spectrum of I don't want to have kids, that number is correlated with when you're going to go into menopause. So knowing, hey, I might go through menopause earlier, that's going to give you this entire, well, I need to look out for these different things. how am I going to approach my health, thinking about your future when it comes to your hormones in a very different light. And I think that information is extremely important and powerful.

The other argument I'll say on this is that the reason they say it doesn't impact your fertility is there was a study done that looked at women with different AMHs and showed that your monthly rate of conceiving in this population study wasn't that different. So with the idea here, if you have six eggs outside the vault or 20 eggs, you're going to all. ovulate one, right? So you have your age-related chance of getting pregnant. But why do you have six eggs? Then the reason there probably is really, really important because things that can cause low ovarian reserve might not impact fertility or they might impact it very much so. So things like I had an ovary amoeuvre for a cyst. There's a genetic factor and I just was born with a lower number

versus I have endometriosis, or I have an autoimmune disease, these things can cause low ovarian reserve, and they definitely impact your fertility or your ability to get pregnant. So that's where I think we miss the mark with this AMH screening. And I've seen a shift even in OBGYNs, despite ACOC saying this, where I, my strong desire would be the moment your OB says, hey, what do you want to prevent a pregnancy? and you have this birth control discussion, the other end of it is, but do you want kids one day or are you interested in checking your ovarian reserve? Because it is a test that if it's normal does not mean you'll be fertile. Doesn't mean you'll have no problem. But for the women who

it comes back low, it's useful data. It's very useful. Then you get to be the one in control of what you do with that data. And maybe, again, maybe you do nothing different. But it was you who got to make it. So I recommend, and I wish all women earlier, would get an AMH test in their mid-20s, regardless if they want to get pregnant or not get pregnant. Can I ask a question about that? If I'm already on hormonal birth control, will an AMH test still be accurate? Fabulous question. Yes and no.

Any profound ovarian suppression will decrease the production of AMH from granulosis cells. Now, it doesn't actually change how many follicles you have or your rate of egg decline, but their production is suppressed in some women and not in everybody. And it can be suppressed the most looks like on continuous birth control pills. So when you don't ever take a pill break or even have a period, you just take a pill every single day, then you're going to have a potential decrease in your AMH. If you are postpartum or breastfeeding or pregnant, you're also going to have a decrease in your AMH. So the same thing. You have a profound ovarian suppression in that moment as well. Do I recommend women get off their birth control check in AMH? I don't because for the

vast majority of the population, it will still be in your normal range. And so we say, hey, even if it's slightly suppressed for me, it's normal. I feel more confident that at least this isn't something I have to deal with. If it comes back low, well, then it's a more nuanced discussion. And this is where I recommend you schedule a visit with a fertility doctor because we love seeing patients in this place and we'll say, hey, what's your follicle count? Should we stop your bird? control and recheck it. And a lot of it might really depend on what you're going to do with this information. Somebody who might say, I might start trying to get pregnant. We might do a complete fertility evaluation, looking at your partner and other factors. Somebody who says, maybe I'll freeze my eggs,

there's going to be a different recommendation for where you are, but we should personalize it. But for the vast majority of people, it'll still fall into the normal range. And so then you'll feel that reassurance, okay, at least this isn't low, doesn't prove I'll have fertility later, But at least it's not one variable I need to deal with right now. And I think, you know, not every doctor is as incredible as you are. And some doctors aren't going to be excited to do an AMH test that's not, quote, unquote, medically warranted yet. So it's worth pointing out that there are at-home kits where you can. We live in an interesting medical world.

In addition to at-home kids, many patients, you can just order one from LabCorp requests, order your own AMH test and get it. And I love that and I hate it at the same time. I think my recommendation if you ask your OB. So let's say you do, go to your OB. You have no issues, but you're curious about it after this conversation. You're at your annual visit. We know there's not much time.

But you want to ask, can you add an AMH to this? And you get a little pushback. Here's what I would say if I was a patient. I'd say, I know this test doesn't mean I'll have infertility or have fertility. I know it doesn't mean that. But this information is helpful to me in planning my feelings. future. And if it's abnormal, I'll schedule a visit with a fertility doctor. You then have taken a little bit of the pressure off of the OBGYN saying, I understand this test is not perfect, but it's

helpful for me. And if it's abnormal, I'm going to go have somebody else help me with this. That would make it, I think, very hard for somebody to say, okay, I won't draw that test for you. If they really won't, then I think this is very important to you. Again, your doctor-patient relationship is a relationship like any other. And I understand the limitations with me saying this is against our medical society and what it recommends. However, patient-centered care is doing what's right for the patient in front of you. And a lot of that does include taking their goals and dreams and wishes into the picture in places where it's reasonable. When they understand the limitations of a test, but they say it's valuable for their future planning, to me it makes sense to draw it. But yes,

you can order it on your own. There's at-home testing options. Same rules apply. Any abnormal result, you should see a reproductive endocrinologist so that we can really talk you through this and try to figure out what's going on. Yeah, and I think you mentioned something so important about it being a relationship. And I recognize sitting here in Boston that we're so privileged to have just an abundance of excellent health care. And this might not be so easy everywhere. But, you know, if you are in a place where there's more than one option and you just feel like your doctor's being really dismissive, I think it is important for people to remember that they can go and get a second opinion or find a new doctor.

Yeah, I think sometimes we hold ourselves back. We feel like we have to stick it out in this relationship. Or it's so hard to find a new one. So hard to find a new one. Oh, I have all these records. But I mean, patients switch care all the time. Nobody's going to be mad at you. It's your health, especially when it comes to your fertility. This is your moment in time to grow your family. And you need to trust that the person on the other side of the table is one that you can trust their advice and recommendations. So I want to just, I guess, open things up a little bit as we think about, you know, practical advice for everybody. So let's go, you know, 20, 30, maybe 45 years old, kind of different phases of life. Like, what should just everybody be doing? So at 20, maybe even 15 years old, right, should everybody be tracking their cycle? If you are not on birth control.

So if you're not on hormonal contraception, yeah, you should track your cycle. Number one, knowing when your cycle is going to come is going to be helpful information, especially if you're younger in the earlier phase of this time period. But then two, a lot of some of these hormonal issues start very subtly. So how I like to think about ovulation, because people think of it as an on-off switch, meaning, okay, you ovulate perfectly or you don't at all and you have no period and like there's no shades of gray in between. And of course, it's not accurate.

There's actually a very well-demonstrated change that will happen as the ovary gets further and further away from normalcy. So we start to see that the first stage is that the luteal phase or the second half of the cycle when the corpus luteum is making progesterone gets short. So we have a luteal phase defect or deficiency, but you're still having regular cycles. The second phase might start to be a change in the follicular phase of the cycle. So you're ovulating either early or late. It can be really reflective of maybe how many eggs you have outside the vault because the fsh signal is getting either diluted or

stronger depending on that because the brain doesn't really know what's happening at the ovary. Remember that hormones are communication systems. And so we'll see that you then have this length, shortening or lengthening of your full cycle. And then you start to get the longer ones, the irregular ones, the erratic ones, and then your cycle goes away. And the reason why that's important is these first couple stages can masquerade in regular cycles. So I think one of the first questions you asked was you can still have regular cycles. but have hormonal issues. And I said, true.

And the reason why is because we often miss some of these subtle signs, this kind of first tier, that our alludeal phase is shortening. And so examples like elevated prolactin from the pituitary gland or thyroid abnormalities, other hormones that need other treatment, they can actually start to first manifest in this shortening of alludial phase. When we start to see high stress levels or inflammatory levels, that actually, that cortisol changes how your body works completely, which we can go into. But in addition to be very inflammatory, it suppresses the brain from sending out FSH and LH to the degree that it should

because it starts focusing on other tasks at hand. And now you're starting to have this what I call hypothalamic dysfunction, meaning the brain or the hypothalamus is not interpreting and responding appropriately. And you're going to start to see this lengthening start to happen. And so this subtle ovulation changes that may masquerade within a normal regular. cycle. Let's say you're tracking your cycle. Yes. You're young, you're healthy. You don't have any symptoms yet. What should I be looking for in terms of a change to trigger for my doctor, oh, this is changed. Because if you go from a 28 day cycle to 29, maybe not so meaningful, but all of a sudden it's four or five days different. What's the threshold for concern?

So I always say, if we're truly wanting to track our cycle, something that's going to help us know when ovulation occurs so that we can know how long is my follicular phase, how long is my luteal phase, that is helpful information. Your body also gives you signals, right, so you can have a change in your cervical mucus. You can detect a whole slew of hormones in your urine, including the LH surge. So I think that for that younger person who's maybe not trying to get pregnant, a wearable is an easy way to really track your cycle. that's more accurate than just your day one to day one. To your question, everybody's cycle is going to vary a little bit. So within one to two days is really, really normal. But when you look back and you've seen a total shift in your cycle length, you say,

oh, it used to be 28, 29 days. And now my cycle's 25, 26 days. That is concerning. Or if you're seeing a variation of four to five days or more month to month. So maybe it's 28 days, then it's 24 days. You know, you're seeing this hop that's a little greater. than that one to two day variants, those are also subtle signs. So it's really helpful to look at that cycle tracking data over months. And so that's why when we went back earlier and we said

stop the pill or stop your contraception months in advance, because you're trying to look for patterns. And so you're really trying to identify when is this happening and what patterns, because everybody's entitled to one wonky month. Yeah. Yeah. And I think that that's what people sometimes don't understand, right, is the variability matters. And in order to get a good read on variability, you're going to need, you know, at least four to six cycles, and that takes four to six months. And so, you know, that sort of first cycle doesn't really count because there's still birth control involved. So then you have to wait for the second month, and you might be an average or a sort of normal range duration, but it'll take a couple months to know if it's variable

or not. Spoken like somebody who loves data, right? But it's true. And I think that's frustrating because as time becomes really important and feels like a very strong currency to pay as we get older or when we're trying to conceive. So part of why you and I are saying, we want women to do this earlier is because knowing that information earlier, say six months of tracking your cycles, gosh, they're abnormal. Now you have to schedule the appropriate visit type. Now you're going to start the workup process. Now you're going to try to figure out what's going on.

That all takes time. And if you know this about your body earlier on, that's going to make it easier. for you either to have fixed the problem or to at least know what to do about it when you're ready to get pregnant. And kind of continuing on this train of thought about sort of normal length and normal months to month variability in that length, I wonder if you could just list off a couple of things that people should look out for that are, you know, raise that index of suspicion that maybe you should follow up with a doctor that have been normalized. I have a good friend who it took 10 years to get pregnant with her son, who's just the cutest little boy. But in

the end, it was endometriosis diagnosis, which she'd had, you know, for over 20 years at that point, completely undiagnosed, not nobody brought up. And as soon as that was diagnosed and treated, but naturally pregnant very quickly, and it's just such a heartbreaking story that I think happens to so many people. I think that we normalize things. Like, you know, having a heavy period is common and there's products out there. And so it makes you feel like, oh, this is a thing because I can go and buy a extra max table on, right? And like, you know, so this must be a common issue because this product's so readily

available or like I get cramps. But if I Google it, loads of information out there. Oh, everybody must be experiencing this. So what's this degree of these are powerful hormones and they're going to do things to your body and that's normal versus, oh, I would go talk to a doctor? here. Okay, this is a great question. And I think we should dive into a few of the things in greater detail that you brought up. But to start really general and then go in, your period should be regular and predictable. You should not have a large degree of spotting, maybe one to two days

of spotting at the very most. If you're having a lot of spotting between, that's not normal. You shouldn't be bleeding through your clothes or through your menstrual products if you're bleeding through tampons or pads too heavy. And your period shouldn't be so painful that it prevents you from doing your normal daily activities, if you're canceling plans with friends because your period's so painful. If you're vomiting, passing out on your period, those are all not normal symptoms

that have been completely normalized. And so that's step one of saying, what's really going on with me and is it normal or is it abnormal? Let's start with painful periods first. Painful periods are a hard thing because pain is extremely subjective. And what we know is that humans, women adjust to their environment. So if this is how your periods have always been, and I ask you

now at 35, well, are your periods painful? You're probably going to say a little bit, but it's okay, I get through it, because that's your reality. And what you don't necessarily have is the relation to how it is for everybody else. One of the most sensitive indicators of your pain being out of proportion or greater than average is if your periods were painful when you were a teenager, especially if you would miss school or after school activities. So if you stayed home from school as a teenager, you wouldn't go to Pizza Hut with your friends or whatever was happening, that's a strong indicator that your pain is out of proportion. And when we're younger, we didn't have all these years of periods behind us to essentially

gaslight ourselves or a little bit or have society gaslight us into thinking that it's normal. We had a more true response to what was happening in our body. And painful periods, we are always concerned about endometriosis, which you mentioned with your friend, and it is a very hard thing. So let's talk about endo and how it presents really quickly and then why it's so difficult. Endometriosis is an inflammatory condition. Essentially, it's an autoimmune reaction within your body. So the idea here is that the endometrium is the lining of the uterus.

This is what we bleed out every month and we have our period. You get patches of endometrial-like tissue outside the uterus. So around the abdomen, what we call our peritoneal cavity, on your intestines, on your ovaries, on your fallopian tubes. and this can impact infertility in a multitude of ways, but the first is through high levels of chronic inflammation because these patches are inflammatory, and they're stimulated by estrogen. So every ovulatory cycle you have, more estrogen feeds the machine, and this endo gets worse and worse. Over time, an advanced stage disease can cause anatomical destruction and scarring as well. So just like you think about if you had a cut, if you picked out it over and over and over again,

that scab would never heal, you'd get a big scar from it. The same thing happens within your body from endometriosis as well. Indo, because of the inflammation, especially when you're on this time of your menstrual cycle, you tend to have extremely bad cramps. You might get GI changes as well, diarrhea, constipation, bloating, and you might have pain with intercourse, especially in certain positions. So usually it's with a deep penetration, depending on where these implants are. Women will frequently say, I really don't like this position because it causes pain or discomfort. And so those are some of the symptoms. But what we know about the disease that makes it so bad is that degree of symptoms does not correlate with degree of disease. You can have asymptomatic

endometriosis. You can know symptoms and have it. You can have terrible stage four disease, have barely any symptoms. You have terrible symptoms and have very minimal. So it's hard because symptoms don't always correlate. It impacts your fertility across all spectrums. the earlier stages because of that inflammation, the later stages because of the inflammation and anatomical destruction. You can have blocked fallopian tubes, scarred ovaries. It decreases your ovarian reserve. It can cause bad cysts in the ovaries. So it can be hugely impactful for your ability to conceive. But it's a surgical diagnosis only, meaning you have to put a camera in the abdomen, look around and see the implants to get a true diagnosis. Now, the caveat I will say

is that sometimes in that later stage disease, when you see anatomical changes, you can sometimes see it on ultrasound. So there are sometimes times where I see a cyst that is an endometriosis cyst, or I see that the ovaries are scarred in certain positions, and I might tell a patient, you have endometriosis. Even though we didn't do surgery and we go get to the diagnosis, what I see here is telling me you have it. Now, important bias is that Indo is very prevalent in infertility population, and I do ultrasounds on lots of people, so I have a different patient population than the regular. But I see very often

women will tell me, well, I had a normal ultrasound, so I don't have endometriosis. And that's not true, right? A normal ultrasound just tells me you have a normal ultrasound. It doesn't mean that you don't have endometriosis, nor there's no blood test that's accurate or proven for it either. Does this mean you should go have surgery for it? I think this is an important question because the treatment for and does really tough as well. If I want to treat these lesions that are stimulated by estrogen, medically, I want to stop your body from having estrogen. So all these treatments decrease estrogen production or stop estrogen and stop you from ovulating. Therefore, they may be good options, but not when you want to get pregnant, right? So they may halt or slow down the disease.

Nothing's going to reverse it or treat it or cure it. And then you have surgery. And surgery can be very powerful, but it's nuanced. So taking out these lesions will decrease your inflammation. So especially if you're an early stage disease, which we don't know until we operate on you, but if you're an early stage disease, taking out those lesions will decrease your inflammation and suddenly you'll have an improvement in your hormonal parameters and your ability to get pregnant. And that's likely, I don't know, your friend, but that's likely the senior that happens to a lot of people is they end up going to surgery, they get early endodagnosis, the lesions get size and then within those first six months, their fertility is markedly improved. And we see a bump

in natural fertility or a response to treatments. Well, that's not the case for higher stage disease. We start to have less of a benefit because we start to see other side effects of this really prolonged chronic inflammation or the drop in a count or the anatomical changes that can't always be reversed the same way. And repeat surgery doesn't show the same fertility benefit. So we only see that benefit to fertility the first surgery, which is very interesting and makes it tough for us because you might say, oh, the girl who has very painful periods at age 20 should go have surgery and have endot taken out. And maybe she should because pain can be extremely impactful for her life. But we have to then think about, is she also going to go on something to prevent

ovulation all these years? Are we going to try to keep it at bay from coming back? Because it will come back. It's how your body is wired to do so. Subsequent surgeries have utility for pain. So it's not that they never have utility, but I always tell a patient, we shouldn't go into this expecting the same improvement in our fertility if we've already had prior surgeries. Pain of, of course, a valid reason to go off surgery. But it's very nuanced. And then sometimes, depending on other factors at play, sometimes surgery doesn't make sense at all, meaning if we're doing IVF anyway, then there are hormonal. changes we can induce in your environment that will give us the same drop in inflammation.

We can't do in natural cycles because you won't ovulate. But in IVF, when we've taken your eggs outside your body, we can. And so sometimes it doesn't make sense to go to surgery, take the time out, spend the money, especially in the patient who maybe doesn't have a ton of pain because sometimes you could actually have more pain after surgery. So it's very nuanced and personalized what you're trying to do. But it's one of those things that no doctor's going to know if you have it or not, but they're definitely not going to know if you're not bringing it up. So going back to that advocacy piece of saying, I don't think this is normal, I am struggling with this, what could it be? And the decision to get surgery or to do this is very personalized,

but you need a doctor who you can have that discussion with, and it'll depend on a lot of different factors. Is it correct that something like one in ten women have endometriosis? One in ten women have endometriosis as many as 30 to 50 percent of women with unexplained infertility. have endometriosis as well. And I think what's so staggering about that stat is that therefore endometriosis is normal. And so I think what happens so often is like you start to talk to your friends. You're like, do you have painful periods? And they do too. And they do too. And so then you're like, oh, you know, this is just like part of the deal. And I think that what's normal and what's like inevitable are different things. And so just because it's normal and you've normalized it for 20, 30 years,

you know, doesn't necessarily mean that, like, there's nothing that can be done. And so even if, you know, this has been how your periods have always been and you've got loads of friends with the same struggles, would just definitely encourage people listening to this if you are experiencing, like, this level of pain to go see a great OB-guine because there are things that can be done. You know, it usually takes seven to nine years to get an endo diagnosis. So it's one of the most heartbreaking things that we see. And so I will say the most common symptom there, is going to be that pain or those GI symptoms, especially if they're really bad on your period, those should start to heighten your sensitivity. Also, if you have thyroid disease or

autoimmune disease in your family at higher risk as well, if you had a mom or a sister who had endo, you should start thinking about it in your brain too and bring these things up to your doctors so that they're aware of them. I love the call out that it's genetic and I think that not enough people talk to their moms and siblings, but moms in particular or grandmothers about periods because it just, it's awkward, right? And we've made these conversations so much more awkward than they should be. But, you know, I think really important for people to have those awkward conversations because they're potentially life-sating. Yeah, the generation above us definitely didn't talk about their fertility of their periods. If we think we're just starting to

have this discussion, it was definitely not talked about. And we have a generation above us who had hysterectomies, had ovaries removed. It's very complex. But asking the women in your life if they had heavy or painful periods, if they had infertility or pregnancy loss, and when they went through menopause, that information is very important and might change how we approach your care if you let your doctor know. You know, back to your question, too, before about what's normal, what's not normal, I think thinking about, hey, I'm having really heavy bleeding is a different thing. With endometriosis, although people can have two different things, you tend to have this painful, but regular. It doesn't tend to impact the regularity of your

cycles very much. If you're having regular but very heavy bleeding, bleeding through your clothes, then we're really worried about uterine fibroids being first and foremost. And these are extremely common, up to 70% of women will develop a uterine fibroid over their life. And so very often not diagnosed or until there's a problem or until later, they can contribute to that. that really heavy bleeding, that anemia, the need for blood transfusion, in addition to almost looking like you're pregnant when you're not, they sometimes impact fertility and they sometimes don't, depending on where they're located in the uterus. And there's sometimes a surgical option that can treat them. But fibroids are quite easy to diagnose unlike endo because

a ultrasound will clearly show them. So if you're having really heavy bleeding, bleeding through your clothes, a vaginal ultrasound looking specifically for uterine fibroids is one of the things that's top on the list. But that's an easy diagnosis to get in a way compared to endo. But again, you have to bring up, hey, I always bleed through my clothes or I bleed through my tampons so that your doctor can start to look at those things because that's not normal. We also don't want you to have that degree of anemia. And I know when you talk about irregular cycles in PCOS. So when it comes to, we said your cycles can't be too painful, too heavy, and they need to be regular. So regular and predictable, as we talked about earlier, is really important. Of course,

the top cause of irregular cycles is going to be PCOS polycystic ovarian syndrome. This is a very complex and misunderstood disease that you see a lot about. In general, when it comes to PCOS to get the diagnosis, you need two out of three. These are called the Rotterdam criteria. One is going to be irregular or absent period, so those period changes. Two is going to be having any clinical or blood signs of high androgens like testosterone. So it doesn't have to be a blood test, but it could be. But if you have acne and irregular cycles, congratulations. You have met the diagnostic criteria for PCOS. And I haven't drawn a lab or looked at you at all. We can say that's the failure of the diagnosis, but that's how it is right now. And the number

three is an ultrasound-determined high egg count. So having a higher than normal number of eggs. Really, PCOS is a miscommunication between the brain ovaries that leads to a whole metabolic downstream impact on your cells. The way I like to simplify it for your patients, if we think about you have that group of eggs coming out of your ovary, and the brain's going to send out just enough FSAH to get one egg to grow. Remember, the brain can't see the ovary, so it doesn't know what's actually happening, and it is sending out its regular amount of FSAH expecting the job to get done.

But if you have 40 eggs outside the vault instead of 20, that FSH signal is diluted. And none of the eggs is getting a strong enough signal to start growing and making that mature egg and making that estrogen that comes with the egg maturing. The ovary loves to make hormones. It's a hormone-making factory. And so when it can't make estrogen at these high levels, it gets really bored.

And the pathway from the brain to the ovary to make testosterone switches on and becomes preferred. So suddenly the ovary's like, I don't know why that one's not ovulating, but I'm going to start making testosterone and do my job. That pathway starts to become preferred. This is multiple downstream implications, one of which is we're going to see an increase in central weight gain. Think of that male beer belly versus that female distribution of fat. But then also we're going to see this bump in insulin resistance, and we're going to see chronic inflammation. And then these changes start to just get worse and worse over time.

The other thing to understand about this process is that insulin resistance and inflammation are a huge part of the picture. Those almost provide interference at the brain level. So the brain's having a hard time sensing what your true estrogen is because it has this interference. And then if you happen to be overweight, which is not a requirement of the diagnosis, but because of this male hormone shift and the insulin resistance, insulin resistance, that high insulin in your blood makes you deposit fat cells. So it's a part of the problem. Even in thin women, they may have an out of proportion of their adiposity for their overall

body habitus. Each fat cell makes estrogen as well. And so then that is also confusing the brain. And so the brain is having a hard time knowing what's really happening at the ovary. The short answer is it never gets the signal to send out more FSAH. Because it says, I think I have enough estrogen happening here. There's enough small, tiny little eggs each making, let's say, one picogram. Nobody's making 200. But I've got a little bit from the fat cells. And then, oh, the insulin resistance and the stress is coming in.

And the brain says, we must be good. We're doing stuff. And so you really get stuck into this pathway where sometimes you'll see delayed ovulation because eventually one follicle has seen a long enough signal of FSAH to be strong enough. And so very classically, you might get these longer cycles, a very lengthy follicular phase, more overall low estrogen days, but high androgen days. You aren't making as much progesterone because you only make progesterone after you ovulate. So if you obviate less, less progesterone.

PCOS is tough because there's a lot of online chatter about it. And a lot of people calling it estrogen dominant and recommending a whole slew of things, which may or may not be the right thing. The heart of PCOS is, well, if I can't change my account, which we've clearly established we can't, we've got to take control of the metabolic factors here. And so reduction of insulin resistance is key to treating the disease. That sounds great in theory, but it's also, it really takes lifestyle change to really try to do that.

But then understanding that estrogen dominance is simply estrogen without progesterone. And if you are not regularly ovulating, you're going to be a longer follicular phase, which is naturally an estrogen-dominant phase. And so if somebody's going on daily progesterone, which I'm seeing every week right now in clinical practice, somebody has irregular cycles, they go to a hormone expert, they are put on daily progesterone because they're estrogen-dominant, and they are trying to get pregnant.

But now they're essentially on birth control pills, because we already talked about how progesterone opens and closes that implantation window. So now this person is being prescribed hormones, even though they want to get pregnant, which are preventing pregnancy. So big red flag, if somebody's handing you progesterone to take every single day, you should say, wait a minute, that's not how my cycle should work. And am I trying to prevent a pregnancy?

Because if you are, great, that might be the right option. But if you're trying to get pregnant, that's not the right thing. And they're showing their cards. They don't really understand how your hormones work right there. You're invited to join the waitlist for Woop Advanced Labs. Advanced Labs delivers clinician-reviewed lab results right into your WOOP app for the most complete view of your biomarkers and biometrics and the most comprehensive understanding of your health. Unlike other tests, WOOP integrates your lab results with your WOOP data. See how your habits and behaviors influence your biomarkers and get clear guidance on what to change to improve your results.

To join the wait list, visit our website or the health tab in the Woop app. In the spirit of helping all of our listeners, can we just list off some of these testosterone or androgen-related symptoms that might be a sign that this is going on? So you mentioned like that central weight gain. We talked about acne. It's also heurcetism. Hearsitism, which is abnormal hair growth. So for a woman that's going to be thinking about like mustache-like hair, chin hair. You can also get, you know, nipple hair or even like happy trail type of hair.

but also meal pattern baldness. So this is where it confuses people. So you can get hair thinning, especially in like the temporal regions where you think about meal pattern baldness happening. So you can have extra hair where you don't want it and losing hair where you do want it. And then in addition, because you have more ultimately your hormones are so oft, we often see a lot of fatigue. So this chronic inflammation is going to cause you to feel bloated, fatigue, headache,

and you get a slew of those symptoms that go along with it. And so that's a lot of different things. Yeah. And so it is a lot of different things. And how many of them would you say somebody should have before, and again, maybe not even yet trying to have a kid, but just to kind of know, oh, there's this potential PCOS, which is a metabolic issue that's going to have all kinds of negative impacts on your life even before it's manifesting as infertility. By definition, you know, one high androgen clinical symptom can get you that. diagnosis. Of course, the more you have, the more concerned we are. And the more severe they are, there are a few things that can cause high androgens that are not PCOS, that we should rule out.

Things like ovarian or adrenal gland tumors, other enzyme defects in the adrenal glands. These tend to present much more profoundly at a younger age, so they're typically not, but things like clitoromegaly. If you start noticing that your clitoris is getting larger, go see a doctor. That's not normal in any context of the world. If your voice is deepening, that is also a sign that you have way too much endrogen for your body that's typically seen only with androgen producing tumors. So there is kind of too much. We're seeing some of those side effects from, you know, young women being placed on testosterone. They're trying to seek care for their hormone imbalance. And my one word on that is just estrogen and testosterone get converted back and forth to each other. Testosterone becomes

exceedingly important in the postmenopausal female. It's not that it's not important before that, but that most of the signs and symptoms you might complain about from having low T are probably low estrogen. And looking at your ovulatory dysfunction and why you're not making enough estrogen is really going to be a better strategy. Taking testosterone if you get pregnant can cause severe birth effects of a girl fetus and is absolutely not recommended in premenopausal women who potentially could get pregnant. So this is super helpful.

And I don't mean to be hating on dermatologists, but I think like so many of the issues that we're talking about, you know, issues with hair loss or hair in the wrong places and acne, people are going to think, oh, I'm going to go to a dermatologist. And while that is definitely one tool in the tool belt, I think maybe a takeaway for our listeners is that there could be an underlying hormonal cause. And if we're just treating the acne or treating the hair loss, you're going to mask that. And so make sure, even if it's an and, not an oar, that, you know, an endocrinologist or an OB-Gine is part of that picture. It's such an important point. And I think part of the reason why we saw this hatred towards birth control pills, you had really bad acne. You got started on the birth control pill at 15, took it for 15 years, stopped it at age 30. Well, you really had PCOS back then that was never diagnosed. And now that you're off the pill, you're going to start to have a raise in your androgens, right? And you're going to start to have irregularity to your cycles. And now. Now you're having adult onset acne, these hormonal imbalances, and you can see why the birth

control pill became the easy scapegoat here, saying the pill caused this post birth control pill syndrome or this litany of things. But the reality was you just weren't diagnosed back then. And now at a much later age, you're trying to figure out how to compensate for them. And for PCOS specifically, if we say, hey, the root of the problem here is this insulin resistance, these are lifelong changes you need to make for your health that you could have started in your 20s. had you been giving the opportunity, you may have chosen to stay on the birth control. You may have said my acne is terrible.

I love being on the pill. But I know that I have PCOS, so I'm going to, one, stop the pill six months before I want to get pregnant so I can see my cycle. And two, I'm going to start changing my life now so that I can learn what decreases inflammation in my body, how to have less insulin resistance, how to change my metabolic health. Because this is a lifelong hormonal imbalance for me that could have serious medical consequences. consequences. Like we've robbed people that opportunity to make those changes earlier to learn about their body. Yeah, I think that's such an important point. And I could talk about this forever. The last thing I'd like to touch on that we haven't gotten to is we talked a lot about how to identify that you have one of these hormonal issues, maybe what the consequences of them remaining

untreated or undiagnosed are. What we haven't talked about really yet is prevention. And I'd love if we could end with what are the things that I can be doing that are sort of available behaviorally to me that will support a healthy period and a healthy cycle? I love this question. And it's interesting because I think everybody's looking for a quick fix and none of these are truly quick fixes and it's not sexy information. There's things a lot of people know or there's a lot of data to suggest and maybe they've just never been clearly said it in a really easy way. Number one is going to be sleep. So most people could sleep more. The easiest way to think about it is that we know a third of all adults sleep six hours or less. We know that your body probably needs seven and a half to eight

hours of sleep at minimum. Sleep is important for decreasing your cortisol. It's important for when your body clears inflammation, when your insulin levels start to go down to fight that insulin resistance. And so not sleeping enough is setting the foundation for your day. So you're starting the day already, inflammatory already in a defect. And so that's going to be honestly free. It's free. the easiest thing that you can do. But most people don't really do it. And that really takes setting a good sleep environment. So making it dark, having a sound machine, putting your electronics away. And if you have a partner, they've got to be on board too, right? Sleep habits impact both male and female fertility. I know we didn't dive into male, but sleeping fewer hours is to see

with lower testosterone levels and a decrease in male fertility as well. So number one, sleep. Number two, kind of in the same vein, chronic stress, that cortisol, it increases. insulin resistance because it's your stress hormone. Your body thinks you're running from a bear. It wants you to have sugar and glucose available to utilize right away. And so it's shifting your hormone paradigm on purpose. Hey, Emily doesn't need to ovulate. She needs sugar ready to run from the bear. And so it shifts everything. The problem is when we're not running from a bear and we have this high stress level every day, these hormone changes start to really become permanent and very detrimental. Stress gets glossed over by physicians all the time, yet it's quite impactful.

And I think one of the reasons it gets gloss over is there's not a magic pill or an easy solution because we're all wired differently. And so what I recommend here is to really think about how do you carve out at least 20 minutes of your day to give you that feeling. And it's all going to be a little bit different. So maybe it's walking, yoga, meditation, mindfulness, journaling, talking to a friend, acupuncture. There's no right or wrong answer there. But we're all going to benefit a little bit differently. Do you need a schedule? Do you not? But of your day, just that 20 minutes can reset your cortisol and really change what's happening in your whole day. So I really want to say to everybody, take that moment to think about what that is for you to decrease

your stress. You know, I think one of the things that people don't realize and you touch down in a little bit is that the environment in which we evolve, stress is because there's some physical threat and therefore I need to move. And so it's like we make all this sugar available. And when you need to run from the bear, you want that. And then you burn that sugar in the process of running for the bear. Now we get stressed because like we have a scary meeting or something. Right. With a bad email. So I have this massive stress response. I still release the sugar to go quote unquote run from the bear, but instead I'm sitting at my desk. And so the sugar just kind of sits around. And so if you sort of realize that physiologically that's what's going on, a really adaptive thing to do when you do

experience stress is to make sure you give yourself movement because then you can burn off that sugar. And obviously, great if you can reduce those stressors and kind of work on why is this email so threatening to me and all that kind of stuff. Prevention is always key. But, you know, stress is not entirely avoidable. And so understanding what is doing to your body and how you can like offset some of that damage is helpful. Absolutely. And you bring it up. And this is why exercise in general is so important too, right? And we think about exercise. All movement is. good. Your skeletal muscle specifically has the ability to kind of override the normal insulin process, right? So we've said it a few times, but insulin is what gets your sugar into the cell

so it can be used, lowers the sugar that is circulating in your body. Well, your skeletal muscle has a way to override that when it's needed. So if you have more skeletal muscle and you use it, you can bypass some of this insulin resistance that starts to build up. And this is why we see strength training and resistance training really building muscle and then using that muscle as such an effective way to counter some of this insulin resistance or chronic inflammation that we see. So I love your point. If you have the stress, you know, get up and walk around, use your muscles, let them bypass that insulin mitigated, you know, need for glucose into the cells. But also think about in a prevention standpoint, I need to not run every single day. I need to carve out some days

of actually building some skeletal muscle with some strength or resistance training so that I simply have more muscle mass because that will help your hormonal health as well. And I consider those to be the foundation of your day, sleep, stress, and exercise. Like, these are things that you will respond to, but you also make active choices on those that are going to set you up for success or they're going to make it harder for you to combat what you deal with in the day. And then the other thing, which we barely touched on, or we haven't touched on at all, is, you know, what you eat, right?

Your gut health is extremely important. Your gut microbiome controls a lot of your insulin resistance and your inflammation. and without us starting an entirely second episode talking about gut health and hormonal health. I think the important thing to say is that your estrogens metabolized in your gut, having an abnormal gut microbiome is much more correlated with infertility than having an abnormal vaginal microbiome is. Yet we see this huge trend to talk about things that are easy to diagnose potentially. But having an abnormal gut microbiome is associated with abnormal hormonal health and insulin resistance. The number one way to combat that is to feed the gut microbiome what they need, which is fiber.

So diets high in fruits and vegetables, which are what have fiber, is going to be the core of that diet, decreasing those ultra-processed inflammatory foods, added non-nutrative sugars. Those need to be decreased from your diet. And then, you know, looking at not all proteins are created equal and vegetable proteins are associated with improved ovulation and lower inflammatory patterns. That doesn't mean you have to avoid animal proteins altogether. the ratio of them needs to trend towards more plants, especially if you have infertility or you're looking to improve your hormonal health. I love that. If you could have a magic wand, what's one thing you would change? Like in the world? Or I mean, what's... In the world or related to fertility? I mean, if I could have one magic wand when it came to infertility, I mean, I would wish that

our ovaries did not accelerate with genetic change as we get older. You know, I talk about these lifestyle changes and anti-inflammatory approach because it is what we can control. You know, the idea that your fertility is just luck is really a false narrative because learning more about your body, getting a diagnosis earlier, knowing what's wrong so you can intervene and then taking control of what you can is really important. But there is for everybody a time period where no fertility treatment will work. And all of us, our eggs, our chromosomes in that nuclear side, they do accumulate damage with age. And at some point, we might, be past the point of no return. And that makes it harder for a generation of women who are chasing

careers and starting later, maybe waiting to find a partner. And if we could change that, that would really change how we view reproduction. And at least for my patients, it would change the trajectory of their fertility journey immensely. Thank you for that. And thank you so much for this incredibly empowering conversation. I loved how we talked about, even if things are normal or have quote unquote always been like this for you, it doesn't mean that it can't get better. And I hope that, you know, everybody listening to this or everybody listening who has a daughter or a female partner or anything like that, you know, is thinking about if any part of your cycle is bothering you, if any part of it is changing or different than it used to be, that they're incredible Obi-Gyines and endocrinologists out there like yourself who can help them. I really hope that people learned a lot from this conversation. I think they did.

Thank you so much for having me. I've loved it. If you enjoyed this episode of The Woo Podcast, please leave a rating or review. check us out on social at Whoop at Will Ahmed. If you have a question to what's answered on the podcast, email us, podcast at Whoop.com. Call us 508-443-9552. If you think about joining Whoop, you can visit Whoop.com. Sign up for a free 30-day trial membership.

New members can use the code Will, W-I-L, to get a $60 credit on Whoop accessories when you enter the code at checkout. That's a wrap, folks. Thank you all for listening. We'll catch you next week on the Whoop podcast. As always, stay healthy and stay in the green. It is nothing.