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3. Ep 75: PCOS and Fertility with Dr. Lucky Sekhon

Ep 75: PCOS and Fertility with Dr. Lucky Sekhon

• Transcript of Podcast Episode

  Rena: Hi everyone. We are Rena and Dara, and welcome to Fertility Forward. We are part of the wellness team at RMA of New York, a fertility clinic affiliated with Mount Sinai Hospital in New York City. Our fertility forward podcast brings together advice for medical professionals, mental health specialists, wellness experts, and patients, because knowledge is power and you are your own best advocate.
  Dara: This month of September is PCOS Awareness Month, and we are very lucky to have Dr. Lucky Sekhon back speaking to us kind of thing, us, a different approach to PCOS. And we're delving a little bit deeper and talking about, you know, the feelings of lack of control. And I know Rena and myself will also give our own input into our own experiences and our experiences with our patients. So, Dr. Sekhon, thanks for coming back.
  Dr. Lucky Sekhon: Thank you for having me. I really think this is an important topic. A lot of people are talking about PCOS and oftentimes the focus is on the solution. Like, how do we make you ovulate? Or if you're not trying to conceive then how do we regulate your hormones? But I think it's really important to focus on how an individual feels when they get this diagnosis and how to work through it. You know, the things you can control, the things you can't control. So I'm really excited to be here talking about this.
  Rena: I think that, you know, the spin we're going to put on this, I'm really excited about, you know, we were kind of all dialoguing before about what we hear from patients and to really sort of start with, you know, this feeling of a loss of control and, you know, oftentimes a patient doesn't really get a PCOS diagnosis until they try and conceive because a lot of times the symptoms are pretty hidden. And so that can be super jarring for someone to find out, okay, I have this thing. I, now someone gave me a diagnosis. I had no idea I've been living my life and it's having this impact potentially on my fertility. And it's a lot for people to process.
  Dr. Lucky Sekhon: Definitely. And I've started to really change my language and the way I express myself when I'm talking to a patient for the first time who has no idea what PCOS is, but I have a strong suspicion that they have it because they think no one wants to be labeled. A lot of patients who are coming to a fertility doctor are relatively young, healthy, and you know, haven't had to see doctors very much. So at baseline they're nervous. And maybe they're really anxious because they've been told they're supposed to have a period every month. And all of the tracking apps and the ovulation predictor kits are really geared towards helping someone with a regular cycle who doesn't have PCOS properly pinpoint the right timing of when they should be attempting to conceive. And so they're feeling kind of in the dark and, you know, you're then labeling them and saying, you have polycystic ovary syndrome. Syndrome. Disease. Those types of words are very triggering to people. All they're hearing is I have a diagnosis. This is going to be terrible. Something's wrong with me. And it's like, really, it kind of shatters them in that moment. Like I can see it. And I'm always like, from my perspective as a fertility doctor, this is a) the easier thing that I can tackle or treat. It's just a matter of, you know, you're you have the eggs. A lot of times patients are younger and they might have really great presumed egg quality. Their body just doesn't know how to properly access those eggs. And that's something that I can help with. We have lots of tools in our toolkit. So I try to explain that, but I find that communication breaks down when there's that anxiety and that like, oh my God, all I hear is the word syndrome. So I have started to say, it's not a disease. It's an alternate state of being. It is basically the way your ovaries pick up communication is different. They beat to their own drum. Your brain is sending a signal, your ovary’s supposed to pick that signal up reliably. And you know, what it's supposed to do is then select an egg to grow and eventually ovulate. The signals are being sent out often at a very high level in women with PCOS, but oftentimes the ovary’s resistant to it, does what it wants to do when it wants to do it. And then eventually might sometimes pick the signal up. And that's why you have this irregular interval between ovulations and for some patients with more severe cases, they might not ovulate or get a period at all. But an alternate state of being is just, you know, your ovaries are a little bit more stubborn, resistant to communication, but we can make them listen. You know? And, and I think reframing it is important because otherwise all someone is hearing is something's wrong with them and they're broken and this is a disease and a lifelong diagnosis which is not helpful.
  Dara: I love that. The idea of reframing.
  Dr. Lucky Sekhon: I think it's also complicated too because people are fixated on the fertility aspect. And so if someone's coming to me, not because they're trying to conceive, maybe they're, you know, just freezing their eggs or maybe they're just there for a reproductive checkup or someone told them, you likely have PCOS go see someone because they didn't know how to counsel them appropriately. Like there's a whole range of reasons why people come to me with PCOS. And so I think it's important, you know, for people to know that it's not just all about ovulation, there are all these other seemingly unrelated manifestations. And what's also hard for patients to understand is not everyone is going to look the same, right? Like snowflakes, there's no two PCOS patients that are going to have the exact same collection of symptoms, degree of symptoms or signs. You know, the classic textbook picture of PCOS is someone who has difficulty losing weight. Maybe they're already overweight. They have hair growth in places where traditionally women shouldn't like on their chin, their face, their chest, you know, all over their body. Acne. These are all signs of excess androgens or male type hormones, which all women or people with ovaries produce, they produce estrogen, progesterone, and testosterone, but things are out of balance. And then there's this other piece, which I kind of mentioned, you know, weight gain, but that ties into metabolism, increased risk of diabetes, high blood pressure, high cholesterol. So that's like someone who has like all of the classic signs and symptoms, but we have tons of patients that have what we now call lean PCOSin quotes, you know, where maybe it's because of lifestyle or maybe it's just who they are genetically, they're lean and they're not overweight. And maybe they don't have all of these other things that we're talking about, but they have ovaries that don't listen to that signal being sent from the brain and therefore they have irregular cycles. So I think it's important to know that PCOS can look very different for different people. And that's okay. The term PCOS is flawed because none of this really has anything to do with actual cysts that are a problem. So I think PCOS needs a new PR firm and needs a complete rebrand. And I think that it's important to understand that it's a long-term thing that may or may not mean you're predisposed to certain chronic health conditions. So, it's just be more vigilant. You know, these are things to look into, like making sure that you're getting regular screenings for diabetes and cholesterol issues and that you might be predisposed to diabetes and pregnancy and things like that. So it's complicated and there's really three main aspects to it. One is the irregular ovulation. The other is metabolic issues, whether it be diabetes, weight gain, et cetera. And then there's the imbalance between male type and female type hormones. And whether you're trying to conceive or not, all of these things are important.
  Rena: And I think from a mental health perspective, you know, I can say I, myself struggled with anxiety and depression and as I've gotten older and had a better understanding of PCOS and gotten very into holistic health, I often wonder if I was mistakenly put on medication back in pay school as a band-aid, if it really was more the PCOS . And I see a lot of patients sort of settle for this pretty poor quality of life, or they feel like, well, this is just how I feel. I'm not going to feel better. And so I really want to encourage people to get help. There's a lot of alternative therapies, but talk therapy to different supplements to manage PCOS. If you have PCOS, you are at increased risk for depression and anxiety. Studies show that people with PCOS do have higher rates of that. And so you don't need to settle to live like that. There are so many different ways to manage it and it's really important to get a team in place of physicians and providers that understand PCOS the hormonal imbalances and can give you solutions because it was, it can be super debilitating.
  Dr. Lucky Sekhon: I also think that when it comes to fertility, there tends to be a lot of focus on the stresses of treatments like IVF or problems that have very few solutions like, you know, egg quality, and quantity and that being something you can't change. And so I feel like PCOS, as an issue tends to be pushed a little bit to the wayside and might not be dismissed, but is, you know, a lot of, I think my patients who have PCOS are sick of hearing, you're going to be fine. We just need to make you ovulate. Like they don't feel validated that this is a real concern for them because a lot of times it's not prioritized. I think because there's a bias towards no, just feeling overly reassured. If someone's young and they have a high egg count on, for whatever reason, we don't really truly understand the science behind it but there tends to be an association between PCOS and having a higher egg count for your age in general. So I think that's a source of frustration being told, like, don't worry, you're going to be fine. You're going to get pregnant because it's very distressing to not understand what's happening with your body or being able to predict when you're going to ovulate when that's like the key thing that you can try to control in the process of trying to conceive which is a process that strips you of any element of control for the most part. And I think it's also, you know, everyone wants to feel like they can control things. And so the first reaction is going to Google or taking, you know, what your physician says, but then like going full force with it. Okay, I'm going to reduce my carbs. I'm going to, you know, start exercising. I'm going to take these supplements, but why is my period not coming? Why am I not getting a regular cycle? And people feel like they're a failure. Their body's letting them down. They feel like they're a failure because they can't self-regulate and there tends to be the stigma, right? I don't want to go on birth control. I'm not ready to try to conceive. And then I say, well, okay, but it's healthy to get a withdrawal bleed and balance out the hormones for the lining of your uterus. You don't want to have excess estrogen and no progesterone to balance it out. And that's what's happening in women with severe PCOS where they never ovulate.Their lining is just building up and over time can predispose them to precancerous or cancerous changes of the lining of the uterus. So there's a reason to be regulating hormones beyond just trying to conceive, but patients are really resistant to the idea. If I take this medication, what does that mean? I'm going to have to be on it for life? Either I'm on the pill if I'm not trying or I'm on Clomid or Letrozole to make me ovulate if I am trying. Like, now I'm destined to a lifetime of medication and I think there's this real resistance and people really want to just feel like they can fix themselves and they can fix this problem. And it's frustrating when they can't and here's like a resignation to, okay, I guess I'm going to have to take this medication. And I think it's all about reframing that perspective.
  Dara: Oh, for sure. And then when it comes to, you know, nutritional components, that may be an area that people can control, but I think would, I often see and when it can be even further frustrating is that people go to the extreme and you know, what's often mentioned with PCOS is carbohydrates or lack or reducing or eliminating carbohydrates. And that can actually add more fear to the patients and to people who have PCOS. And I think when women are properly educated, that it's not a matter of eliminating carbohydrates or doing anything extreme, but at baseline focusing on controlling your carbohydrates so you're not overwhelming your pancreas to produce insulin and it's carbohydrate control and focusing more on the carbohydrates that are great, focusing on the quantities so the qualities and the quantities and pairing them up with proteins can really help people feel confident and not only physically, perhaps see changes in their body in terms of if they're eating for weight loss, but eating for blood sugar management to begin with can really make people feel better. It can also pair with in terms of their stress hormones, it can lower their cortisol levels and make them less stressed if they're also not having all those sugar cravings. And then also reassuring people, just like, you know, in terms of exercise, exercise is so important. But what I see so often with my PCOS patients is more is better, harder, faster, lots of cardio. And that can actually be very taxing on someone's overall health on their metabolism, their adrenal glands inflammation. And I think, you know, finding a workout plan that they actually enjoy, that's sustainable, that can balance out what they're eating. It's amazing how much people can feel in more control, feel better, and it can work great in conjunction with the medications that need to be on. But I think part of it is, is reassuring them that a PCOS patient, what they should be eating or what they, you know, could be great for them really is great across the board for all of us, whether you have PCOS or not. And for me, in some ways, this is a great way for someone to, you know, to find a great goal that can be helpful for life, not just for fertility.
  Dr. Lucky Sekhon: I think that's so key because if you make it all about PCOS, you might be disappointed because there's no guarantee that you can restore your normal periods by just changing diet and exercise. But that doesn't mean that you shouldn't strive towards a healthier lifestyle. And I think, you know, something that Rena could probably speak a lot to is the effects of PCOS on mental health or at least the association between PCOS and mental health issues. And I think exercise, my patients who have a regular exercise routine as an outlet, tend to do better in that regard.
  Rena: But I do want to jump in and say, I mean, so I know a lot of times people get really upset because they find that they have PCOS and then they think that their provider has told them they can no longer run or spin that, you know, it's really only beneficial for them to do like this low impact. I, myself am an endurance athlete. I run marathons, I've done Ironman and it is just a part of my life. So it is not without a lot of management and a lot of really working on my diet. You know, it takes supplements to figure out how I can do that in a way that I still feel good with PCOS. And it has certainly been a struggle with a lot of ups and downs. It has been very difficult to manage so I admit that, but I do want to give people hope you can do these things, but it might just take extra work and seeing extra doctors building out physicians. You know, the body is such a crazy, crazy machine. And the more information, the more, the more knowledge, the more power you have, but I, you just want to say, so people don't feel like I have PCOS and I have to give up, you know, my coping mechanism - exercise is so important for mental health - you, you certainly can. It might just take some extra management or sometimes it's figuring out that at different parts of your cycle, you might feel better doing different activities. And so where you’re at in your cycle, like a HIIT workout might be okay, but then the next week, a different phase in your ovulation cycle, you might feel better just doing gentle exercises, like walking or yoga. So it is a lot of trial and error, but I really, really do recommend seeking help. You know, the best investment you can make is in yourself. So to find how to live with this in a way that you want to live and not let it control you.
  Dr. Lucky Sekhon: And I think it's funny that both of you are co-hosts of this podcast and we're having this discussion about this particular topic, because I feel like this is like the power team right here, like a physician, you know, for the diagnosis and management of certain aspects. But I, you know, at RMA we have both of your expertise and a lot of my patients, particularly those with PCOS are seeing, you know, a nutritionist or seeing Dara and they are seeing Rena to deal with the anxiety and lack of control. So it's just kind of full circle to be having this talk about this topic.
  Rena: Well, and I love what you said, and it's why you're such a wonderful physician. You know, I know myself when I was going through IVF I felt so scared. Right? You know, so out of control, guilt, shame, all the things. And then kind of later I found out like PCOS is viewed as a quote unquote easy case. And I do agree that a lot of times I think the physician may deliver the message in a diminishing way. Like you're forgetting you just, it's like, bam! You have PCOS. Bam! You have to do IVF. And you have this patient who is so scared. And so I love that you recognize that and you realize that delivering the message requires sensitivity, not like, oh, don't worry. You're going to be fine. This is an easy case. Because to remember to someone else finding out all of this for the first time you totally rock their world and they feel so scared.
  Dr. Lucky Sekhon: Yeah. And a lot of times the initial treatment isn't going to be IVF because it's going to be, well, let's just get you on a regular ovulation cycle and maybe you just have timed intercourse. You have sex around the time that we tell you to because of ovulation. And even that, like, we might view it as, oh, it's not as much work. It's not as expensive as IVF. Therefore, you know, it's a, a lesser treatment it's easier to go through. But I think a lot of patients feel robbed of the opportunity to do it naturally where, you know, they're just being able to use the ovulation predictor ktd, and they're able to just have sex when they want to have sex and know that every month they're ovulating. I think they feel medicalized. I think they feel like it's unfair that they are just starting out, but they have to have this additional burden of coming in and taking pills. And maybe it's not as much of a medical burden as taking the shots that are associated with IVF, but it's a lot and it's fatiguing, right? If we have traditionally patients with infertility coming to us at the six month mark or the 12 month mark, and they've gotten that chance to try on their own and now they're there, that's a separate issue. This is a different cohort of patients that haven't even had an opportunity to try because if you're not ovulating regularly, you're not really in the game, especially if you're not ovulating at all. And so they're coming to you to just even have the opportunity to just try. And I think that that can make this whole trying to conceive process even more taxing because they even haven't even had that runway of like, laid back. Let's just have fun and try on our own. They haven't had that opportunity.
  Rena: Yeah. I think that's a good point. Really great point. And then Dara, I would, I would say I just, you know, people always always ask about nutrition. So I know we talked about it, but if you could tell them and with PCOS okay, here are three main things you should do. What would you say?
  Dara: For me, focus on protein. Protein really does fill you up and it's so important for your cells and that could really help sustain you, especially when you do eat carbohydrates. So eating protein, making sure that you pair a protein when you do eat any type of carbohydrate. I think those two things are really important and focusing on better quality carbohydrates, focusing on slower-acting carbohydrates that raise your blood sugars at a much slower rate. And that comes from fiber, whole grains, fruits, vegetables, whole foods. So when in doubt, think foods from the earth foods, that are not found, that comes in a package can really be real helpful for PCOS.
  Rena: What about sugar?
  Dara: Sugar? I mean, for me, it's not avoiding sugar. It's being mindful of how much you have and finding out what your triggers are. And if there's any foods that are trigger foods for you, those things should be minimized. But more importantly, it's learning to have a better relationship with food which takes time, but learning the pairing, that carbohydrates on their own, even something that's like candy is much better paired with a protein to help prevent those blood sugar spikes. And you want to avoid the blood sugar spikes and the blood sugar drops. You want to avoid those extremes and find that healthy balance. And that comes from not only the quality of the carbohydrates, but the quantity and also the timing of the day. So first thing in the morning, end of the day, your bodies are much more sensitive to carbohydrates. So those are probably the best times to avoid more of the processed sugary carbohydrates.
  Rena: And I think the final thing before we wrap up, I know, I think we're very aligned on this. I know there's so many, there's a lot of dialogue out there about intermittent fasting and PCOS and I know a lot of times, you know, since PCOS you have high testosterone, you can not feel hungry. Like I know myself, I'll be like, sometimes I'm just not hungry, but I think we're aligned in that it is very important to eat breakfast, snack, lunch, snack, dinner, and the intermittent fasting for a lot of reasons is not necessarily the way to go
  Dara: I'm with you, you know, or the idea of at least including breakfast, having a window of fasting is not, you know, it's not something that I am opposed to, but for me, it's more of an earlier window having that breakfast, lunch, and perhaps an earlier dinner, I think can be much better for blood sugar control than skipping that morning, that morning meal.
  Rena: Well, this is a great little mini PCOS episode. You know, we have a lot of other content on our podcast about PCOS, but we want it to kind of get the three of us together just to talk and give info since, you know, it affects so many women and we're all so aligned with this sort of trifecta of nutrition and mental health and physician with managing PCOS.
  Dr. Lucky Sekhon: Yeah. I think this was great. I think everyone should take a holistic approach, especially when it comes to an alternate state of being like PCOS that is so multifaceted and it's confusing and it's complex. And I think that you need more than one type of expert to tackle it appropriately.
  Rena: Absolutely. And yeah, I mean, I'm super open about it. It was, as I reflect back, I think it really impacted my life and I'm really grateful. I guess I'll go into the gratitude now. I'm really grateful now that I have a, I work with a wonderful functional medicine doctor and some great athletic trainers to really help me manage this. And I'm always checking on my body and looking at stats and really looking at data and I found that that's the way that I can manage it and feel my best mentally and physically. So very grateful for that.
  Dara: Yeah. I'm going to piggyback on that. I mean, I'm grateful for having PCOS because it led me to RMA when I was going through my fertility struggles and that's when I was diagnosed with PCOS when I was trying to conceive. And it led me not only to being a patient at RMA and having two beautiful daughters through IVF, but also having a job, getting a job out of it. And now being able to give back to those people with PCOS and helping support them.
  Dr. Lucky Sekhon: That's so wonderful. I feel grateful, you know, to have an environment that I work in, where I have so many valuable experts and tools that I can use to help my patients in a multifaceted way. I'm glad that I'm not just, you know, providing them with the solution to one problem, which might be fertility or trying to balance out their hormones, but taking a more holistic approach because it would be foolish for any of us to just focus on the body. You have to focus on the mind-body connection and nutrition and what we put into our bodies is the best medicine and the root of a lot of disease or prevention of disease. So, I'm grateful to work in a place that facilitates being able to treat patients using multiple disciplines and approaches. And I feel like it just makes for an overall better experience and more success.
  Rena: Absolutely.
  Dara: Thanks so much for being on. Appreciate it.
  Dr. Lucky Sekhon: Thanks for having me guys. I learned a lot from you today.
  Dara: Thank you so much for listening today and always remember: practice gratitude, give a little love to someone else and yourself, and remember - you are not alone. Find us on Instagram @fertility_forward and if you're looking for more support, visit us at www.rmany.com and tune in next week for more Fertility Forward.