Conquer Your Weight

Dr. Sarah Stombaugh: Before we get into the episode, I am thrilled to announce we are launching an online course, The GLP Guide. The GLP guide is a must have resource for patients who have been prescribed any of the GLP medications such as Wegovy, Ozempic, semaglutide, Zepbound, Mounjaro, tirzepatide, Saxenda, liraglutide. There are a lot of them and this course is available for anyone to purchase. We often hear from people who haven't been given much information about their GLP medications. No one has told them how to handle side effects, what nutrition recommendations they should follow, or what to expect in the longterm. And it can be really intimidating and simply frustrating to feel like you're alone in your weight loss journey. With the GLP guide, you'll get access to all of the answers to the most common questions for patients using GLP medications, not sure how to use your pen, struggling with nausea, wondering how to travel with your medications. We've got you covered for only $97 for one year access. This is an opportunity you do not want to miss. The course is launching on October 1st. For more information and sign up, please visit www.sarahstombaughmd.com/glp. You don't have to be on this journey alone. We are here to guide you. And now for today's episode, this is Dr. Sarah Stombaugh and you are listening to the Conquer Your Weight podcast. Announcer: Welcome to the Conquer Your Weight podcast, where you will learn to understand your mind and body so you can achieve long-term weight loss. Here's your host, obesity medicine physician and life coach, Dr. Sarah Stombaugh. Dr. Sarah Stombaugh: Hello everyone, and welcome to this week's episode of the Conquer Your Weight podcast. We are talking about a very common health condition, PCOS or polycystic ovarian syndrome, and I'm really excited to share this topic with you. It affects so many women. It can be a really frustrating syndrome to treat, frustrating to feel like, oh my gosh, how do I deal with this thing? How do I actually lose weight? And then certainly other health consequences that come alongside PCOS. Before we dive into today's episode, I want to invite you if you live in Illinois, Tennessee or Virginia where I'm licensed to practice medicine, I would love to work with you to help support your weight loss schools. Maybe you're already taking one of the GLP medications. Maybe you're wondering, okay, are these medications too good to be true? Am I someone who could actually lose weight and improve my health with these medications? Or alongside even just lifestyle changes? I'd really like someone who's an accountability partner. I would love to be that for you. If you're interested in learning more about me and my medical practice, you can visit www.sarahstombaughmd.com. It's W-W-W-dot-S-A-R-A-H-S-T-O-M-B-A-U-G-H-M-D (as in medical doctor)-dot-com. We will put that link in the show notes as well, so you can go down there and click on it. If you have been looking for support, this is your invitation. I would love to help you out. Reach out today and we can get you started. So I'm super, super excited to help anybody who needs that additional support in their weight loss journey. And maybe you are someone who has PCOS and you'll listen to today's episode and wonder, okay, gosh, how does this apply to me? I've been so frustrated. How can I lose weight despite having PCOS? Let's dive into that because while everybody with PCOS does not struggle with their weight, it is very common that this can be the case. And PCOS is often a very cyclical thing by which we struggle to lose weight. Yet weight gain can worsen PCOS. So let's talk about what is PCOS, why does it affect our weight? And then what do we actually do in order to help support and treat this condition? So when we think about PCOS or polycystic ovarian syndrome, it's an actually incredibly common condition. So it's estimated to affect about one in 10 women, and it can go alongside things like weight issues, whether that's trouble losing weight or noticing that just sort of no matter what you do, you're just gaining, gaining, gaining. It can go with insulin resistance. So this can be something that we're seeing in labs can be significant insulin resistance that creates pre-diabetes or even diabetes in some conditions. And then other hormonal irregularities. When we think about the balance of our normal estrogen, progesterone and testosterone, it's very common that in PCOS we have elevated androgenic hormones, androgenic being male hormones like testosterone for example, whereby, which a lot of times, in addition to some of the other symptoms of PCOS, there may be things like acne, hair growth, so noticing growth on sometimes the chest or on the abdomen or facial hair for example, that can be related to those high male hormone levels that can happen. And when we think about this, there are three different criteria that if you have two of these three criteria, they're called the Rotterdam criteria, that if you have two of these three that you can diagnose PCOS. So what is really interesting is that you actually do not need to have evidence of cyst on your ovaries in order to demonstrate that you have PCOS. So the three criteria are one that you have irregular menstrual cycles, and this is irregular non-medicated menstrual cycles if you are on birth control, whether that's pills, whether that's an IUD, whether that's an implant like an Nexplanon or any of the other options that are hormonal birth control, that will override your natural cycle. And so if you are having consistent cycles on birth control, that's great, but we're not able to say, is it regular? Is it irregular? So are you not medicated having irregular cycles? What I find is very common is that women were having a regular cycles or we're having menstrual issues in a lot of different ways for which they were put onto oral birth control pills. And so the question is irregular cycles if you were not on any sort of hormonal birth control option, so irregular cycles, then we have that androgenic piece. So do you have signs of elevated male hormone like testosterone in your body, signs of acne, signs of excess hair growth on the face, on the chest, on the abdomen, for example, or do you have poly cyst on your ovaries? So polycystic appearing ovaries on ultrasound. So this does not actually mean having a single cyst on your ovaries. When we look at the natural ovulation period, when your body is making an egg and releasing an egg, there are natural cysts that occur as your body is going through that process, or I should say a single natural cyst that occurs. Sometimes that process can become dysregulated and a single cyst can be enlarged, but I'm talking about a polycystic ovary, meaning that you have many little small cysts on the ovaries. So when we look at the diagnosis of PCUS, you have to have two of those three things, menstrual cycle irregularities elevated or signs of elevated androgens. You actually don't even need blood tests, but just clinical signs that you have elevated testosterone or the polycystic ovaries on ultra ultrasound exam. And so when we look at that, you don't even necessarily have to have labs, you don't even necessarily have to have ultrasound. You may have either or both of those things depending on the rest of what's going on. But if a woman's coming in and she has irregular menstrual cycles and she has signs of elevated androgen levels like that, acne, like that hair growth, those two things alone are enough to diagnose polycystic ovarian syndrome. Now, it's important to note that this is labeled syndrome not disease. So it's a really broad presentation and different women will have different symptoms that go alongside of this. So one of the most common things is insulin resistance. And this can happen even in an individual who has a clinically normal weight. And so very commonly people will notice that their weight is elevated, but there are people who live in what we would traditionally call a normal BMI, for example, that are still struggling with insulin resistance. This may look like the way their body responds after eating a sugar load or a high carbohydrate load, for example. This may look like weight gain centrally in their body. So storing abdominal fat, even if their total body weight is still within the limits of what we would say is a normal weight, the insulin resistance piece is very common in PCOS. This often comes with those weight difficulties, though so many people will have difficulty losing weight or even feeling like, oh my gosh, despite everything I'm just gaining, gaining, gaining alongside PCOS, very common that people will have fatigue, they'll have cravings. Sometimes mood changes. Fertility can often be a challenge because while it may be irregular cycles for someone, it means going many months at a time without even having a ovulation or releasing of an egg. So it can be really challenging to get pregnant when you're releasing an egg. And if you are releasing an egg, if that process is not understood, if you don't know if your body is cycling regularly, can be really challenging to get pregnant if you're not ovulating as expected. So this can be a major cause of infertility as well. So when we think about diagnosing this condition, it's a condition that I think over the last decade or so, there's been a lot more of an understanding of PCOS, a lot more common diagnosis of it, but it is still, I guess at least in my perspective, a fairly underdiagnosed condition. A lot of women may have had irregular cycles going back even to their teens, for example, and put on birth control pill, and now they find themselves in their twenties, they find themselves in their thirties having these symptoms consistent with PCOS, but not really knowing or understanding if that's what's going on because they've had a birth control pill that has been sort of masking the piece of it, but they're still dealing with other pieces of that syndrome, particularly that insulin resistance piece. So we've talked about in some of the recent podcast episodes, what is insulin resistance? And I'll actually encourage you to go back to last week's episode if you haven't listened to that already. The piece of insulin resistance where we're talking about the very early presentations of metabolic disease, actually PCOS is a very perfect example. I don't know that I even mentioned it in that episode, but PCOS is a perfect example of what can be an early presentation of metabolic disease. It is a presentation of insulin resistance and a rest of a syndrome that goes alongside of it, but it's not always talked about from a metabolic standpoint. So when we think about insulin resistance, insulin is our fat storage or our energy storage hormone. And what when we have insulin resistance is that our body is releasing higher and higher amounts of insulin in order to store the food that we eat away as energy for later. When there is a resistance, it's because there are these elevated amounts of that hormone. The body has been ignoring that signal. That's where the resistance piece comes in. And so those levels over time become higher and higher. It tips the body into a state where it is storing energy rather than burning energy. And so when the body needs energy, ironically, your body starts craving food, asking for food a lot of times, feeling intense hunger or intense cravings for food rather than being able to dip into our fat stores, which would be sort of the normal metabolic process that our body at times of needing energy could dip into fat stores in order to do that. So with insulin resistance, there can be this gaining of weight in general, particularly gaining of weight around the center part of the body, around the abdomen, and so that can be very common. The frustrating thing with PCOS, but then insulin resistance just in general is that it's this really cyclical thing by which we gain weight, which can worsen insulin resistance, worsening insulin resistance can create weight gain, which can create more insulin resistance, and the cycle can be really challenging to break. Now, there are things that we can do in terms of both lifestyle changes as well as in terms of even medical therapy and medications. So let's dive into a little bit, even if you feel like, okay, I'm not totally sure if I have this condition, what are the things that you can do? So first of all, I do think it's worth bringing up to your doctor, particularly if you are having irregular cycles. You don't really know when to predict your period. You're like, some days it's four weeks, some days it's seven weeks. Some days I have no idea when I'm going to bleed or if I'm going to bleed. If you have that in combination with acne, with excess hair growth on your face, on your chest, on your belly, that may be a sign of PCOS. So I would encourage you to make an appointment with your physician. This might be your primary care physician. This might be your OB GYN physician, but to make an appointment to say, Hey, I've been wondering if I'm dealing with this condition, and to talk to 'em a little bit more about what that might look like for you. Now, either way, as we think about some of the lifestyle pieces, the good news is these are, even if you don't have PCUS, they are things that could be helpful for you. Generally, we can think about how do we lower the insulin load in the body, which can be something that reduces insulin resistance, therefore improving insulin sensitivity because our body is not having to release high levels of insulin all the time. Insulin is released in response to eating carbohydrate, eating protein, actually even to some extent, and particularly if we eat a very processed carbohydrate. So a flour, a sugar, something like that, especially if it doesn't have a lot of fiber. So in a sort of extreme case, like a soda for example, that can spike our blood sugar very quickly, which then also necessitates that we have an elevated level of insulin in order to store that away. So we really want to avoid these insulin spikes or these blood glucose spikes. Well, we can't really track our insulin in a normal setting minute by minute in the way we could track a blood glucose, for example, on a continuous glucose monitor, avoiding a spike in your blood sugar and therefore then a spike in your blood insulin can actually be really helpful in reducing insulin resistance. I will refer you back to the episode of No Naked Carbohydrates, which was a couple of weeks ago where we looked at why partnering carbohydrates with proteins with healthy fats, why that can be such a valuable thing to do. And that's actually exactly related to this in that it's lowering the insulin load. So if you are going to have a carbohydrate, choosing a carbohydrate, let's say a processed carbohydrate like crackers for example, that contains flour, you want to make sure that instead of having just a few crackers by themselves that you think about how can I make this a more well-balanced meal? So that might mean having crackers and nut butter that might, having crackers and cheese, that might be meaning having crackers and dip something that's going to give you a little bit of protein, a little bit of fat, so it's not just crackers by themselves. It can even be if we're talking about a healthy carbohydrate like an apple, for example, that we partner it with something, a nut butter, a handful of nuts, a slice of cheese, something else that is going to make it a more comprehensive meal is going to blunt that glucose response, blunt that insulin response, which can be really helpful in improving our insulin sensitivity. So thinking about throughout the day, are we getting enough protein? Are we getting healthy fats in our diets? Those are really helpful from a satiety standpoint, and our body actually does not have to release any insulin in order to store away fat for later, getting plenty of fiber. So fiber found in fruits, vegetables, and whole grains also helps to slow down the digestion of things and ideally, a meal that contains all three of these elements. You've got this carbohydrate, but you've got one that's really fiber rich. You're pairing it with protein, you're pairing it with fats that's going to help provide this well-rounded glucose response and help a lower insulin load to store that away for later. Also, thinking about the foods that you eat, the timing throughout the day, some consistency to your schedule, or at least not allowing yourself to get in the sort of roller coaster of eating. Sometimes when we start the day with a very sugar forward or flour forward type meal, let's say you have a blueberry muffin for breakfast, you can start with this rollercoaster by which your entire day, your blood sugar spiked. Then it's crashing, which leads to, okay, now I'm hungry. I'm craving sugar. I'm looking for something that's going to give me a quick kit of energy. And it's very common that I talk to people who eat many times per day. I'll talk to people who eat eight times per day even, but they're having just a little bit of something here and there, a muffin. And then a few hours later, a few cherry tomatoes and a few hours later, a few raspberries and a few hours later, a few crackers, and all day long they're fueling themselves with carbohydrates, some of which may be very healthy carbohydrates in the forms of fruits or vegetables, but they're not ever partnering it with something that gives them that satiety, helps them feel full for longer periods of time. And so anything we can do, and that Naked Carbohydrate Podcast to reference that again, is really a excellent one to listen to. Go into that a little bit more in depth. Now, if you really like having a name to your diet, you're like, okay, you talk about some of these principles, but I want to go and do an internet search for a name of a diet. This might look like the Mediterranean diet, a low glycemic index diet, or even a lower carbohydrate diet. Now, I don't feel strongly that you need to be doing a ketogenic diet or anything like that. You certainly can. People have lots of experience in doing that in different health conditions, but particularly a diet that's going to minimize processed carbohydrates. So minimizing sugar, minimizing added flour in the diet, those two things will be really valuable. But that Mediterranean low-glycemic index or a lower carb diet might be things that if you're looking for something tangible there to go search, those are some search terms that you might put in. Now, other things we can do from a lifestyle factor would be to think about our movement moving our bodies regularly, both in terms of cardiovascular movement as well as in terms of resistance training or strength training. Both of these things can be really helpful for improving our insulin sensitivity. Now, part of it, if we think about the timing of our movement, there's some really interesting data that if we are to go for even a walk after our meals, how it helps to use that blood glucose. So the energy from the food that we eat in it's actively circulating in our bloodstream if we go for a walk shortly after our meal, what that does is it allows our body to burn that glucose to walk to fuel that movement that you're doing before it gets stored away as energy for later. This is actually one of the best things we can do. We have a lot of data for walks and improving insulin sensitivity. We can also do strength training, which can be really great for building up our muscle mass and changing metabolically what our muscle mass to fat mass ratio looks like. And this can be helpful from an insulin sensitivity, insulin resistance standpoint as well. I will also a lot of times emphasize gentle movement. So if you're into running, if you're into interval training and intense HIIT type workouts, for example, if that is your thing, great. I think sometimes though we lean into those things because we see this bootcamp or that's maybe what we did when we were younger or whatever it is, and we go into these really intense exercise programs. I will tell you there is no reason that you have to be just insanely exhausted, insanely sweaty at the end of your workout doing gentle exercise. And gentle movement actually can be really good on our body from a insulin resistance standpoint and improving our insulin sensitivity as well as from an inflammation standpoint and reducing chronic inflammation. But what I would say most importantly is that you're leaning into the type of movement that you enjoy the most. So if you love getting sweaty, doing a huge burn bootcamp, pit bootcamp, something like that, you love going for a fast run, absolutely go for it. You do the things that your body enjoys, that feel good, that feel fun, that is going to be so much more important than following a vague recommendation that I am giving here in a podcast. The most important thing though is you're doing a little bit of both the resistance training as well as that cardiovascular training. The role of sleep and stress management are also very important. Making sure that you're getting both good quality sleep, making sure you're getting good quantity sleep, and then thinking about what your stress management looks like throughout the day. Do you have opportunities for your body to decompress? If you're feeling overloaded, do you have a moment to step away and do a deep breathing exercise or to just sort of decompress from a difficult situation? What are the things that you're doing to address that? And it is wild. I have had patients who have been in very stressful job situations that they have left their job and their weight has just fallen off of their body. And not that I'm telling you to quit your job because you absolutely do not have to, but it tells me so significantly. And for those patients, what they've seen is, oh my gosh, look how my body was responding to this stressful situation. There are absolutely other things you can do in terms of working with therapists, for example, working on what is your stress response? Is it an appropriate stress response? Are there times where you're responding out of proportion to what the actual stressor is? Sometimes we're acting like a tiger is attacking us when we open our email, and the reality is it is not healthy or helpful for our body to feel like we are going to die as we're reading an email. And so if you're finding that you have this hyperactive stress response, working through that with the support of a mental health professional can be really important. Now, those lifestyle pieces are going to be really important. Beyond that, we can also think about medication therapy. So this can look like things like metformin. Metformin is a phenomenal tool for working on underlying insulin resistance. We can also look at some of the newer GLP medications. These are a really wonderful tool for people who are dealing with that insulin resistance related to PCOS or honestly otherwise, both the metformin and GLP medications like Zepbound, Wegovy, Ozempic, Mounjaro, the ones you hear me talk about all the time, the ones you're seeing in the media, these can be a really nice fit for patients who have PCOS as well. The thing you want to be really careful with is that both of these medications, whether it's Metformin or whether it's the GLP medications, is that they can actually improve fertility, restore ovulation in a pretty profound way. You may have seen some of the news reports of Ozempic babies. I feel like about a year ago, everybody was talking about Ozempic babies because there were many women, particularly those with PCOS, who had been struggling with infertility. And then in taking these medications, particularly the GLP-1 medications that are so effective that it improved their insulin resistance, it restored their regular ovulation, and oh my gosh, now they were getting pregnant despite perhaps years of infertility. And so not that it is a guarantee of fertility being restored in taking those medications, but it is really important that before starting those medications, if you are a woman that you are clear of what is your age? Are you ovulating? Is there a risk of you ovulating? Do you desire pregnancy so that you and your physician can make a good plan for, are we preventing pregnancy effectively? What are the things that we're doing in order to help support your goals, whether you do or do not desire a child, and how do you do that in the safest way possible? Also, thinking about, it's very common on PCOS that women are given oral contraceptive pills or other hormonal options in order to treat the symptoms of PCOS. A lot of times this tends to be sort of a bandaid in that it can be helpful for regulating the cycle, perhaps protecting the bones because there is some hormonal stimulation of those medications, for example. More importantly, actually as I'm saying that we're talking about synthetic hormones, but really importantly is protecting the lining of the uterus, making sure that the lining of the uterus is not overly growing thick, that there's not a concern of risk of endometrial cancer, which can certainly be a concern if someone is not having regular bleeding episodes. That oral birth control or other hormonal birth control, for example, can help protect thinning out the lining of that. And then regular shedding during that period of withdrawal when you're taking the placebo form of that birth control, for example. So medications like oral contraceptives are very commonly used. I will give a shout out to my good friend Dr. Monica Minjeur. She is a family medicine physician who works to help patients restore their fertility naturally, and she has a clinic in Iowa. So if you are in Cedar Rapids, Iowa, that's where her clinic is located. It's called the Radiant Clinic, although she does see a lot of patients by telemedicine, and I'm sort of thinking of this as I'm saying it, so I couldn't tell you, but she's got about 10 or a dozen states that she sees patients by telemedicine. So if that's something that appeals to you, check her out. It's the Radiant Clinic, Dr. Monica Minjeur, but she has a podcast as well called Cycle Wisdom, and she has a whole series actually dedicated to PCOS. It's a handful of different episodes where she talks through different pieces of that, some of the hormonal piece, and then how you can work to treat that naturally, both with some of the lifestyle pieces as well as then also in diagnostic and supporting from a hormonal standpoint. So if you feel like you're struggling with PCOS and wanting to learn more about that, she is a phenomenal resource and won't just put a bandaid on it, we'll actually work to help treat some of that underlying cause piece. And a lot of too, what I'm doing in my clinic with patients who are dealing with PCOS is working on that underlying cause in the context of lifestyle, in the context of other medication piece, we can really help to improve that underlying insulin resistance, and we see significant improvement of health alongside of that. So as we wrap up this episode, I just want you to know PCOS is a real disease. It is a complex disease, and if you're dealing with PCOS and weight changes, it can be incredibly hard to lose weight and to treat your condition. It is not impossible though, and so I want you to have hope that between the combination of lifestyle changes with potentially layering on medications, if that makes sense for you and for your journey, it is absolutely possible to treat and even reverse your PCOS. So I highly recommend reaching out to a doctor that you trust. If you are in Illinois, Tennessee, or Virginia, I would love to support you in your health and weight journey. Check out my friend Dr. Monica Minjeur, if you're interested in learning more about restoring your fertility naturally. She's a phenomenal resource for that. Thank you so much for joining me for today's episode. I will see you all next week.