Your PCOS & Ovulation Questions Answered [Podcast]

“What is interesting about the ovulatory issues and PCOS is that every woman is a little bit different and every woman over the course of her lifetime might not be the same.”

“There is a finer art to confirming that somebody is truly ovulating and having that normal sequence of events that leads to a period, but there are a lot of other forms of uterine bleeding that can happen and confuse the picture. So, a big part of my job is helping people sort out what exactly their cycle is doing.”

Dr. Rashmi Kudesia

Anovulation (lack of ovulation) is one of the hallmarks of Polycystic Ovary Syndrome (PCOS), but it is widely misunderstood. Award winning Fertility Specialist Dr. Rashmi Kudesia returns to the podcast to break down the basics of ovulation, dispel some mythology, and answer some of the most commonly asked questions. Whether you are trying to conceive or just figure out what is going on, tune in (or read the transcript) and learn:

• Why your period may be heavy, long, short, or non-existent
• Ways to increase chances of ovulation
• Supplements & herbs that can help
• The impact of gestational diabetes on you and your children
• Do patients with PCOS enter menopause later?
• Can you have a period and not ovulate?
• Why is a birth control pill period not a true period?
• How should women with PCOS to track their cycles?
• What is the impact of insulin resistance and extra weight?
• Can acupuncture help?
• What is the difference between your OB-GYN and a reproductive endocrinologist?

All PCOS Diva podcasts are available on    

Mentioned in this podcast:

• PCOS & IVF- Your Questions Answered [Podcast]
• Improving Quality of Life with PCOS [Podcast]
• The Good News About PCOS and Menopause
• Letrozole v. Clomiphene in Women with PCOS
• Dr. Kudesia on Instagram and Facebook
• CCRM Fertility

Complete Transcript:

Amy:

On today’s PCOS Diva podcast, we are going to be answering all of your questions about ovulation and when I say we, I mean, myself and one of my favorite PCOS diva podcast guests. This I think will be her fourth time on the show, Dr. Rashmi Kudesia. So welcome back Dr. Kudesia.

Dr. Rashmi Kudesia:

Thank you so much, Amy. It’s such a pleasure to be back here with you.

Amy:

If you’re not familiar with Dr. Kudesia she is a Board Certified reproductive endocrinology and infertility specialist. She works out of Houston, Texas, and she works for CCRN fertility clinics in Houston. She used to work in New York City where she was named a New York Super Doctors Rising Star for two years in a row and she really is one of the stars of my guest experts on the PCOS podcast.

So, if you haven’t heard our other episodes, she’s talks on episode 85 about improving quality of life with PCOS, Episode 38, we talk about PCOS and IVF and Episode 30, a topic that a lot of women are interested in, PCOS and menopause. There’s just not enough information about that. So check those episodes out, but today we’re going to be talking about ovulation. So, I thought we could start with maybe just the basics. What is ovulation?

Dr. Rashmi Kudesia:

Yeah, I think I’d love to start there and actually, any patient that I see in the office too, it’s usually where we start as well, because for many of us, we didn’t really receive very comprehensive sexual education growing up and if we did that might have also been a long time ago. So I like to start with the basic physiology. So really, I think, what is ovulation, in simple terms, that’s essentially when we release the egg each month if we actually are ovulating, which sounds deceptively simple, it’s actually a little bit more complicated than that.

So, I think the interesting story behind that is that for us as women, we are born with all of the eggs that we’re going to have and interestingly, it’s about something about one to 2 million and actually, believe it or not, the biggest drop off in the number of eggs that we have happens before we’re even born, because actually, at about 20 weeks, so halfway through our own pregnancy of being just dated ourselves, we’re probably at six to 7 million. So that biggest drop off happens before we’re even born.

So, I always think that’s a really interesting factoid, but at any rate, each of those eggs is sitting inside of a little fluid filled sac that’s called a follicle. Basically, once we hit puberty, and then shortly thereafter, we may begin to have a fully functioning reproductive access. What happens is that each month there’s a cohort of those follicles that starts to grow and if we did an ultrasound, we’d be able to see how many follicles were in that cohort.

So, let’s say for the average teenager or 20-year-old, between the two ovaries, there can be easily 20 something or 30 something follicles each month that start to grow. Now, if we actually are ovulating, then out of that group of follicles each month, one of them gets the message from the brain to become the dominant follicle and that matures the egg inside. Over the first two weeks or so of the cycle, that’s kind of the process that’s going on. So we go from having lots of little, little follicles when we start our period to over the course of usually about 14 days, having one mature egg.

Then finally that egg is released from the follicle and that’s your moment of ovulation, and then during that cycle, any of those extra little follicles that were not the dominant one actually just die off and get reabsorbed by the body. Then if somebody gets pregnant and your fertile window is kind of your day of ovulation, and about the five days prior to that, if you get pregnant then two weeks later, you’d be able to see that on a pregnancy test and if not, then that triggers the next period to come. So, then the whole thing starts all over again. So that’s what’s meant to happen, but obviously, we’re going to dive deep on the topic today but for a lot of women, that’s not exactly the pattern that we’re seeing.

Amy:

For women with PCOS, having issues with ovulation is actually one of the diagnostic criteria.

Dr. Rashmi Kudesia:

Exactly. So, that’s really interesting, because it’s not that infrequent that I actually have patients come in and they tell me that their cycle seems regular, or they think that they have a regular cycle that’s coming, and that we sort of define that as something that’s coming every 21 to 35 days. So, it is actually a minority of women, of all women that have that textbook 28 day menstrual cycle, but so that’s kind of an important thing to keep in mind as well, but anything that comes fairly regularly every 21 to 35 days, you would say is a, “normal menstrual cycle.”

That being said, I’ve seen many women over the years that came in and told me that they were having that and then when we actually try to follow along and see if they are ovulating, we find that they’re not. So, for women that have PCOS, as you said, that’s one of the three main criteria that we use, we were using that Rotterdam criteria to actually diagnose PCOS. Not having ovulatory cycles is the foundational ones to be honest.

Amy:

Just to clarify, women that are listening that don’t have problems with ovulation, and they have these regular cycles, they can still have PCOS.

Dr. Rashmi Kudesia:

Yeah, exactly. If you have the other two, so that would be kind of have the ovaries up on the ultrasound and then either symptoms or bloodwork that would indicate a higher than average level of the androgen hormones, then you could definitely still have that diagnosis. Actually, so what I think is interesting about the ovulatory issues and PCOS is that every woman is a little bit different and every woman over the course of her lifetime might not be the same.

So, what oftentimes happens and I’m sure you’ve talked to God knows how many women at this point with the story, but many times people will come in and have difficulty starting their family and maybe we use medications to help spark the ovulation. And then at a later point, they may actually become ovulatory on their own. So, I always make sure to tell my patients, essentially, when the cycle is coming irregularly, there’s a couple different possibilities for why that could be.

So, one possibility is that out of all of those little follicles that are sitting there, in PCOS, what often happens is that that message from the brain to sort of get one of those follicles to mature, the egg inside gets kind of lost in translation, but particularly when we’re young, all of those follicles are sitting there making some estrogen. So cumulatively over time that estrogen goes to thicken up the uterine lining and eventually, even if there’s never an ovulation, it kind of just gets this big, unstable uterine lining and eventually it needs to shed.

So, that’s women come in and they say, I have this very, very heavy period, sometimes it lasts for a week or more. Sometimes people come in and tell me that they’ve had months of bleeding. It’s often what I just describe, sort of call anovulatory bleed where, essentially, there’s the hormone pattern didn’t follow that normal pattern we would expect, but that estrogen has thickened up the uterine lining, and it needed to shed. So that’s one possibility, but the other possibility is that sometimes people do release an egg, they do ovulate, but instead of it taking about two weeks for that to happen, it could take, let’s say, a month.

So, let’s say it takes four weeks for that cohort of little follicles to have one that actually respond to that message and ovulate and then if somebody doesn’t get pregnant again, two weeks later, you would get that period. So the whole cycle would be six weeks, which might sound irregular, and you might think, okay, well, no, I don’t have to use birth control or anything like that, because I’m not having a regular menstrual cycle, but you could actually ovulate.

So, I’ve had a lot of patients that have had “ooopses” along the way because they were convinced that they didn’t ovulate or maybe they had difficulty achieving their first pregnancy and then they had this escape ovulation that occurred kind of sporadically. So it’s really important to kind of to know that, those are options as well, those are possibilities as well that just because maybe you’re anovulatory at one period of time doesn’t mean that that’s always going to be the case.

Amy:

Is it true that women with PCOS 10, as they age to become more ovulatory?

Dr. Rashmi Kudesia:

Yes, I’m so glad you mentioned that, because that’s part of this, I wouldn’t call it a myth, but there’s sort of this thing that gets said, which is that women with PCOS become more fertile as they become older. I wouldn’t quite put it that way, but people when they say that I was referring to exactly what you said, which is that as we age for all of us as women, whether we have PCOS or not, basically that number of eggs that we have each month, that cohort is smaller and smaller. As a result, the hormones that are being produced are also decreasing as well.

So, what happens as we get older for many women, their hormone levels come more in line with sort of the typical hormone patterns we would expect to see and as a result, they actually become ovulatory. So for someone with PCOS, they may in their late 30s or early 40s, all of a sudden start to have regular ovulatory menstrual cycles, which comes as quite a surprise, but I’ve had patients ask me over the years, let’s say they’re 35, I’ve had patients ask me, should I just wait.

Maybe in a few years, my cycle will become ovulatory spontaneously? The answer to that is, if you’re trying to get pregnant, definitely not because the chances of that egg being healthy also go down as we get older, but it’s really interesting that you may actually be more likely to become ovulatory on your own as you get older.

Amy:

I think to go along with that question, are you finding that your patients with PCOS seem to enter menopause later?

Dr. Rashmi Kudesia:

That’s a great question too and it’s interesting because, the answer to that is generally not really. The average age of menopause in this country is 51 and there is a distribution around that, but it doesn’t seem that necessarily menopause is meaningfully later with women that have PCOS. I think it’s just that we’re kind of going through more follicles every month and even if you’re not ovulating, that cohort of follicles that starts to grow still is kind of gone through in that cycle.

So sometimes people wonder, if I don’t ovulate every month, or if I’ve been on birth control or something, does that somehow save my eggs, and the answer to that is no. Then I think, the correlating question to that, but I’ve also seen people ask is, is it possible that my reproductive window is later. So, if I have all of these eggs, does that mean it’s more likely that I could get pregnant further into my 40s, let’s say, than a woman that doesn’t have PCOS.

I would say that with outside of the IVF option, so if you become ovulatory on your own, or if you’re using oral medications, like ovulation induction medications to get one or two eggs to release, I would say not really because as we get further into our 40s, we have fewer and fewer eggs that are chromosomally healthy and able to turn into a healthy pregnancy. So, no, I don’t think that the menopause age is super different and no, it doesn’t also allow us to necessarily spontaneously get pregnant later into our lives and later into our 40s with the PCOS diagnosis.

Amy:

Okay. So I have heard you answer this question earlier, but I just want to be really clear so listeners understand that, and I guess I’ll just pose the question again. Can you have a period and not ovulate?

Dr. Rashmi Kudesia:

Yes, that is very important. You’re right, I should really see that very clearly. So, when we talk about a period as a reproductive endocrinologist, I’m talking about, there was a follicle that grew and ovulation that happened, and somebody did not get pressured. So as a result, about two weeks later, they have a period, as opposed to what, some of the other things that I described. So there’s a couple different other things that could happen.

So, one is what I described previously as an anovulatory bleeding, which in our sort of everyday terminology, we might call it a period, because we’re having uterine bleeding, but that’s coming from a totally different hormone pattern. There was no ovulation that ever came in that kind of a pattern. So it’s not really a true period in that sense. Also, similarly, a lot of times people will come in and they’ll say, on our questionnaire, we always ask, do you have regular periods?

They’ll say, yes, I do and then when they come in, I’ll be chatting with them and they’ll say, oh, yeah, well, when I’m on birth control, my periods always regular and that’s also important to recognize that that’s not a true period. Actually, when you’re on hormonal birth control, what that’s doing is kind of recreating a normal menstrual cycle and that you’re getting exposed to estrogen and progesterone. Then when you get to the end of that pack, and then that progesterone goes way, that mimics what would happen if somebody ovulated and then didn’t get pregnant.

So, you will naturally have a bleed that comes after that, what we call a withdrawal bleed, but again, that’s not a true period. So, I think there is a finer art to confirming that somebody is truly ovulating and having that normal sequence of events that leads to a period that comes, but there are a lot of other forms of uterine bleeding that can kind of happen and confuse the picture. So a big part of my job is helping people sort out what exactly their cycle is doing.

Amy:

I think that’s what’s so frustrating for a lot of women with PCOS where and I know this is certainly the case for me when I was younger and trying to plan my family and charting my cycle. I was at the time using the Creighton model of family planning or Napro technologies, another word for it. I had a very hard time trying to figure out when I was ovulating, because my cycles were so long and I know I was having some of these, like you said, “periods that really weren’t true periods.” Maybe if you could just speak again to the longer cycles and let us know what can we do at home? How do you advise your patients with PCOS to track their cycles?

Dr. Rashmi Kudesia:

I think Luckily, there are so many more options now for tracking because, back in the day, when we had to write things down in a journal or calendar at home, I think it was much harder to keep track. Now most of my patients and me included, have some sort of app on our phone and can really keep track of that prospectively. So that really helps kind of the ability to go back and look at the dates and seeing, is there a consistent pattern even if it’s long or is it just totally unpredictable, what’s the story.

So, when we’re having these longer cycles that are outside, let’s say longer than 35 days, so longer than five weeks, as I mentioned, there’s basically two possibilities. So one possibility is that somebody does have these sporadic ovulations, but instead of taking about two weeks for that egg to grow and ovulate, it takes longer than that. So that makes the entire cycle take longer, because from the time of ovulation to the next period is going to be more reliable about two weeks.

So however long it takes for the egg to grow and release itself, you can just add two weeks to that, and you get the length of the total cycle. So for some women, that’s kind of what happens is that they get a random ovulation and if they’re trying to get pregnant, it’s very frustrating because it’s very difficult to track. You may not get a lot of ovulatory symptoms, or you might be trying to track for days or weeks, kind of hoping for that ovulation to come and it gets very exhausting, and I think very stressful, honestly.

So, that’s option one, and then the option two is what I mentioned before, which is that actually an ovulation never occurs but uterus gets so thick after being exposed to all this estrogen that eventually that lining just sheds. So, the question is okay, well what can be done, A, to kind of track that and then maybe bring it back into a more normal ovulatory pattern.

So, the first thing is regarding tracking. So there are a lot of, as you mentioned and I mentioned, Amy with the Creighton model and Napro and all of that, there are a lot of different things out there and some of them will involve checking your basal body temperature or using urinary ovulation predictor kits or monitoring for other ovulatory symptoms, like changes to your cervical mucus or your libido or maybe other symptoms that people might experience.

Some of these can just be I mean, again, some of them are just very frustrating. I’ve had a lot of patients that have been checking basal body temperatures for months or years and then I have to sort of explain to them that maybe if they haven’t been ovulating, they were never going to see that bump the whole time. That can be very frustrating. The ovulation predictor kits do work for some women, but in general, I’m not a big fan of them for women that know they have PCOS, because many women that have PCOS have kind of a baseline higher level of LH, which is the luteinizing hormone that is measured in those predictor kits.

So, we see generally a fairly higher rate of false positive testing and many of my PCOS, patients come in and tell me that they’ll say, oh, but I keep getting these random positives on my predictor kits at home and that’s just because their baseline levels of LH hormone are high and that’s part and parcel of having PCOS for many women. So it can be a little bit tricky to do that, to kind of keep track but at the very least, I would definitely keep track of the dates of bleeding that you have, because I think it’s important to know that and be able to see kind of what the pattern is over time.

I think the hardest part is how do we get that cycle to kind of come closer to coming with some regularity and hopefully, having an ovulation that occurs. For some women that have PCOS, part of their PCOS could be that maybe they have insulin resistance, maybe that’s making it harder to kind of keep the weight where we want it to be. We do know that having extra weight that we carry does further throw off the menstrual cycle.

So our body kind of has this set, sort of threshold, I guess you could say, and sort of a range of weight that it sort of thinks is healthy and if we get above that, or below that our menstrual cycle gets thrown off. So for some women, they do notice that if they’re able to kind of change their diet and exercise regimen, that they’re able to actually notice that their cycle changes.

So again, patients will come in and tell me, hey, when I’m at this weight, I feel like my menstrual cycle is much more regular, and everybody’s a little bit different that way, but that’s kind of the first thing is looking really hard at the lifestyle and truly Amy, that’s where I refer a lot of my patients to your book because you have so much good stuff in there about diet and meal planning, and stuff like that. So that’s a really good starting point. For many of my patients to try to adopt that PCOS diet and become a little bit or a lot bit healthier.

Amy:

Thank you.

Dr. Rashmi Kudesia:

Yeah, I found it really useful when I read your book, that section of it because I think a lot of people struggle with sort of affecting a healthy lifestyle, like they kind of know, I often tell my patients, if I gave you a multiple choice quiz on what to eat, or what to do, you would pass it with flying colors, but making it happen in your everyday life is what’s really hard.

Amy:

And making it sustainable too. I think it’s the quick fix diet that’s hard to be sustainable. I wanted to ask you about the weight loss. Years ago, there were studies that showed that a 10% decrease in weight or body mass really helped with PCOS symptoms and ovulation. Do you think does that still stand? Do you think that that’s kind of a good benchmark?

Dr. Rashmi Kudesia:

Yeah, I think for women whose, and so body mass index is not the perfect number by any means, but it takes into account your height and weight and for any women who kind of find that their body mass index is falling into an overweight or obese category, that’s a good starting point is something like a five to 10% weight loss. Again, if you’re doing it in a healthy sustainable way, then for many women that will help their ovulation come back more regularly.

I think a big part of that is understanding too that, there can be a big variation. Some women might even be in that obese category and still ovulate like clockwork and some women might have been able to work really, really hard on their lifestyle and do everything that we’ve ever asked and still not ovulate. So, I definitely start with that because getting your health in a better place and eating better is also important to make sure that you’re not at risk for developing diabetes or prediabetes or any other metabolic issues.

I always warn people too, I don’t want you to get so fixated on this, with the goal of I must ovulate as a result because for some women, their PCOS was just really strong and like I said could be doing everything perfectly and may still not see their cycle become persistently or reliably ovulatory.

Amy:

That’s a great point. It really is, there is no one size fits all approach.

Dr. Rashmi Kudesia:

Totally

Amy:

Yeah. I think your point about lifestyle intervention, I do think it’s first line therapy. You can’t out supplement or even kind of take pharmaceuticals to counteract a poor diet and lifestyle, not getting enough nutrients. Your body needs so many nutrients in order, and stress. I’m sure you see that too. If you’re super stressed out, you’re not going to ovulate.

Dr. Rashmi Kudesia:

Yes. Yeah, that can definitely throw off the menstrual cycle. There’s no doubt about that. So yeah, I agree with you. That’s definitely the first part and the thing that’s difficult is that’s the hardest part. Like you said, many women come in and they say, okay, what are all the supplements I need to take, and they would be, much happier to just spend the money and take a bunch of pills. Unfortunately, as you said, you can’t out supplement your body.

Unfortunately, sometimes you just have to put the hard work in, but the benefits are so broad, honestly, in terms of all of the good things that we’re doing, because all of those changes, forget about ovulating and fertility and all that stuff, but all of those changes are just so important for your long term health, because even my patients that are trying to get pregnant, there’s two things that I always say, which is one, you want to be healthy and not developing diabetes in 10 years.

Believe it or not, I diagnose a lot of diabetes in 20-year-old women with PCOS, 20 something old women. It’s just creeping up on us because the American lifestyle in general is just really, really unhealthy. Then the other thing is, and this is just an aside, but it’s so cool is that when you are pregnant, a lot of what the fetus is learning during that nine months of gestation is really guided by what you’re eating that time.

So, I try to tell people, because I think as mothers oftentimes, we’ll do anything for our children or our family, but we don’t always do for ourselves. I think that’s the important thing is that these lifestyle changes immediately impact your baby before their even born, which I think is so cool and I think is a really big motivation to make those changes. So if you can become ovulatory that way, awesome. I’m sure we’ll talk about this more in a second, but there are some supplements and other approaches that I think can help too, but you’re right, the first one is definitely, diet, diet, diet, and then getting exercise as well.

Amy:

I’ve wanted to just again, another aside, you were talking about gestational diabetes, or you were talking about diabetes in your younger, but gestational diabetes, a lot of women with PCOS are at risk for that. Does having gestational diabetes, does that make you or your offspring more susceptible to diabetes down the road?

Dr. Rashmi Kudesia:

Oh, for sure. So having gestational diabetes yourself is probably the biggest and strongest risk factor for getting type two diabetes down the line. So the way I always think of it is that once you get pregnant, basically, the placenta starts making hormones that make you a little bit more insulin resistant. So it kind of creates more sugar or glucose, kind of floating around the bloodstream and the idea of that is we’re trying to free up some of that sugar so that it can go to the pregnancy and help the fetus grow, but it sort of pushes you over the edge.

So, if somebody is on the brink of developing pre diabetes or diabetes, getting pregnant is sort of this tests on the body that’s sort of like a stress test, and then it sort of shows you, hey, you’re definitely susceptible. So, that is definitely a big warning sign. So for patients, let’s say that never get testing to see where their sugar levels are at, but then they get pregnant and then they have gestational diabetes, definitely should be thinking really hard after baby’s born, what they can do to kind of improve their lifestyle and prevent eventually developing type two.

If those sugar levels are not well controlled during pregnancy, then definitely that has an impact on baby just through what I was mentioning. So the scientific term for that is epigenetics. So that’s kind of like how our environment influences our genes. So if somebody, let’s say, has PCOS but then they have one of those sporadic ovulations that I was mentioning, and they get pregnant, and maybe they don’t even realize they’re pregnant right away, because they’re used to having irregular cycles.

Then they get into prenatal care late as a result of that, this is a story that I see all the time. Then now, they haven’t made a lot of changes in their diet and maybe now their sugar levels are totally out of whack because they’re pregnant now, there’s all those extra hormones and now they’re kind of into their pregnancy. What happens is that with those extra sugar levels floating around, it can result in the fetus ending up weighing too much or weighing too little, actually can go either way.

What ends up happening as a result of that is that the baby, once they’re born, kind of doesn’t have a great metabolism already in the sense of its been exposed to kind of abnormal sugar levels, and it doesn’t really have the same ability to properly metabolize sugar as a baby that is just stated in a more healthy uterine environment does. So to me, it’s really motivating because for my patients, we’re monitoring, we’re catching pregnancies early, we’re right at the moment where you could know that you’re pregnant, we know.

So, we’re talking about all of this head of time, so that hopefully people can make those changes and I always tell my patients, it doesn’t matter what you did last year or 10 years ago, all your baby knows is what you’re doing right now. Because so many people just struggle their entire life trying to get their weight where they want it to be, or to become ovulatory for years, people can struggle, but once you get pregnant, all that is out the window. Whatever you’re doing at that moment is what matters, which I think is very cool.

Amy:

In my book, I talk about having your big why to really motivate you to make these lifestyle changes and if you’re listening and you want to get pregnant and be a healthy mom and have a healthy baby, I don’t know what better big why there is.

Dr. Rashmi Kudesia:

Yeah, exactly.

Amy:

To really work on your diet and healthy lifestyle. So yeah, thanks for that information. So let’s pivot back to ovulation and some other ways that we can increase our chances.

Dr. Rashmi Kudesia:

Right. So I think in the world of supplements, I think the one that we probably talk about the most is inositols, and that I think has really good data in terms of helping women, again, not all women, nothing is 100% guaranteed. I think for a lot of women, that’s kind of the first thing that they might try and it might impact and it takes time to have an impact. It takes at least a couple weeks, if not a couple months to kind of kick in, but for many women, I’ll find that they may be able to use that to kind of spark their cycle becoming ovulatory.

That’s probably has the most data behind it, but there are a lot of other supplements out there. There are a lot of other herbal treatments out there and also some of my patients will turn to acupuncture, and I’ve seen some good results with that as well in terms of helping women to become ovulatory. So I think, again after that first line of diet and exercise, then these other things can help make the difference.

Amy:

Now with the acupuncture, are you finding that the regular acupuncture is enough or I know a lot of the studies are based on like the electro stimulated acupuncture.

Dr. Rashmi Kudesia:

So I’m not an expert at all on traditional Chinese medicine, but that being said, I’ve had a lot of and continue to have a lot of really strong relationships with fertility acupuncturists in all the places that I’ve worked, and mostly they’re doing the regular acupuncture. The ones that I feel like are experts in this area feel pretty strongly that traditional acupuncture can do the job. Again, for somebody that’s maybe not necessarily, so it depends on the situation.

For some women that are actively trying to get pregnant, they may also prescribe some other herbs or give them some other herbal treatment to help support the cycle. Sometimes we don’t do that if we’re, let’s say, doing an IVF cycle, because we don’t want there to be interactions between all of the herbs and then all of the medications and stuff like that, but if somebody is let’s say, just trying on their own to help get themselves ovulatory, then a lot of times they’ll do acupuncture plus herbs, and I’ve seen that work for a lot of women.

Amy:

So, I know one of the traditional things any medicine kind of herb formulas, and it’s something that I really recommend you work with someone and not self-medicate with the herbs.

Dr. Rashmi Kudesia:

I agree.

Amy:

Peony and licorice can be a powerful combination to I think, induce ovulation but it’s something that you really need to be working with somebody on.

Dr. Rashmi Kudesia:

Yeah, I agree just to kind of back that up. Because, again, I’m not a traditional Chinese medicine provider, but from what I understand, it’s just a very nuanced way of giving the body, which I love and it’s very much about the interconnectedness of different organ systems, which I think is the main thing that I really love about that view of the body. So I guess my point is to say that, not everybody’s the same and so there’s definitely not, but I see that sometimes.

I kind of lurk, I guess you could say in some online PCOS groups, and I’ll oftentimes see people post and they’ll say, hey, what supplements should I take for my PCOS and then 50 women will say, well, here’s what I take. That hurts me a little bit because I just feel like okay, well, none of these are tailored to that specific woman. It’s like everybody’s sharing what worked for them, which is awesome, but there’s no guarantee that that combo is going to work for anybody else. So, having a guidance is really helpful.

Amy:

I think one of those herbs is Vitex that for some women, it can be really helpful with cycle regulations, but other women it can really disrupt their cycle. So I think that one in particular is one herbal that I just, it bothers me when people like you said, list out all the things they’re taking and it really could kind of disrupt your whole progress that you’ve been making on your cycle by even taking a couple doses of it. I’ve seen that with women.

Dr. Rashmi Kudesia:

I would be careful because you don’t want to undo your progress actually.

Amy:

Exactly. So inositols, anything else that you can think of across the board that would be helpful?

Dr. Rashmi Kudesia:

I think aside from that, you mentioned some, and I think there’s just a lot of other things that, and I know, you describe a bunch of them on different aspects of your program and your website and stuff. So I think that after inositols, there are other things that a lot of people talk about, but I would say that probably falls outside of where there’s a lot of data behind it or outside of what I can speak to from a professional standpoint, and like I said, point to some data to back it up.

I think that’s where I would really encourage someone to, if they’re really interested in doing all of the things to get their cycle ovulatory outside of medication, then that’s where I would really encourage people to work with somebody that’s an expert in that area, I think, along the lines of what’s, more of a western medicine approach, it just kind of depends again, on someone’s individual situation, because let’s say somebody is really does have that insulin resistance phenotype and maybe weight as part of what their struggles are, then sometimes Metformin can be helpful.

Metformin is a medication that re-sensitizes our body to insulin. So for some women, it will not only help them prevent getting pre diabetes and diabetes, it might help their weight loss and as a result, it might help them ovulate. I don’t think of it as a medication to induce ovulation but it certainly can help. So that could be appropriate for some women as well.

Amy:

So a while back, you wrote a great post and I’m going to post it in the show notes, about the difference between letrozole and Clomid and a lot of doctors I’m finding still are not that familiar with letrozole as an ovulation inducing agent. So I was wondering if you could, I want people to definitely read that article, because you go in detail there, but just give us an overview.

Dr. Rashmi Kudesia:

Yeah, so that’s a great transition from the Metformin thing. Because the history of it is relevant. So, for a long time, Metformin was really the only traditional pharmaceutical type medication that we had to try to help improve ovulation and then clomiphene or Clomid came on the market and that was shown to be much better than Metformin alone in terms of actually inducing an ovulation to happen. Then fast forward, so then everybody kind of got in that mode of like okay, Clomid is the ovulation induction medication, and then fast forward we have letrozole which is also an oral medication.

It’s what we call an aromatase inhibitor, and it just also sort of helps spark the body to realize that an ovulation needs to happen or a follicle needs to grow and it’s actually been so long now. I think it was actually in 2014, or maybe in the very beginning of 2015, that the trial that demonstrated that in women that have PCOS, letrozole is superior to clomiphene in terms of sparking ovulation and in terms of live birth rate, this was the PP COAST II trial.

So, it’s been out now for like, five, six years and as a result, for those of us that are really passionate about taking care of women with PCOS, we pretty much switched over to using letrozole for ovulation induction for first line for women that have PCOS, but I totally agree. I still see lots of people out in communities use Clomid for everything. I think the good news about letrozole is that in general, the side effect profile is better. I think people tolerate it better.

I think also importantly, the chance of having multiple follicles grow with letrozole is less than you would get with Clomid. So that just increases the chances of having a healthy singleton pregnancy. So that’s another huge plus in my mind, and then also for some women, Clomid can actually thin out their uterine lining, which is really counterproductive to what we want to see when we’re trying to get pregnant and letrozole doesn’t do that. So there are a lot of advantages for women that have PCOS, But definitely, if you’re moving on to ovulation inductions that are going to help spark that egg to grow, then letrozole should be the first choice medication.

Amy:

Great. So did we miss anything that we need to cover before we wrap up?

Dr. Rashmi Kudesia:

I think we’ve covered it all. I think it’s just, sometimes it’s very confusing and I want to kind of wrap up on a uplifting note, which is that, I think there are a lot of great health care providers and physicians and reproductive endocrinologist out there that want to help people figure out what’s going on. For me, it’s a really big win on my day if I have a patient that comes in and sometimes people come in with binders full of things that they’ve been tracking over the years and they just come in and they’re still so defeated because they don’t know, have they been ovulating, have they not, what’s going on with their cycle.

They’ve been doing everything temperatures, predictor kits, the whole nine yards and they just want some answers. The thing is, from the perspective of what I do, it’s so easy to figure out if somebody’s ovulating or not. So I want people to feel empowered that if they’re struggling and they’re not sure if they’re ovulating, find somebody that will support you on your journey because I will help a lot of women.

I always offer when they come in, I’ll say, look, if you really just want to know if you’re ovulating or not, we can do essentially what we call a natural cycle. We’ll follow things along, we’ll see are you growing follicle by ultrasound, and or sometimes we’ll just do bloodwork to see if the progesterone level goes up in the second half of the cycle after a presumed ovulation. So there are really simple ways to help you figure out what’s going on or not.

So my point is just that if you’re out there and you’re listening and you’ve been trying to get your ovulation cycle more regular and you’re not sure if it’s working, don’t hesitate to reach out for help before you drive yourself crazy because it can be a lot to try to track and we’re here to help and it’s not that hard.

Amy:

Yeah, that’s a great point and maybe just to close, I think a lot of people don’t understand the difference between your OB-GYN and a reproductive endocrinologist. Maybe if you can just explain that difference.

Dr. Rashmi Kudesia:

Sure. So yeah, I am first and foremost an OB-GYN basically. To become a reproductive endocrinology and infertility specialist, you do three extra years of training after your OB-GYN training has finished. So that’s a three year fellowship and basically our training during that time is specifically in the hormones related to the reproductive system. So this is what I’m used to talking about all day long, every day. So that’s really helpful and I think the difference that can be helpful for coming to see a reproductive endocrinologist versus just your OB-GYN is that we have ready access to an ultrasound machine right in our own and I’m doing scans all day long.

So, some OB-GYNs do as well. So it really depends on your situation individually, but for us, we are just used to monitoring where exactly where people are in their cycle, and I scan everybody right away on their first visit. So you just can sometimes get a little bit more information right away and we’re open every day of the week. So, that I think, is also helpful for somebody trying to track their cycle.

So if you feel like you’re not getting enough explanation from your OB or you’re not able to monitor your cycles or kind of confirm one way or another, or if they’re telling you something like, I don’t know, maybe you have PCOS because I see a lot of that, then I think all of those are reasons to seek out a consultation with a reproductive endocrinologist so that you know what your diagnosis is, you know whether you’re ovulating or not, and if you’re trying to get pregnant, we can help make that happen too.

Amy:

Great, and you are again, located in Houston. You’re part of the CCRM fertility clinic and you also do telemedicine. So, if somebody is listening and wants to have a consult with you, how do they go about doing that?

Dr. Rashmi Kudesia:

Yeah, so we’ll, I guess in the show notes we can have, I think you have a link to our practice page or, I don’t know. We’ll look at that but basically, if you come to our practice page, you’ll see our phone number, and you can just call to make the appointment and if you’re a local in Houston, then fantastic. If it’s going to be a long distance thing, then we can do that over Skype, not Skype, but it’s over video, audio video consultation, and I’m happy to review any records that definitely makes the visit bit more helpful and kind of go through everything and help you figure out are you ovulating or not.

Amy:

Great, and also, please follow Dr. Kudesia on social media. She posts often and has some really great content. So I was hoping, if you could just give your handle, I will put that in the show notes for those that are listening.

Dr. Rashmi Kudesia:

Yeah, so I’m probably most active on Facebook and Instagram and it’s just, @rkudesia. So really straightforward.

Amy:

Just spell that for everybody.

Dr. Rashmi Kudesia:

Yep. It’s R-K-U-D as in David, E-S as in Sam, I-A

Amy:

Perfect. Well, thank you for recording our fourth podcast together. I think this was really answered everybody’s questions about ovulation.

Dr. Rashmi Kudesia:

Awesome. Well, it’s my pleasure. Thanks, Amy.

Amy:

Thank you everyone for listening. I look forward to being with you again very soon. Bye bye.