PCOS Renamed PMOS: Root Causes, Hormones, Metabolism, Labs, and Integrative Treatment with Dr. Felice Gersh
Dr. Ben Weitz introduces an interview with OB-GYN and integrative physician Dr. Felice Gersh on PCOS, newly renamed polyendocrine metabolic ovarian syndrome (PMOS) per a May 12, 2026 Lancet announcement, meant to shift focus from “cysts” to hormonal and metabolic dysfunction. Gersh argues ovaries remain central, describing impaired aromatization leading to low estradiol, high LH-driven testosterone, and downstream effects including insulin resistance, inflammation, leaky gut, altered microbiome, sympathetic activation, elevated cortisol/DHEAS, obesity, mood disorders, sleep apnea, and autoimmune risk. They discuss legacy and practical issues with renaming, updated diagnostic criteria adding anti-Müllerian hormone in adults, and PMOS as a diagnosis of exclusion. Recommended evaluation includes total testosterone, DHEAS, SHBG, thyroid panel with antibodies, lipids including apoB, hsCRP, nutrients, ANA, prolactin, and select rule-outs (17-OHP, Cushing’s, tumors). Treatment emphasizes lifestyle, plant-focused diet, time-restricted eating, exercise, supplements (myo-inositol, NAC, quercetin, melatonin, mitochondrial support), cautious pharmaceuticals (metformin/berberine, spironolactone), and cyclic bioidentical estradiol/progesterone; low-dose dexamethasone is noted for select adrenal-driven cases.
00:00 Podcast Intro
01:02 PCOS Renamed PMOS
04:51 Hormone Pathway Explained
09:04 Systemic Effects Cascade
13:15 Prevalence And Risks
17:29 Name Change Debate
18:28 Follicles And AMH
22:54 Inflammation And Immunity
26:17 Origins And Modern Triggers
31:40 Why Rebranding Falls Short
35:05 PCOS PMOS Searchability
35:48 Updated Diagnostic Criteria
37:52 Teen vs Adult Criteria
39:01 Key Lab Workup
44:07 High DHEAS Red Flags
45:00 Diagnosis of Exclusion
47:39 Lifestyle Treatment Plan
49:16 Diet and Fasting Strategies
53:45 Meds and Herbal Options
54:43 Mitochondria and Supplements
57:54 Inositol Ratio Debate
01:00:47 Hormones and Antiandrogens
01:04:03 Adrenal DHEAS Suppression
Dr. Felice Gersh is a board certified obstetrician and gynecologist and she is also fellowship-trained in Integrative Medicine. Dr. Gersh is the Director of the Integrative Medical Group of Irvine, where she sees patients. She also lectures for A4M and various other conferences and she writes on various topics relevant to women, including on PCOS now PMOS. She has written 3 books, the first of which is called PCOS SOS and the second is PCOS Fertility Fast Track.
Dr. Ben Weitz is available for Functional Nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure. Dr. Weitz has also successfully helped many patients with managing their weight and improving their athletic performance, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111.
Transcript:
Dr. Weitz: If you’re looking for clinically useful insights, not wellness hype, then this is the place for you. Welcome to the Rational Wellness Podcast, the podcast for functional and integrative practitioners who want to practice with greater clarity and precision. I’m Dr. Ben Weitz, and each week, I sit down with the leading clinicians, researchers, and lab innovators to explore the science, lab testing, and clinical reasoning behind modern root cause medicine. This is a show focused on practical, evidence-informed insights that you can actually use in patient care. Please subscribe to the Rational Wellness Podcast on Apple, Spotify, or YouTube. Please tell your friends and colleagues, and if you could give us a ratings and review on Apple or Spotify, we would certainly appreciate it. Finally, to access the show notes and the full transcript, please go to my website, drweitz.com.
Hello, [00:01:00] Rational Wellness podcasters. Today, we’re going to be having an interview with Dr. Felice Gersh on PCOS, which is now called PMOS. In fact, that’s one of the reasons why we are decided to have this discussion, because on May 12th, 2026, it was announced in the journal The Lancet that polyendocrine metabolic ovarian syndrome is the new name for polycystic ovary syndrome. And this apparently resulted from a multi-step global consensus process that, according to the Endocrine Society, took 14 years , which gives you an indication of how slow the medical world changes. The name was changed to change the focus from the ovaries to the fact that this condition is [00:02:00] primarily a hormonal and metabolic condition, and there really are no cysts on the ovaries. Some patients have what appear to be cysts, but these are actually immature egg follicles that have stalled at an early stage of development. And many women with PCOS do not have these. So this is really a condition of insulin resistance and excessive male hormones in women This insulin resistance can lead to diabetes, obesity, hypertension, abnormal lipids, fatty liver.
The hormonal imbalances can result in irregular menstrual cycles, infertility, facial hair, acne, a whole series of other k- symptoms. But those of us in the integrative medical world have been focu- focusing on the metabolic and hormonal [00:03:00] aspects of this condition for many years, including our guest today, Dr. Felice Gersh. Dr. Felice Gersh is a board-certified obstetrician gynecologist. She’s also fellowship-trained in integrative medicine. She’s the director of the Integrative Medical Group of Irvine, where she continues to see patients. She lectures around the world for A4M and various other conferences. She writes on various topics relevant to women, including on PCOS. Now she’ll have to change the title of her books to PMOS. She’s written three books, the first of which is called PCOS SOS, and she’s a good friend of mine, and she’s now making her seventh appearance on Rational Wellness. Thank you so much for joining us, Felice.
Dr. Gersh: Well, thank you, and that was a lovely introduction to both PCOS/PMOS and to me. And I have to make a few [00:04:00] comments since that’s why- Of course … we’re here together. And the reality is that, This really is an ovarian condition. What it– I mean, of course, they have the word ovarian in it. They left it in it. But if you’re going to look for, like, root cause medicine type stuff the ovaries are very much root cause, and the total body impacts are primarily secondary, which are huge impacts. But if we go to, like, what is the root cause of PCOS? And the answer is, and I’m gonna call it, you know, PCOS and PMOS, and I’m gonna make my case for why the names should both be together and why we can’t just you know, if– eliminate the PCOS part in a few moments. But if we get to, like, root cause, like, what is this anyway?
What’s going on here? Well, we really don’t know if the root cause starts in the brain, or it starts in the pituitary, or it starts in the ovary [00:05:00] because they’re working together in this, you know, incredible trio of effects. But what is happening from the ovarian point of view is that the ovary makes testosterone, and it makes it in the theca cells.
And the ovaries of women with this metabolic condition will– I’ll call it PMOS. Sometimes I’ll call it PCOS to keep everybody on their- I want to keep everyone on their toes. Right, right? So, it starts with the production of testosterone in the theca cells. Then it’s like an assembly line. It goes down the road, and it goes from that group of cells, and the testosterone moves into the granulosa cells. And there, there’s an enzyme called aromatase, which works under the control of FSH, follicle-stimulating hormone, to convert testosterone into estradiol, the estrogen produced by the ovaries, and the [00:06:00] pituitary gland produces LH, luteinizing hormone, which controls the production of the testosterone. In women who have this condition, PMOS, I’ll say this time-there is a problem with this process of conversion or aromatization of testosterone into estradiol. Now, why is that? That’s like, okay, that’s a big question. Why is it a problem? Well, it turns out in women with this condition, the levels of FSH tend to be quite low. Now, is that a problem from the brain or the pituitary or a feedback loop? That is where we really don’t know at this point exactly what’s going on there. But there’s no problem with the production of testosterone. It’s a totally different skill set. So the brain has sensors to estrogen, but it doesn’t have sensors to [00:07:00] testosterone. So you can make, as a female, enormous amounts of testosterone or other androgens, and the brain doesn’t pay attention.
Like, there’s no feedback loop to lower the production. But for estrogen, there is a loop, and there is sensory perception in the brain. So the brain says, “Oh, I don’t have enough estrogen. Estradiol is not being produced enough.” So it puts out the signal to the pituitary through the little gonadotropin-releasing factors or hormones that tell the pituitary, “Make more testosterone as the precursor to estradiol.” So LH levels go higher, and the testosterone produced by the ovary goes higher. Then it goes down the assem– It travels down the assembly line, and in the granulosa cells, due to a lack of adequate aromatization, [00:08:00] you don’t make enough estradiol. So this now becomes a real chronic problem.
Not enough estradiol, and the brain keeps saying, “More, please.” So in the process of trying to make more estradiol, it causes the ovaries to make more and more testosterone. So you can consider PMOS to be a condition of androgen excess and too much testosterone and not enough estradiol. And that really leads to all the downstream effects throughout the whole body, including every organ system, because there are estradiol receptors on every organ system. That’s why the metabolic consequences of PMOS are identical to the metabolic consequences of perimenopause going into menopause. The same consequences of estradiol insufficiency in perimenopause, and of course, menopause is more [00:09:00] extreme. You have no estradiol produced by the ovaries. But you have this extra problem where you have testosterone excess, and because you don’t have enough estradiol, and then you get leaky gut. That was proven back in two thousand fourteen by the Chinese, that you have leaky gut with this condition, and that creates more inflammation as you have endotoxins coming into the body. That creates more insulin resistance. And then you also don’t have enough estradiol to make enough of the neurotransmitter and functionality acetylcholine in the vagus nerve.
So you have then not enough parasympathetic and you get into, because of inflammation and the stress reaction and the not enough vagal tone, you have the stress response, too much sympathetic activation, which creates more adrenergic activation, [00:10:00] adrenal, and the adrenal gland then produces more cortisol. Well, the trigger to more cortisol is ACTH, and ACTH also triggers the adrenal gland to make more DHEAS, the androgen, the dominant androgen from the adrenal gland. So now you get even more androgens coming into the situation, and the gut microbiome changes to actually become more male-like and actually can cause more production of testosterone, and you get the insulin resistance from all the inflammation that’s going on and lack of adequate estradiol, and that increases insulin circulating, which causes more IGF-1, insulin-like growth factor one, which can actually go into the ovary directly and directly trigger the ovaries to make more testosterone. Wow, you can see that this is complex. This is so complex, right? But it [00:11:00] really initiates with this re- this relationship with the hypothalamus in the brain, the pituitary and the ovary, and the imbalance of the production between too much testosterone and not enough estradiol. And I certainly don’t think the new name tells all of that, you know? And, ugh, you know, so we’ll get into like why was this name change important? Why did people think it was important, and so on. But just a little background on the complexity of this- Yes … metabolic condition.
Dr. Weitz: it’s interesting. I was wondering prior to us having this discussion what role the insulin resistance played in leading to more testosterone increase, but it sounds like the hormonal factors are driving this whole thing.
Dr. Gersh: Yeah, but then you have… Absolutely. Then you have the extra problem of high insulin, high IGF-1, and then that, the IGF-1 goes [00:12:00] into the ovary directly causing more testosterone. And some of these mechanisms are why women who have obesity can have a very similar look to women with PCOS. And something like 80% of all women with PCOS have very significant overweight and obesity because there are adipose tissue a- adipokines like adiponectin, leptin. They’re all modulated by estradiol, which is insufficient in these women, creating a similar profile like with the abdominal visceral fat production and fatty liver, which of course has a new name too, another conversation. You know, so women with this metabolic PMOS have similar situations with visceral obesity and fat depositions in organs like the liver, the pancreas, the bone marrow, around the pericardium.
All those things happen more similar to what happen to women as they transition [00:13:00] into menopause because of lack of this vital hormone, estradiol. But then of course, you have all the androgen excess symptoms that come into play with PCOS, PMOS. So it’s it’s really quite the thing to have, you know? And I hope, you know, that changing the name is going to change something because this condition is the most common endocrine disorder of women of reproductive age. It’s the most common cause of female infertility, and it occurs in, nobody knows ’cause where’s the data keeping, but somewhere between 10 to 20 or more percent of all women.
Dr. Weitz: Yeah I’ve heard 25% here.
Dr. Gersh: I know. Yeah. Me too and it depends on where you are and how you track it, and it’s so prevalent and growing in frequency. And we can talk about like why is that happening too because that’s not in the name either, you know?
Dr. Weitz: And [00:14:00] then of course the increased insulin drives diabetes and cardiovascular disease and obesity and even cancer, along with higher IGF-1 levels, which also can play a role in increased cancer if the levels get too high.
Dr. Gersh: Yes, and because you have impaired gut barrier and an altered gut microbiome, you really get this endotoxemia to a low, you know, systemic but low degree that’s ongoing, and that increases the whole systemic inflammation, and it all links together. And, you know, you have a…
Dr. Weitz: Isn’t it amazing how the gut plays a significant role in everything?
Dr. Gersh: Yes. Yes, absolutely. And you know, they’ve shown that in women who are transitioning into menopause, that they have a negative modification of their gut microbiome. It is all interconnected. And then you have this [00:15:00] back and forth between the vagus nerve, which has efferent and afferent, you know, fibers going back and forth to the brain communicating, and then you have more, because of all these things that are happening, you end up with high rates in women with this condition, PMOS, of anxiety and depression. And because the brain centers that deal with breathing are affected, you have sleep apnea, and that also can relate, of course, with obesity, but even separately, sleep-disordered breathing. So it,
Dr. Weitz: You know, you just mentioned transitioning, and the thought came into my mind, what about these women that decide to transition to become men and taking injections of testosterone, given all these negative effects of ramping up the testosterone levels? Nobody’s looked into this, and I’m sure it’s not that large a number of people, but the, there’s gotta be some most likely will be negative health consequences of trying to [00:16:00] transition a woman by taking large amounts of testosterone
Dr. Gersh: That’s a great question, and I don’t actually deal with that problem. I have, you know, it’s, I mean, or condition, I should say. Right. That’s ’cause I’m not taking care of those patients. But yes, I mean, I’ve thought about that too, because now you have a similar kind of a thing, and genetically, women are not really programmed to have… We all have paracrine conversion of testosterone into estradiol. Men have a ton of estradiol, but it’s not circulating. It’s in the organs, produced directly in the organ, and even in cells, intracrine, and there’s paracrine production of estradiol. That’s why in the reproductive years, men’s brains make six to eight times as much estradiol as a female brain, but it shouldn’t matter because females get all that estradiol coming from their ovaries.
But of course, [00:17:00] after menopause, that’s not happening, and it’s also true in women with PCOS, and it’s really an issue in terms of mood disorders. And of course, women, if they go into menopause, have, make up 70% of all age-matched Alzheimer’s patients. So, you know, we don’t have the transitioning into being more male-like just because we have more male hormones. So it is definitely a concern. And and I do want to say that I respect and I really can understand the motivation for wanting to change the name, because certainly I don’t think anyone, myself included, can argue that PCOS, polycystic ovary syndrome, tells everything about it. And like you said, a lot of women think it means that they have big cysts.
Now, they really are cysts if the definition of cyst is a little contained structure with fluid in them. So they are cysts. [00:18:00] They’re just little tiny follicular cysts. They’re not big functional cysts or tumorous cysts or something like that. But technically, they are little cysts. So when we say, you know, just…but they’re not the cysts that most people think about as cysts in the ovaries. Sometimes I’ll have patients and they would come in and they would say, “I have an ovarian cyst that ruptured. I must have PCOS.” And it’s like, “No, that’s not-” “… these tiny little cysts. They don’t rupture. They, that’s not…” So it is confusing. It is confusing.
Dr. Weitz: And are these cysts that they have, are these are these eggs that haven’t matured?
Dr. Gersh: Yeah, they’re like primordial follicles, Okay. So what happens is, it’s kind of, if you picture it like, I think of it like a beauty contest, okay? Old-fashioned beauty contest Okay, so, you have this-
Dr. Weitz: Is this run by Donald Trump in Russia?
Dr. Gersh: Could have been. So is he responsible for this condition? I don’t know. So you have this interesting hormone that has the weirdest name ever, [00:19:00] called anti-Mullerian hormone.
Dr. Weitz: You just have to bomb all women, and then we’ll solve it.
Dr. Gersh: Ah! No. We’ll get there.
Dr. Weitz: Okay, just kidding.
Dr. Gersh: Well, I know. You know.
Dr. Weitz: Sorry, sorry to change your train of thought.
Dr. Gersh: Well, we’re having fun. So you have this crazy named hormone called anti-Mullerian hormone, AMH. And the the reason it has such a crazy name is that in embryological times, it causes regression of certain structures. Like people know that, “Oh, when we were an embryo, we had a tail, and then the tail went away.” Well, that’s because we have these regression of these little features, and this hormone anti, like against Mullerian, these structures hormone. But in an adult female, they really should change the name to follicle recruiting hormone, right? If you’re going to change the name to mean what it means, right?
Because there’s no anti-Mullerian function in an adult female. So [00:20:00] but it causes the recruitment of these tiny little follicles. So and that’s under the control of FSH, okay? So you have all of these little follicles coming on the scene, and they’re all saying, pick me. I wanna be the special chosen one.” And it takes, We don’t even know how that happens. Like, how does all of these little like lining up, you know, primordial eggs and these little follicles line up, and how does one get chosen to be, or occasionally two, if you get twins- … you know, to be ovulated? We don’t know. But in order for that to happen, you have to have like FSH levels rising, and that’s not happening properly in women with this condition, so you just keep having the recruitment, and anti-Mullerian hormone needs to be shut down by FSH, but it’s not happening because you don’t have high enough FSH.
So you keep having follicles recruited, [00:21:00] and that’s the origin of these little follicles that form around the cortex or rim of the ovaries that has been designated sometimes like a ring of pearls. It looks like tiny little like circles all the way around the outer rim of the ovaries, and that’s the origin of the name. But of course, they don’t have to only be around the rim. They can also kind of be in else, you know, elsewhere in the ovary. But that’s where they start, and then they tend to pile up. But the, it’s like the the pot, if you know the fairy tale where the porridge is just, they just don’t turn it off because there was a magic spell that was not properly put out. So you have this problem of constantly recruiting these little follicles And there’s no shutdown that’s proper, and you don’t get the proper chosen one for ovulation ’cause you don’t have high enough FSH. So that’s like the origin of this whole problem, and it’s all linked to the enzyme as well, aromatase, [00:22:00] that converts– which requires proper FSH to convert the testosterone into estradiol.
And it’s even more complicated because we also have this other factor called myo-inositol, which is a stereoisomer of the inositols, which are sugar alcohols. And in a normal female ovary of reproductive age, the ratio of myo to D-chiro inositol should be 100:1. But in PCOS ovaries, it’s only 12:1, and that’s also really involved in the function of aromatase. So there’s a whole bunch we need to know and learn about this, but it really is an ovarian problem, whether it is originating in the ovary or elsewhere in the brain or pituitary, we don’t know. But it really is ovarian. And then you have this widespread effect because once you recognize that estradiol [00:23:00] has receptors everywhere on every organ system, and when you have this added state of chronic inflammation, and then you have the insulin resistance, you have really like metabolic chaos, and it really is a very complex situation.
The women who do get pregnant, they have the highest failure rate for IV when they do in vitro fertilization, and they have very high rates of pregnancy complications and, like I mentioned, high rates of obesity and mood disorders so, you know, and autoimmune diseases because estradiol is critical for the T regulatory cells, which are involved in regulating self versus, you know, in the whole immune system type of thing. So you also have situation where this was studied and actually shown back in a study in 1998 that women with this condition have immune cells because all the immune cells have estradiol receptors too. The [00:24:00] innate immune cells, that’s like the mast cells or macrophages or neutrophils, they have a lower threshold to trigger to create inflammatory cytokines. So it’s like even a lower amount of endotoxins entering the body from the gut will trigger this more massive explosion of inflammatory cytokines circulating through the body. And so it’s true the name PCOS doesn’t tell anything about any of that. And so there is something I wish in a way that the new name maybe was the old name.
The problem with changing a name Is that you have a legacy of huge numbers of published articles that are, you know, archived, for example, on PubMed, that all have PCOS or polycystic ovary syndrome in the name. You have books like you mentioned. There are organizations, there are companies whose logos, whose trademarks, whose everything [00:25:00] is related to PCOS, not PMOS. And you have all of these really important advocacy organizations, these nonprofits that have spent decades, you know, advocating and trying to educate and promote research monies being put into this condition to understand more about it and to get more appropriate treatments and so on than the same old stuff that’s been used forever. Like everyone gets put on birth control pills, which is actually pro-inflammatory, you know, and so it has a lot to be desired. And metformin, which is okay, but obviously not getting to root causes. And so the bottom line-
Dr. Weitz: By the way, you keep mentioning FSH as being a big factor. Have researchers looked into using FSH to help manage this condition?
Dr. Gersh: Oh, yes. When women have problems conceiving, they will often use FSH. But the strange thing [00:26:00] is they often overreact to FSH and get over-stimulated. So yeah, it’s really complicated. Yeah. But yeah, that’s definitely been looked into, but we don’t have the, there’s no, like, long-term drug treatment with FSH. Yeah.
Dr. Weitz: And- Do we know about the origin of this condition? Does it… are there genetic factors? Does it start-
Dr. Gersh: Yeah … there are. So, we don’t have, there’s no a single gene that’s been recognized or chromosome or something like that. But we do know that if you have PCOS or if you have a first-degree relative with this condition, you have a 50/50 chance of having it. So if you have a mother, a sister, a daughter, any of those kind of relationships, you have, like, at least a 50/50 chance of having this condition. So it does tend to run in families. But one of the biggest things that’s causing the [00:27:00] explosion, like it’s, this condition has always been around and it’s believed that it was around back even in prehistoric times as a very mild disorder, where women who had it had a slight increase in testosterone and a slight decrease in fertility, which actually turned out to be an advantage because by having a little bit more testosterone, those women tend to be more, like, fearless and bold and the leaders of the tribe and so on.
And in fact, they’ve done some studies on women who’ve won gold medals in the Olympics, and they naturally tend to have this very mild version where they naturally have a little bit higher testosterone, but not enough to create all the problems, just enough to give them that little edge, right? Right. And the thing is that- When you have this problem, and then you add in what is now our modern world, okay? We have food that creates, even in the best of circumstances, [00:28:00] if you have the healthiest genes on the planet, right? And then you eat ultra-processed food, good luck, right? So you’re going to have gut dysbiosis just from all the chemicals that are put into food and the lack of adequate polyphenols and nutrients, so you’re going to have all kinds of metabolic problems. I mean, think everyone knows that,
Dr. Weitz: right? And the endocrine-disrupting substances that are- That’s- … present in the pesticides- Exactly … and the plastics and-
Dr. Gersh: Oh, that’s exactly where I was heading. You jumped ahead. Yes, so we know that women with PCOS, PMOS, they tend to have higher body toxic loads of endocrine-disrupting chemicals. The, there’s been quite a bit of research, a lot actually, but the most common one that’s been researched is bisphenol A, and of course the other bisphenols that have replaced it which are equally toxic or more toxic, and they definitely have a role, a very big role, these endocrine disruptors [00:29:00] that prevent proper functioning of our endocrine system. And something like BPA, not only is it an endocrine disruptor for estradiol, it also alters the function and elimination of testosterone, and also of melatonin, which is a critically important hormone- Interesting … and also related to ovarian function and PCOS, PMOS as well. So it is complicated, and this endocrine disruption can occur in utero when the endocrine system is being developed.
So there’s actually published data that women with this condition have altered endocrine receptors for estradiol and other hormones as well. So their receptors are resistant. So everyone’s heard of insulin resistance, right? So the insulin doesn’t work properly on the receptor. The same thing is happening in PCOS, PMOS, [00:30:00] that the estradiol receptors are not working properly, so even the small amount, the reduced amount of estradiol produced by the ovaries isn’t working adequately on the receptor because it doesn’t matter how much hormone you have if the receptor isn’t receiving today and isn’t working. So it’s really, it’s an extra problem, and it’s so magnifying, exploding this medical condition because of endocrine disruptors like you totally wisely brought up, and the change in our food supply, and also our circadian rhythm, which is modulated by estradiol. So many women now are staying up late. They work night shifts. They have too much light, ambient light all the time, and it’s really affecting our circadian rhythms, which are very heavily involved in our metabolic functioning systems. So it’s all of this. It’s like an explosion of ancillary [00:31:00] problems that are creating this drive towards more and more of this condition, and it is important that it get recognized.
My only complaint is what about the legacy of all the companies the nonprofits, all of the research, the books that are all under the label of PCOS? For these companies that are just working on, like, shoestring budgets, this is going to be extraordinarily costly. Plus, a lot of them have built up social media followings all with the name of PCOS, and for them to suddenly change it and then, like, they lose their whole social media presence, it can be very difficult.
Dr. Weitz: And really, the important thing is to change our understanding and our management- Yes … of the condition, not the name.
Dr. Gersh: Well, that’s exactly it. I keep thinking to myself, “Why is it so critical to change the name?” This took, like you mentioned, all those years over, you know, over a dozen [00:32:00] years, and thousands and thousands of hours and millions of dollars to get this name change to this point, and this is just the beginning. ‘Cause this, the, they’re saying that it’s going to be eased in, you know, over the next three years. That all the names have to be changed, and everything is gonna be reworded, and all of this and so on over the next three years. But what is the cost of all this? And could that time of all these medical experts and all this money have been better spent on actually educating our medical workforce-
Dr. Weitz: Yes
Dr. Gersh: and the public? Yes. My thing, right? Yeah, that’s what I’m thinking. It’s like, could all that effort have been better directed? I think so, because changing the name right now is creating a lot of buzz, right? But you know how they have the news cycle, so what happens in two months from now when nobody’s talking about this-
Dr. Weitz: Two weeks from now.
Dr. Gersh: Yeah, two weeks from now. That’s right. And so is anything gonna actually [00:33:00] come of this? Is, are all the medical students in medical school suddenly going to be on a better curriculum to learn about this? Will the public know more? Just change– Like, if you think about all the other medical conditions that have changed their name, has it… I mean, I don’t know the answer to this. Has it really poured more research dollars into those conditions? Like, they changed the name of chronic fatigue syndrome to myalgic encephalomyelitis, which by the way, almost nobody actually knows that or calls it by that name. So it’s so confusing that they made the name ME/CFS. And what about painful bladder syndrome, formerly known as interstitial cystitis? Well, I asked my son, who’s a urologist, “Does anyone get referred to you for painful bladder syndrome?” He said, “No, it’s always interstitial cystitis.” And because– But, you know, it,
Dr. Weitz: And the same thing with fatty liver. It’s so much easier- Yes
to [00:34:00] just call it fatty liver- And- … than to use that long name,
Dr. Gersh: you know? I know. That’s what I’m saying. But even with, like, the burning bladder syndrome, because nobody knew what it was. So now they made it BP, burning bladder. So, … burning… No, painful bladder, that’s what I’m getting. PBS. So yeah, so it’s IC/PBS. Okay. But here’s the thing about- Polyendocrine ovarian… Nope. See, now I already got it wrong. Polyendocrine metabolic ovarian syndrome. That is a lot of words. And also, nobody’s gonna remember it, and no one’s gonna say it, so they made it PMOS. And they don’t want to make it confusing, I think, with PMS, ’cause they sound alike, so it’s do you have PMS or do you have PMOS? Do you have both? Okay, I don’t know. So, so, so they ne- they’re gonna call it PMOS. So it’s not gonna be PMOS, it will be PMOS. So yeah, so two weeks from now, is [00:35:00] anyone gonna know what PMOS even stands for?
Dr. Weitz: No, this is all a big waste of time and money.
Dr. Gersh: So that’s how I feel. Yeah. So PMO- so this is my suggestion to them out there. If I can’t change the whole thing, I can’t go back in time, so maybe we have to make it PCOS/PMOS. We have to keep PCOS in there so that it’s called searchability, so that … if somebody goes to PubMed… or they go to Amazon- Right … and they want to get a book, right? They can put in PCOS or PMOS and it will direct them to this article.
Dr. Weitz: Or Barnes & Noble.
Dr. Gersch: That’s right. I don’t want to- … just say Amazon. That’s right. I like Barnes & Noble. Or your independent book dealer.
Dr. Weitz: There you go. So, the old guidelines for giving a diagnosis were the Rotterdam consensus.
Dr. Gersh: Yeah. And that-
Dr. Weitz: And that meant having two of three irregular [00:36:00] periods, high androgens, polycystic ovaries. Do we need a new way to define this condition?
Dr. Gersh: Well, they made a difference, a mild difference in terms of the criteria, a committee. There are always committees of doctors. A lot of them are coming from Australia, but not all. And they had another-
Dr. Weitz: I’m surprised they don’t have private equity people on the committees.
Dr. Gersh: Well, you know what? Actually, I was wondering about that too, you know? Like, is there anyone gaining something from this financially?
Dr. Weitz: Probably.
Dr. Gersh: I don’t… That’s what I’m like, what is… Does yeah. Does anyone have all the domains that have PMOS in it? You know, it’s like, “I’ll sell it to you,” you know? Maybe. So- Probably … they… I would… Yeah, that, that’s not a joke. If you wanna get a PMOS in your social media- … good luck to you now, right? Good luck. But now what were we talking about?
Dr. Weitz: Oh, we were talking about how to define this condition.
Dr. Gersh: Oh, yeah, the Rotterdam. Do we need- The Rotterdam …
Dr. Weitz: Do we need [00:37:00] a new criteria?
Dr. Gersh: So they added… This is what they added. Yeah, they added a little something. They separated out adolescents from adults. And so for adults, so adults would be like 20 and up, okay? So they can also have, in addition to what you said, they can have l- instead of having polycystic ovaries on ultrasound, which is defined somewhat arbitrarily as 20 at least of these tiny little follicular cysts on at least one ovary. I’ve never seen a single radiologist ever count any numbers. So they just say many, numerous, consistent with. I’ve you know, so I let it go at that. But now they added a high level of anti-Müllerian hormone. So now anti-Mullerian hormone can be part of the definition-
Dr. Weitz: Okay … for,
Dr. Gersh: you know, getting the condition. And then for younger women, teens, they took– you cannot– it does not include either [00:38:00] anti-Mullerian hormone elevation or the ultrasound findings of polycystic ovaries because those are common in those years, in the teen years. So it would be confusing. So the only criteria for a teenager to have the definition would be they have to have both Elevated androgens clinically or by blood testing and they have to have irregular cycles. So those are– That’s for adolescents. And for adults, they made it that you could put into the mix two of the following three, where they have the anti-Mullerian hormone or the PCOS ovaries. So that the criteria for getting the label for being diagnosed with this condition has not changed, so nor have the treatments changed. So changing the name hasn’t changed anything but the name. I think that’s really important to take- Okay … nothing else has changed.
Dr. Weitz: So let’s go into labs and then, you know, and then let’s use the [00:39:00] rest of the time for treatment. So what are the most helpful labs?
Dr. Gersh: Well, of course you have to get labs testing androgens. So it- if you have, and this is important-
Dr. Weitz: And that’s not just testosterone.
Dr. Gersh: Well, no. It’s really important to understand that in a young female where does… And also with aging as well. Testosterone comes from both the adrenal gland and from the ovaries and indirectly from fat tissue through conversion of androgen precursors. So you get 25% of circulating, that’s, you know, measured in the blood, circulating testosterone comes from the ovaries, just 25%. Twenty-five percent directly comes from the adrenal glands, and the other 50% comes predominantly, but not exclusively, but predominantly from the adrenal gland by conversion of androgen precursors [00:40:00] like DHEAS and DHEA. So all circulating DHEAS, dehydroepiandrosterone sulfate, comes from the adrenal gland, 100% of circulating. But 80% of DHEA comes from the adrenal, but 20% comes from the ovaries.
So that’s why we don’t normally ever measure DHEA. We measure DHEAS because if that’s high, that’s an adrenal origin of androgen excess. Now, in women with PCOS, because they have the adrenergic component activated of the sympathetic drive because they’re in a stress state, they have usually mildly elevated DHEAS along with high elevations, but not levels like you’d see with a tumor. I mean, so that’s the other thing. There’s, you know, ovarian tumors and other kinds of conditions can really produce dramatically high levels of testosterone into the male ranges. That’s not what you [00:41:00] see with this condition, PMOS. But so you definitely want to check the androgens, and the only ones you need to test would be total testosterone- and DHEAS.
There is no harm, but there is also no real benefit in testing free or unbound testosterone because the levels are so small, they’re not really reliably tested. But I do recommend sex hormone binding globulin to be measured. Sex hormone binding globulin binds up a lot of the circulating testosterone. In fact, 99% of testosterone normally is bound up primarily to sex hormone binding globulin and some to albumin And if you have very low sex hormone binding globulin, which happens in states of insulin resistance and inflammation and low estradiol production, you will have more unbound testosterone, which is the same as having more testosterone because it’s [00:42:00] more available to bind to the receptors on the tissues creating androgen excess types of symptomatology.
So I like to always order sex hormone binding globulin. Then you wanna measure thyroid. Hashimoto’s thyroiditis is really common in women with PCOS because of their altered status of their T regulatory cells and inf- and the leaky gut that they have. So you wanna measure not just TSH, you wanna get free T3, free T4, and the thyroid antibodies, you know, thyroglobulin antibody and anti-TPO. And then you want to get the lipids because lipid problems like high cholesterol are really common in women with this condition, so you wanna get a standard lipid panel, but then I also wanna get things like apolipoprotein B and apolipoprotein A1 and at least one basic Lp. And then you wanna get some inflammation markers, at least high– one high [00:43:00] measurement of high sensitivity C-reactive protein to begin with.
But, you know, you can also get others, you can get homocysteine, you can get you know, other types of markers like myeloperoxidase if you want, you know. So but- Right … the sky is the limit, but at least get an hsCRP. And you wanna check nutrient status because they will often have low status with like B12 and omega checks, so those types of things are important. And I get an ANA because of the increase in autoimmunity, so I like to get an ANA. So you can see it’s quite, quite a lot of laboratory testing, and if the person has the funds, it is really interesting to get tests for toxicants. You know, like look at, you know, phthalates and solvents and BPA and such. You know, those are all extra. They’re never covered by insurance.
Dr. Weitz: By the way, what about other androgens like androstenedione?
Dr. Gersh: Not [00:44:00] necessary.
Dr. Weitz: Okay. Is it helpful?
Dr. Gersh: No.
Dr. Weitz: Okay. All right.
Dr. Gersh: That won’t really be helpful. You get all you need. Now, it’s important to know that if someone has really high DHEAS, okay, they could have-
Dr. Weitz: So what do you consider really high?
Dr. Gersh: 700. But
Dr. Weitz: even- 700 …
Dr. Gersh: but even if it’s like-
Dr. Weitz: Is 400 high?
Dr. Gersh: Oh, yeah, that’s high. But what I was saying was something like 700 is like, a tumor. It’s a tumor until proven otherwise. Now- Okay … that doesn’t mean that you like 400 and 500. No, but I mean, and there’s nothing wrong with people referring patients who have really high DHEAS levels to an endocrinologist. They often will really need to have CT scans. They also need to be screened for acquired or late onset adrenal hyperplasia. They could also– Some of them could have Cushing syndrome, so cortisol. So it’s really getting into the real nitty-gritty of the endocrinology [00:45:00] world. You know, that’s why it’s important for people to know that PCOS/PMOS is a diagnosis of exclusion.
Every woman who walks in the door with irregular cycles and like acne and facial hair should not be labeled immediately PCOS, PMOS. No, because you have to rule out things like acquired adrenal hyperplasia. You have to rule out elevated prolactin. Oh, I didn’t mention that. You have to check a prolactin level.
High levels of prolactin will interfere with the production of cortisol to some degree and some of the pathways and pushes down towards androgen production of high levels of DHEAS in the adrenal gland when you have high levels of prolactin. So you always want to check for they could have a prolactin tumor of the pituitary that could give you androgen excess and irregular or missing cycles.
And so you need to test for Cushing syndrome if they have like high [00:46:00] cortisol. So these are ’cause you know, and it could just be straightforward, but not really straightforward, obesity issues, you know, where you have insulin resistance, and then you’re making more testosterone from the ovary as a result of obesity.
So it’s really important that to know that it’s a diagnosis of exclusion. You do have to rule out all these things. And if it’s not really in your wheelhouse, then give it to someone who it is in their wheelhouse because you don’t wanna miss some of these really important conditions. Like, you know, like I mentioned, like adrenal tumors can happen as well.
So, you know, this is really not like a, you know, one and done. They walk in the door, and you instantly make the diagnosis. You really do need to take a lot of time and consideration to rule out. Another test, if someone has high DHEAS levels, and even if they don’t, if you’re not sure, they need to get a 17 hydroxyprogesterone.
That is what happens when you have acquired a late onset adrenal hyperplasia, [00:47:00] and you have a fundamental defect in one of the enzymes that goes along the pathway to making cortisol. So you end up having the like a backup and you have too much of this other precursor, 17-hydroxyprogesterone, which then pushes down the other pathway to making more androgens in the adrenal as the brain is trying to push the adrenal to make more cortisol. You actually make some cortisol, but you also make a lot of adrenal androgens. So it’s, it is complex. It’s– You have to understand endocrinology to really understand the rule-outs of PCOS, PMOS.
Dr. Weitz: So let’s use the rest of the time we have for treatment. And I know for you and other clinicians in the functional medicine world, having the right kind of diet that helps regulate blood sugar is really important.
Dr. Gersh: Oh, well, absolutely every lifestyle trick in the book- I’m teeing it up for you. [00:48:00] Yeah, no, I love it. Every lifestyle trick in the book needs to be applied, so everything. You need to screen them. I didn’t mention that they have– I did mention they have high rates of, like, sleep apnea you know, obstructive sleep apnea, and also sleep-disordered breathing, so virtually all of them should have a sleep study.
Usually they’re just done at home these days. So you need to work on also sleep hygiene because they often do have sleep problems. You want to eliminate toxicants, so you want to buy everything, as much as possible, organic and natural and reduce chemical exposures, plastics, solvents, pesticides, you name it, right? You want to reduce as much of that as you possibly can, and you want to get into fitness. They’ve done s-so many d-studies now, fortunately on the impact of high in-intensity, you know, interval training as the best way to get women healthier with this condition. But you don’t want to just do this on your own.
You might [00:49:00] have an injury so, you know, because of the inflammation in the joints, they have higher rates of joint pain and so on. So you want to definitely get it– you know, get your exercise routine put together with an expert in the beginning, and then you can take it on your own. And so that’s really important.
In terms of diet, there’s been a lot of talk, and it– when I was at many of the meetings in the past from some of these societies, they all said, “You know, there is no special diet for this condition.” But actually, in my opinion, looking at my own patient population, you really have to nurture the gut microbiome, like we talked about since the…
And the foods that the gut loves are fiber foods, and there’s this magic with polyphenols. Many of them are phytoestrogens that have been shown to be very beneficial. So I want a plant-focused diet, really heavy on all different kinds of plants, and that includes, like, I call the ancient grains, like buckwheat. Buckwheat actually can increase myo-inositol. I mentioned it [00:50:00] earlier that we need more myo-inositol in those ovaries of women with this condition. So, like, the ancient grains, like eating oatmeal, like steel-cut oats or, you know- Oat groats, but definitely not instant oats. That can lower cholesterol naturally.
There was a study out of Bonn just a couple of months ago where if you ate just oatmeal, slow-cooked rolled oats or steel-cut oats, oat groats for just two days every month, you could lower your cholesterol by 10%. And lipidemia problems are, you know, very common, hyperlipidemia in women with this condition. So we definitely want to work on diet. I limit animal protein as much as women will let me, even go vegan for six months, because we now know that when you don’t have the right gut microbiome and you put in a lot of choline and carnitine, that they make TMA and then the liver makes TMAO, which is a toxin directly to the cardiovascular system.
So we [00:51:00] definitely want to limit animal protein and then we can add some back. But, you know, or limit as much as people will let me and focus a lot on plants and of course of some healthy fats, but not over the top with fats because they do have high, you know, caloric levels, and we definitely have to work on diet with these people.
I do a lot of time-restricted eating, you know, where you have a window of at least 13 hours of fasting from dinner to breakfast and trying to push more of the food into the first half of the day when the insulin is more functional and the gut is more functional. So we want to try to, you know, have less food in the evening as the hours are approaching, you know, the end of the day.
We want to eat less and more in the first half and no snacks so that it gives the gut some time to rest. And also fasting mimicking diets can be very helpful. That’s more advanced. We’ll say after you do other things to kind of get [00:52:00] started so that you don’t have, problems dealing with fasting when people have no metabolic flexibility.
You have to be able to switch from carb burning to fat burning, and a lot of people are not very good at that switch, so- Right … you know, you have to work on, you know, getting a little bit more metabolic flexibility before- Right … you start doing fasting routines. You know, just, like, just eat real food. Get away from all the ultra-processed food. Work on a gut rehab, you know, where you give, you know, things to help reestablish liver health, gut health. I get a lot of ultrasounds of livers. That’s the best way, ’cause if you wait for a liver enzyme elevation, that’s really late in the fatty liver stages. Right. So I get ultrasounds where you can actually see the amount of fat to some degree. Right. You can’t even detect it at the very early-
Dr. Weitz: You get the elastography?
Dr. Gersh: I get that in people who have a question of already having fatty liver- Right … you know, and you want to look for fibrosis and such. Right. And often I’ll refer them to specialists [00:53:00] because I don’t, you know, want to get over my head in what I’m not really an expert on. But absolutely, I like to order the tests, and then I can refer them. But we do know that there’s a variety of things that can help actually with diet and exercise and maybe the GLP-1 receptor, you know, agonist, and that’s another whole group of drugs that now are being used much more in women with this condition. But the problem is you have to stop it before pregnancy, and in pregnancy, women who’ve been on those meds seem to do worse. So it, you know, that’s a whole nother topic for another day, the GLP-1s. Yeah. But it’s like, it’s not all rosy. It’s good, but not all rosy, unfortunately, for this category of patient.
And so in terms of pharmaceuticals- No, so you do all the lifestyle stuff. In terms of pharmaceuticals, you know, there’s the old, you know, metformin, which, you know, does have certain definite benefits, but it’s not [00:54:00] a wonder drug. When they’ve tried to do it for fertility, it really hasn’t panned out that it really improves fertility, and it hasn’t been useful in pregnancy. In fact, it hasn’t been useful at all in pregnancy. They thought it would reduce all these complications in pregnancy, and it did not. So it’s like, ugh, you know? But it does help a little bit in terms of, you know, insulin resistance and so on.
Dr. Weitz: What about metformin’s herbal form, berberine?
Dr. Gersh: Berberine? Oh, I use berberine all the time. Also good, but not a miracle, you know? Right. And I use… You know, for cholesterol I use bergamot, plant stanols, and so on. So I’m, you know, I’m a big user of herbal remedies as well instead of pharmaceuticals when possible, you know? And I use, you know, things for, like stress, ashwagandha, bacopa, and now I’m using a lot in terms of the supplement world, mitochondrial boosters. Okay. We now know that mitochondria have estradiol receptors everywhere, the electron transport chain, manganese superoxide dismutase, [00:55:00] sirtuin 3, the mitochondrial membrane potential. Everything that has to do with mitochondrial function relies on estradiol, everything. And so when you don’t have enough, which is the case in women with this condition, you have mitochondrial dysfunction.
Well, mitochondria where estradiol is made, that’s where the start is, in the steroid hormones are made in mitochondria. So now you have another double whammy. So you have mitochondrial dysfunction, so you can’t burn fat, you can’t burn glucose because you c- you know, and you gra- create inflammation in cells as the mitochondria create damage signals as they’re, like disintegrating and harming everything in the cell. And in addition, you don’t make estradiol properly ’cause you don’t have mitochondria function to where estradiol is made. So that’s another, like, ugh, more downstream terrible effect.
Dr. Weitz: So are we talking about CoQ10, [00:56:00] PQ2- Yes. Mi- Yes … are we talking about urolithin A?
Dr. Gersh: Yes. And, you know, the NAD+ precursors, I like NMN, nicotinamide mononucleotide. Okay. Yes, all of those, absolutely. Yeah, you got it. You know, the you know, add in, you know, the other B vitamins, you know, to boot. So, you know, the-
Dr. Weitz: And NAC seems to have some special benefit, correct?
Dr. Gersh: Oh, yes. Well, NAC is very special, yes. It’s been shown to help with ovulation. It’s an antioxidant, it helps with glucose regulation, insulin sensitivity. So absolutely quercetin as well.
Dr. Weitz: And doesn’t it also help to lower testosterone in women, NAC?
Dr. Gersh: Well, everything that lowers inflammation will be beneficial Okay Absolutely. Okay. And quercetin, you know- Yeah … which is another polyphenol, also a phytoestrogen, resveratrol. These are all some really amazing supplements for women with this condition, can be really beneficial. And little [00:57:00] doses of melatonin. I mentioned melatonin is a powerful effector on the ovaries. There are receptors for melatonin all over the ovaries, and women with this condition, PMOS, do have melatonin problems. They don’t make it as well, and so that’s another very big deal. So with small doses, and sometimes higher doses, like when I say higher, three milligrams-
Dr. Weitz: Oh ’cause lower doses aren’t going to be
Dr. Gersh: high. I,
Dr. Weitz: I consider 300 a higher dose.
Dr. Gersh: Well, no, we’re not, no, we’re not into that range. Okay. But, you know, we need more research. Okay. We definitely need more research. And women with this condition, PMOS, do have circadian rhythm disorders. And so, you know, doing light therapy, light box therapy is also very beneficial to try to get their clo- time clocks in their body sort of organized into the same time zone, which is really important.
Dr. Weitz: Right, or going out in the sun in the morning when the sun rises. Well- What about myo-inositol or myo and D-chiro?
Dr. Gersh: [00:58:00] Well, absolutely. My… So I give myo-inositol because we have the problem… You know, there’s this little bit of data on the D-chiro, but to me it didn’t-
Dr. Weitz: And then there’s this big argument should the ratio be 40 to one or two to one or-
Dr. Gersh: No, but, but here’s the nuttiness of that. Okay. Okay. So in the ovary, I mentioned myo-inositol is the key player, okay? And in a normal, healthy reproductive age woman, the ratio of myo to D-chiro is 100 to one, and in PCOS, PMS, it’s 12 to one. What’s the ratio normally of these two sugar alcohol stereo isomers in the serum? It’s 40 to one, 40 times more myo.
Dr. Weitz: I think that’s why some people are recommending that 40 to 1.
Dr. Gersh: Yeah, but here’s the thing. If you swallow… First of all, it takes a leap of faith to believe that in that little capsule there’s really a ratio of 40 to one. Like, who’s testing that? I mean, so there, that’s a leap of faith [00:59:00] right there for 40 to one in that cap. But if you swallow it as 40 to one, let’s just say it is 40 to one.
Dr. Weitz: Okay.
Dr. Gersh: What makes anyone think it’s going to be entering into the bloodstream? Just ’cause you swallow it, is it going to be that same ratio in your serum? Right. Right. And also, D-chiro actually in the gut blocks the absorption of myo. And even if you got it to happen, even if you did, that the ratio in the serum was 40 to one, how is that going to make it that it’s 100 to one in the ovary anyway? You know? And D-chiro blocks myo in the ovary. It actually blocks it. But D-chiro is really important in the liver for insulin sensitivity. So if an older woman can definitely take a lot of D-chiro, but a younger woman… And there’s a lot of research on just straight myo. Now, I don’t think there’s any danger to taking a 40 to one ratio, ’cause I don’t think it actually gets in as 40 to one anyway, but [01:00:00] I can’t- Okay. I see … prove any, I can’t prove any of this. I can’t prove any of this 40 to one, I mean, thing kind. But I don’t think it’s dangerous. I just think it’s superfluous. But that’s my opinion, okay? Right. But the myo is the key one. So yes, myo-inositol, which is two grams twice a day, and the NAC and quercetin and-
Dr. Weitz: What do you think about this combination of herbs I hear some in this field mention, which is the peony and licorice combination?
Dr. Gersh: No. So there’s some toxicities from that, and also licorice can elevate blood pressure, which is already trending up in women with this condition. So not my favorite. Okay. I’m not against… Spearmint tea may lower testosterone a little bit, so if somebody likes to drink a lot of spearmint tea, go for it. But that would be where I would, you know, sort of pause. Now, in terms of drug therapy for androgen excess, spironolactone actually, which is aldosterone blocker, is actually very beneficial. But, you know, it’s not a miracle [01:01:00] either. But it can be very useful for acne for women who have, like, recalcitrant acne. Accutane can be helpful, but there’s a very high- by the way, spiro-
Dr. Weitz: spironolactone also helps modulate blood pressure.
Dr. Gersh: That’s right. Well, it– because it’s an aldosterone blocker, it is a mild potassium-sparing diuretic, so it, like, gets extra fluid out of the body. That’s how it works on blood pressure. It can be useful in heart failure. So, you know, it, like, it has multiple uses, and it’s a– but it, it does seem to be an androgen blocker, probably also by lowering inflammation. So, it actually has some interesting properties. It is– cannot be used in someone who’s trying to get pregnant because it can be– it’s a teratogen.
It can cause birth defects, especially in males, by blocking testosterone. So it’s something that you cannot use in someone who could or wants to become pregnant, so that’s, like, really important. And so the– that’s a helpful [01:02:00] drug for people. And one of the things that I’m using now, and I’m gonna write an article on it, is, like, duh, why would you give birth control pills unless you– obviously someone has to prevent pregnancy.
I can’t argue against that issue, you know. But with caution, because it does increase blood clotting risk, and women with this condition already have an elevated risk of blood clotting because of their pro-inflammatory state. So I’m not a huge fan of the oral contraceptives, but I do see benefit. It does increase sex hormone binding globulin, so it can be beneficial for acne. So there are some symptomatic benefits, but it’s not really the ideal treatment.
Dr. Weitz: Women and their hormones, let’s just block them
Dr. Gersh: Yeah, it’s the usual. But what I’m recommending now, and I have really good results with this, is giving bioidentical hormones, just like I would give to a perimenopausal woman. They’re not– It’s not replacement, it’s supplementation. So women with [01:03:00] PCOS, PMOS, they’re not making enough estradiol. And of course, because they’re not ovulating, they’re certainly not making enough progesterone. So if you give them cyclic, just like if you would give to a woman who had hypothalamic amenorrhea, like they weren’t having periods ’cause their brain wasn’t putting out the signals at all to the h- to the pituitary, and the ovaries were just, like, not doing anything because they weren’t getting the proper signals.
Just the same kind of thing, only there it would be more like replacement. Here, it’s supplementation. If you give bioidentical estradiol and progesterone, you actually repair things like the mitochondria, like, you know, the gut microbiome. So it’s one of those catch-22s. You can’t heal without the hormones, but until you heal, you won’t make the hormones. So you give the hormones. Like, you want to put a cast on a broken arm, you can put the cast on, and then when it heals, you can take the cast off.
Dr. Weitz: So you can do these hormones for a period of time and then wean the women [01:04:00] off?
Dr. Gersh: Yes. Yeah.
Dr. Weitz: Interesting.
Dr. Gersh: And for women who have really high but not tumor-level DHEAS, and it’s primarily an adrenal origin, so this is not your classic PCOS. It’s an androgen excess of unknown origin that– but at the, in terms of the etiology, the root cause, but it’s the adrenal gland. There’s no tumor, there’s no acquired or late onset congenital or, I mean, adrenal hyperplasia. There’s no high prolactin, there’s none of these other things, but they just have high DHEAS. We don’t really know why. If you give tiny doses, like half pediatric dose of dexamethasone, it will suppress, but it’s not suppressive of the adrenal like you’re giving prednisone. You give these tiny little doses. It just suppresses the DHEAS, and it could go from, like, four hundred and fifty to two hundred and fifty, and suddenly their acne is clearing, their cycles are regular, and then
Dr. Weitz: also- Did you just use cortisol?
Dr. Gersh: No, I [01:05:00] used the data’s on dexamethasone. Okay. So it’s like 2.5 milligrams. Okay. It’s a mere of it. It’s very tiny dose. And you– I give like the pediatric elixir, I give half a teaspoon and I give it for like a year and then I wean off of it. And often it’s like it just sort of stopped the problem and then they continue to do well and they have regular cycles. There’s some published data on this. Of course, we need more on everything that has to do with women’s unique problems. But there there is definitely hope and I think giving bioidentical hormones, recognizing that this is a-
Dr. Weitz: When you say cyclic, you mean estrogen throughout the month and progesterone for two weeks?
Dr. Gersh: Correct.
Dr. Weitz: Okay.
Dr. Gersh: Right. So when you recognize that the problem really, if it’s the real PCOS, PMOS, not a different adrenal disorder, but it’s primarily ovarian focused, then you can [01:06:00] give ovarian hormones in addition to all these other issues that have to be addressed. So I think of it like a house on fire. You have to put out the fire, but then you have to assess the damages. So with women with PCOS, you have to give them back their hormones that they’re not making and then try to suppress the extra testosterone, and then you have to assess all the damages, like what’s the status of their gut microbiome, their emotional state their joints, their lipids, and all these things have to be evaluated.
Dr. Weitz: Awesome. Awesome discussion. A tour de force discussion about PCOS/PMOS.
Dr. Gersh: PMOS. That’s it to me. I’m gonna always call it that from now on.
Dr. Weitz: So how can listeners get in touch with you?
Dr. Gersh: Well, I’m in my office right now. This is actually… I have an exam table over there- … converted, a converted exam room. And so I’m the doctor of my office, which is Integrative Medical Group of Irvine, and I have a team here with nurse practitioners and PAs who work with me, and I have massage therapists, and I have a gym, and I have nutrition, and I have fitness, you know, exercise. So we try to cover most of the lifestyle issues associated with everything, right? Everything. I’m a lifestyle medicine doctor. You know, I really start with lifestyle. But but it’s not always enough. That’s why I have to sometimes prescribe stuff. And, and you have- … I see patients here.
Dr. Weitz: And you have books, and you have courses.
Dr. Gersh: I do, and I hope to do more of all of the above. And I have my YouTube channel and my Instagram, and, you know, I’m trying to educate as much as I can so that women have options and they know and understand, as best as we all can, you know, what’s going on in them so that they can take the appropriate measures to optimize health and happiness and their futures.
Dr. Weitz: Thank you for all you do, Felice.
Dr. Gersh: My pleasure, and same to you.
Dr. Weitz: Thank you for making it all the way through this episode of the Rational Wellness Podcast. For those of you who enjoy listening to the Rational Wellness Podcast, I would very much appreciate it if you could go to Apple Podcasts or Spotify and give us a five-star ratings and review. As you may know, I continue to accept a limited number of new patients per month for functional medicine. If you would like help overcoming a gut or other chronic health condition, and wanna prevent chronic problems, and want to promote longevity, please call my Santa Monica Weitz Sports Chiropractic and Nutrition office at 310-395-3111, and we can set you up for a consultation for functional medicine. And I will talk to everybody next week.
And get a free ebook: "How to Reduce Digestive Distress"
