Female Hormone Health, PCOS, Endometriosis, Fertility & Breast Cancer | Dr. Thaïs Aliabadi

Dr. Aliabadi emphasizes that PCOS cannot be treated effectively by merely prescribing birth control pills, which only address symptoms. The core of her protocol involves tackling the five pillars of PCOS. This includes regulating the brain-pituitary-ovary axis, which is often disrupted in PCOS, leading to an imbalance in FSH and LH and excessive androgen production. Crucially, she targets insulin resistance, which affects 80% of PCOS patients, even lean ones, as high insulin exacerbates androgen production and inflammation. Reducing chronic inflammation, often linked to visceral fat, is another key component. While genetics are a factor, epigenetic influences (lifestyle choices) are highly actionable. The treatment plan integrates lifestyle modifications, targeted supplements, and, if necessary, medications to restore metabolic and hormonal balance.

Dr. Aliabadi stresses that managing insulin resistance is paramount for PCOS patients. This involves a multi-pronged approach starting with lifestyle: regular exercise (especially walks after meals), adequate sleep, stress reduction, and an anti-inflammatory diet low in processed foods and refined carbohydrates. For those needing more support, she recommends specific supplements like inositol, vitamin D, and mulberry leaf, which are known to enhance insulin sensitivity. If these measures are insufficient, metformin is introduced, starting with a low dose and gradually increasing. For significant weight loss and insulin regulation, GLP-1 agonists are considered, especially for patients who have struggled with weight loss despite other interventions. The goal is to lower insulin, which in turn reduces visceral fat, inflammation, and ovarian androgen production.

Dr. Aliabadi advises PCOS patients to consider egg freezing at a relatively young age, ideally between 28 and 30. She highlights that while PCOS often results in a high number of eggs (falsely elevated AMH), the quality of these eggs can be poor. This means that even if a 40-year-old PCOS patient produces 30 eggs during an IVF cycle, they might not yield a single viable embryo. Therefore, freezing eggs when they are younger and of better quality is a strategic move to safeguard future fertility. She recommends aiming for a higher number of frozen eggs (around 40) for PCOS patients compared to the general recommendation (20 eggs) to account for potential quality issues. She also notes the financial barrier, as insurance typically doesn't cover egg freezing, making it more accessible to employees of large tech companies.

Dr. Aliabadi explains that endometriosis lesions thrive on estrogen. Therefore, hormonal suppression, particularly with progesterone, is a key treatment strategy. Progesterone-only birth control pills or progesterone IUDs (like Kylina or Mirena) are effective because they create a local or systemic progesterone-dominant environment, inhibiting estrogen's effect on the ectopic tissue. This can significantly reduce pain, irregular bleeding, and inflammation associated with endometriosis. She notes that for patients with mood disorders, IUDs might be preferable as they offer more localized hormonal action. Hormonal suppression is often used as a first-line treatment, especially for younger patients, and post-surgically to prevent recurrence. She also mentions GnRH antagonists as a more potent option for severe cases, though they induce a temporary pseudo-menopause.

Dr. Aliabadi emphasizes that every woman should know her lifetime risk of breast cancer, not just rely on general guidelines. She advocates using the Tyrer-Cuzick risk assessment tool (available on her GMD platform) to calculate this risk. If the lifetime risk is 20% or more (high-risk category), women should advocate for earlier and more comprehensive breast imaging, potentially starting at age 30. This includes mammograms, breast ultrasounds (especially for dense breasts), and breast MRIs. She highlights that insurance companies often require the lifetime risk percentage on the prescription to cover MRI costs. She shares her personal story of having a double mastectomy despite no family history or genetic mutation, based on her 37% lifetime risk score, which led to the discovery of an early-stage cancer. This underscores the importance of personalized risk assessment and proactive screening.

Dr. Aliabadi passionately argues that the current medical system fails women by not adequately diagnosing PCOS and endometriosis. She compares this to the rarity of an ophthalmologist missing a cataract, yet these widespread conditions in women are routinely overlooked. This leads to millions of women suffering from infertility, chronic pain, and other health complications, often being told their symptoms are 'in their head.' She believes that if every 20-year-old woman were properly screened, many fertility clinics would become obsolete, as early intervention could prevent the progression of these conditions and the need for expensive, often unsuccessful, IVF treatments later in life. She even treats 13-year-olds with endometriosis, emphasizing the need for early screening.

Dr. Aliabadi contends that the standard fertility plots, which show a gradual decline in fertility with age, are misleading. She explains that because PCOS and endometriosis are so prevalent and often undiagnosed, many women's actual fertility trajectories are much worse than these general statistics suggest. For example, endometriosis can severely deplete egg count and quality at a young age, while PCOS can lead to a high egg count but poor egg quality. This means that a woman might appear fertile on paper (e.g., high AMH) but still struggle to conceive due to underlying, unaddressed conditions. She advocates for individual screening for PCOS, endometriosis, and AMH levels at a young age to provide a more accurate picture of a woman's specific reproductive health.

Dr. Aliabadi details the four different phenotypes of PCOS, explaining why it's so confusing for doctors to diagnose. The classic phenotype includes PCOS-looking ovaries on ultrasound, elevated androgen symptoms (or high blood testosterone), and irregular periods. However, other phenotypes exist where patients might have androgen symptoms and irregular periods but normal ovaries, or they might have PCOS-looking ovaries and androgen symptoms but regular periods (due to estrogen withdrawal, not ovulation). There's also a phenotype with irregular ovulation and PCOS-looking ovaries but no androgen symptoms. This variability means that relying on a single symptom or test (like normal testosterone or absence of cysts) can lead to misdiagnosis, as patients can be thin, have regular periods, or lack certain androgenic signs and still have PCOS. This complexity contributes to doctors 'scratching their heads' and often dismissing patients.

Dr. Aliabadi states her strong belief, based on her clinical experience, that more than 50% of PCOS patients also suffer from endometriosis. She hypothesizes that the chronic inflammation prevalent in PCOS, driven by factors like visceral fat and insulin resistance, may fuel the development or persistence of endometriosis implants. This overlap is critical because if only PCOS is addressed while endometriosis is ignored (e.g., dismissing painful periods), the patient's infertility and pain issues will persist. She emphasizes the need to check for both conditions, especially since both are leading causes of infertility, and addressing one without the other may lead to incomplete or failed treatment.

Dr. Aliabadi argues that the current combined OB/GYN model is detrimental to women's health. She explains that the demanding schedule of delivering babies, often at unpredictable hours, leaves gynecologists exhausted and with insufficient time to properly diagnose and treat complex conditions like PCOS and endometriosis. She recounts her own experience of delivering 80 babies a month while pregnant, highlighting the immense burnout. By separating the specialties, she believes gynecologists could focus entirely on women's health, allowing for more in-depth patient consultations, better training in specific conditions, and a higher standard of care. This would prevent the rushed, often dismissive, appointments that many women currently experience, leading to better patient outcomes and reduced physician burnout.