 Hello everyone. So we are going live today and we are talking about polycystic ovarian syndrome which is commonly known as the PCOS. Myself, I am Ajay Riddhi and today I'm going to be talking to four brilliant doctors who are specialists in this field. Let me tell you that PCOS is a hormonal condition that actually affects women during reproductive years. And today, the experts from Manipal Hospital are going to talk about this condition that has been growing in large numbers around the world. So first of all, I'd like to welcome the doctors. Welcome on board doctors. Thank you. Thank you. Let me start off with introducing all the doctors who are there today on the panel. First, I'd like to introduce Dr. Arunima Haldar. She's a consultant IVF and reproductive medicine. Manipal Hospital's Waifil Bengaluru. And Dr. Haldar specializes in IVF, infertility and reproductive endocrinology. Welcome on the panel today, doctor. Thank you, Riddhi. The next doctor we have is Dr. Geeta Veerappa Komar. She's a consultant of districts. I'm sorry if I'm pronouncing this wrong though. And gynecology from Manipal Hospital, Vartu Road, Bengaluru. And Dr. Geeta specializes in managing high-risk pregnancies, infertility, histerectomy, gynec infertility, and intrauterine insemination, which is IUI. Welcome, Dr. Komar. The next doctor we have is Dr. Monica Sharma, who is a consultant, diabetic and endocrinology, Manipal Hospital from Dwarka, Delhi. And Dr. Monica specializes in diabetes, thyroid, PCOD, pediatric, endocrinology, obesity, and bone disorder. Welcome, Dr. Monica Sharma. Thank you. And the last doctor on the panel we have is Dr. Nabanita Saha. So Ms. Nabanita Saha is a chief clinical dietician, Manipal Hospital, old airport road, Bengaluru. And she specializes in therapeutic diet planning for obesity, diabetes, cardiac, renal, PCOS, pediatric, and critically ill patients. Welcome, Dr. Nabanita Saha. Thank you, Raveen. So doctors today we're going to be touching upon a couple of questions. And basically that speaks about PCOS. I will start with Dr. Geeta Birappa Komar. I'd first like to ask you, what is PCOS or PCOD? Dr. your mind is off. Can you hear me now? Yes, I can. Yeah. Yeah. Welcome everybody to this live broadcast and a very good afternoon to you all. So as Riddhi has rightly started with the question, what is PCOS or PCOD? We use the two terms interchangeably. So PCOS expands to polycystic ovarian syndrome or polycystic ovarian disease as we use the terms interchangeably. So now when we're looking at a woman and we're diagnosing her as a PCOS, we're looking for three criteria. So the first one we look as whether they have irregular cycles. So it could be very short cycles within 21 days. It could be a long cycle about three to four months apart. So when a person has irregular cycles, it means that they're not ovulating correctly. So it's a sign of an ovulation. The second criteria that we're looking at is signs of hyperantrogenism, which basically means we are looking whether the person has signs of excess of male hormones in very simple terms. So now this we can either see in the patient clinically, you know, somebody who's got excess acne, somebody who's scalp hair is thinning. They're losing hair. They've got hair in unwanted places like the upper lips over the chin. Or at times we do the blood test. We look at the various hormones like the testosterone, the DHEA, and we find that they are raised. So this male hormone could either be clinically evident, or we could do a laboratory test. And the final criteria that we look for is the ultrasound criteria. So when we're doing an ultrasound, we look at the ovaries. How they look, how big are they? So if anyone of the ovaries is more than 10 cc in volume, that's the criteria for the normal ovary. And they appear polycystic, wherein they've got multiple small cysts. So when I say small cysts, I mean cysts which are less than 1 cm in size because we have a lot of patients who come up with, you know, 4 cm, 5 cm. Is that PCOD? That is not PCOD. So we're looking at multiple that is more than 12 cysts which are less than 1 cm in size. So if any of the two criteria out of three is present in a patient, so we diagnose it as a polycystic ovary syndrome. All right. Thank you so much, Dr. Geeta. As in when you were speaking, someone who suffers from PCOS, I was just tick-marking all the boxes. Do I have this? Do I have this? Do I have this? Yes. Let's ask you another question. Can it affect the young girls? Or is it at a particular age that it comes in? No, I mean PCOS now we're increasingly diagnosing it across all age groups, right from the post-ministerial up to the pre-menopausal age group. So studies say that about 5% of the women between the ages of 15 to 24 and about 4.8, which is almost close to 5% of the women from the age of 24 to the 45 are diagnosed with PCOS in the present age. So almost everyone after the menstruation till the menopause can be diagnosed with a PCOS. All right. Thank you so much, Dr. Geeta. I'd like to move to Dr. Arunima. And I want to talk about the myth around PCOS. A lot of statements that I've heard, which says PCOS means I have cyst in the ovaries. Can you tell us if it's a myth or it's true? So this is a very common question, which a lot of girls, they will come and ask, Doctor, do I actually have cysts in the ovaries? They're clearly scared. What to do about the cysts? So let me just define like Dr. Geeta very rightly told right now. So the target is less than 1 centimeter. So I'll just differentiate between cysts and follicles. So basically cysts are any fluid fill structure in the ovary, which is more than 1 centimeter inside. And usually they may or may not be secreting a hormone. They may be something called as a simple cyst, basically clear kind of a cyst or they may contain blood inside them or they may be chocolate cysts. So these are all pathological cysts. One more thing about cysts is that usually they will maintain the size throughout the cycle. A follicle on the other hand is a small fluid fill structure which is actually containing the egg inside it. And this follicle will be actually growing throughout the cycle and probably around the ovulation time it will rupture. So this is the difference between cysts and follicles. Now in PCOS what happens? There is a continuous effort of growing the follicles to the level where it reaches the desired size and ruptures but that does not happen in PCOS. So there are several attempts, monthly attempts of growing in this fashion. Ultimately there is something called as stockpiling. So the small follicles get studded all around the ovaries and it looks like many follicles are there. So probably PCOS polycystic is a misnomer. It should have been probably polyfolicular but this is what it is. It is how it has been named. But definitely people who are polycystic do not have any pathological cyst per se in the ovary. So that's a myth which a lot of people do. Thank you for clearing and clarifying that. I'm sure a lot of people might find relief in your answer. There's another myth around PCOS. Only overweight women get PCOS. A lot of people are like, I am thin, how can I get PCOS? So can you tell us about that please? Yeah, it's true that a lot of overweight women get PCOS but some thin women also may have PCOS. Basically this is not related to your weight or your hyperinsulinemia which we will eventually talk about. It is mainly related to the amount of one hormone called as luteinizing hormone, LH hormone which is secreted from your brain. This hormone, this is predominantly LH hormone. The luteinizing hormone is secreted more than the FSH hormone so there is an imbalance there as a result of which you get the PCOS. This is something which could have been genetically predisposed or it could have been something which would have happened. Epigenetic modification would have happened in your mother's uterus when you were there in the uterus. So this is something which the woman will not usually have any role in developing this kind of PCOS. Usually they will be very depressed saying that what did I do that I got PCOS? I'm not even obese. So such women should not feel depressed because this is something which is not in their hand. It is probably from the time they have been but it has been programmed in that way. So yes, lean women can develop PCOS. Alright, that answers also a couple of doubts that is running in people's head. Moving on to Dr. Navanita Sahar since we were talking about weight there is this question that I'd like to ask you that does the diet for lean and obese PCOS differ? Okay, so we all know obesity is a very common symptom in PCOS and as Dr. Rindoma also said that there are people who are lean and still have PCOS. So before telling the diet whether it's differ for both I want to tell what should be the diet for PCOS if she is suffering from PCOS. So apart from obesity there is another sign of PCOS that is insulin resistance. Almost 70% of girls or women who are having PCOS suffering from insulin resistance that means they have a lot of insulin in their body running and it's not been utilized by the body cell. So that is one thing and apart from that they also will have inflammation chronic low-grade inflammation so other than having losing hairs and having facial hairs and other acne and all that so diet plays a very important role because you just cannot just lose weight following a low-calorie diet or just following a certain fat diet because here you have to follow a diet which can balance your hormones control your insulin levels so for that there are various diet which is available something you can go for a low GI diet that is a low-glycemic index diet food which doesn't increase your sugar levels after you eat them especially like whole grains, cereals, pulses so food at their most natural form we should include secondly you also can have Mediterranean diet which focus more on healthy fats like olive oil fish which contain omega-3 lots of fruits and vegetables in your diet whole grains, cereals so those kind of diet again there is something called dash diet that mainly for hypertension patient it is dietary opposed to stop hypertension but that also a very healthy diet which focus mainly on fruits and vegetables and having less of salt less of processed food so one have to follow a low-glycemic index diet that is have more of whole grains avoid any kind of processed food refined products, sugary food which are a simple form of sugars you can have more of fruits and vegetables secondly have mindful eating maintain your portion size so people will have a lot of cravings because of their insulin resistance they feel hungry frequently and crave for sugar so when you follow proper diet your cravings will come down secondly include amount of protein have lean protein include lean chicken you can have fish as I said you can have eggs include legumes you can have nuts healthy fats include healthy oils oily seeds also focus on hydration good hydration, should do a lot of fluid your body should be able to remove all the toxins from your body so you should flush out everything because this all can cause inflammation and PCOS women are prone to inflammation so this is what you should follow also apart from that they should focus on certain nutrients like some vitamin D omega 3, magnesium, iron because they will be deficient on those nutrients so make sure your vitamin D is always above 30 I have seen so many patients the first thing I ask them to measure their vitamin D and it will be always low so that also related to infertility over weight all those problems will be there also they can have certain herbs like spearmint tea there are lot of studies which show it's beneficial if you are taking 2 cups of spearmint tea in a day and it will help to with PCOS symptoms so this is the kind of diet that one should follow and of course exercise should play an important role both go hand in hand so yeah that's what and yes when it comes to lean and obese PCOS diet wise is almost similar in obese PCOS we need to ensure that there is some weight loss because 5 to 10 percent of weight loss definitely improve their symptoms where in PCOS lean PCOS they don't have to go for weight loss but they can maintain weight so maybe we have to restrict little calories in obese PCOS but in these PCOS we have to ensure that we maintain the weight and follow a healthy PCOS diet alright so doctor one main thing that you mentioned exercise I need to do it I will try and do it for sure but doctor Navanita I'd like to ask you another question is how is our gut health related to PCOS and how can one person improve the gut health okay so as I said your gut PCOS also says the high risk of information right most of the women will be having a low grade information most of them they are not aware of it right and the more the information is this lead to more of insulin resistance that means overweight that again aggravate your PCOS symptoms right so when we talk about gut health our gut our digestive tract it contain lot of bacteria it called microbiome which is a mixture of good and harmful bacteria in PCOS women the gut is always have more harmful bacteria in compared to a healthy bacteria there will be a dysbiosis so what will happen in PCOS we also see something called leaky gut means when there will be more of harmful bacteria they make there will be a you can say just in a simple word there will be holes in the gut small holes where our food or any other substance can directly leak into our blood circulation right and can cause information so that is very common in PCOS women so what we have to do is we have to ensure that our gut is healthy for that we have to ensure we have good healthy batteries how can we achieve that through diet of course we have to include certain food items which can support our gut microflora food like having high fiber food right which will will help for it's like a food for this bacteria so include high fiber food like you can include whole grains cereals, pulses vegetables right fruits those which will go there and digest and it will work it will act as a food for this bacteria so for normal women the recommendation is around 25 gram of fiber per day but for one with PCOS the recommendation is increased to 30 to 35 grams so what have to take more of this fiber rich food in their diet secondly you can include more of probiotics that is food which already hunted live cultures of bacteria healthy bacteria like you can have yogurt or curd you can include certain fermented food right your idli, dosas you can have you can have pickles you can take kimchi like this fermented cabbage right so those kind of food also will help you to improve your gut function right so this is how and avoid any kind of food which you might be allergic to or having intolerance that can lead to again a lot of inflammation in your gut and again lead to further leaky gut so avoid those food if you are aware of anything and focus on this kind of food. Alright thank you so much Dr. Navneetha Dr. Monika I'd like to ask you that how long does one have to be on medication to see any sort of positive results so basically PCOS is a very as ma'am mentioned that is a very simple disease but it is a very complicated pathogenesis we still don't exactly know what exactly what the trigger is that causes PCOD and why some obese women will develop PCOD and why some of them will never develop PCOD so since we don't have an exact explanation as to why it happens unfortunately the therapy is also symptom based so we don't exactly treat the cause of the PCOD the cause is mostly treated holistically as Dr. Navneetha mentioned via diet and exercise but for symptom control and for reducing for resuming the for reducing the hair growth on the face and the body all these are practical things that the young girls really do need to take care of so for that purpose medications are needed now the the duration for which the medication has to be given and the effect that it shows depends upon what the purpose of giving the medication is some patients who present primarily with the phenotype of PCOD that has only reduced production in the menses without any increase in hair growth normally they are treated with combined oral contraceptive pills or estrogen progesterone combination pills these contain low doses of hormones that are natural body hormones that are not synthesized in the body or they are synthesized in the body of a PCOD woman in unequal amounts. Normally what we see in a PCOD woman is they have an increased estrogen effect and a reduced progesterone effect so the imbalance between these two in addition to increase in the androgens or which are the male hormones this causes all the symptoms of PCOD. So in case a patient is an ovulatory PCOD that is she is not ovulating properly she is having irregular menses in that case they are treated with combined OCPs and these can start having the positive effect right from the get go from the first few cycles the cycle regularizes that is because the patient's own menses the endogenous menstruation ceases and what we give to the patient is a withdrawal bleed that is we give cyclical menses menstrual menstrual pins and then we withdraw them and that is called a withdrawal bleed. So the ovulation ovulation never resumes but the patient does have a normal menstrual cycle while the second treatment for the hair growth it takes time the effect can last anywhere between 4 to 6 months and normally we ask the patient not to stop the medication for a longer time almost 9 months to an year before they see any positive effect on the hair growth now why is that so that is because the cycle different differs the hair cycle that is the anagen phase on the on the phase it last for about 4 to 6 weeks so any drug that is given to reduce the amount of hair on the body on the face has to be given for at least 3 to 4 cycles for anagen cycles for it to show any positive effect. So normally we see a positive effect only after 4 to 6 months of regularly taking the medications. So even in the beginning when we start describing the medication for PCOD it is very essential that you let the patient know that the menses will resume within the next month 2 months but if they are taking it primarily for the purpose of hair growth reduction it takes time because the cycle of hair last that long so any medication given will take minimum 6 to 8 months of time for it to show any positive effect. Another thing which we commonly see is the fear especially with pregnancy right so what are the ways pregnancy can get complicated if one has PCOS. So there are two kinds of one is that there is a difficulty getting pregnant in patients with PCOD obviously since the ovulation itself is impacted they are not ovulating normally or not ovulating at regular intervals so there is an infertility aspect related to it and this is known as it can be either primaries infertility or secondary that is it can happen at the get go or it can happen even if the patient has conceived normally previously. Since PCOD does not have any age to age of onset so these patients do have a difficulty in conceiving naturally the thing that helps in non-natural conception is what Dr. Nabilita has said that a good diet with at least a 5 to 10% weight loss it really helps in conceiving naturally if even after doing all that the patient is not able to then there are certain drugs which have a very low side effect profile which can be used there is there are liposomes there is all of them induce ovulation naturally in a PCOD patients and in case that is not working then we have a low growth gonadotropin therapy or in case that doesn't work then obviously the patient can obviously go for an IUI or an IVF normally but I would like to allay the fear that normally what we see in our practice is the natural conception rate of PCOD patients are more than 90% so they need not worry that it's not such a big thing but yes there is a difficulty in conception coming to a pregnancy complications since patients having PCOD are obese most patients are obese these patients have a high risk to develop gestational diabetes of pregnancy so that is one thing that they should be careful about that's why we do regular testing for gestational diabetes of pregnancy at the beginning when the patient is receiving and then again at 16 and 24 weeks so that they can be taken care of at the beginning alright thank you Dr. Monica I mean since we were talking about pregnancy I'd like to come back to Dr. Arunima and the thing that I'd like to ask you is what are the treatments that are available is IVF the only option no it's not that IVF is like the only option Dr. Monica already mentioned quite a bit about it so we have basically two types of patients one is the ovulating kind of PCOS and one is the patient who is not ovulating now the patient who is not ovulating our job is to make her ovulate so the treatment which we give here is ovulation induction so we do it with certain medications which are you know they trigger the ovulation which is which can be anything from letrosol or clomyfine along with that we may or may not add something called as metformin okay so this being said we can try it for some 3-4 cycles if this has not working out then we can probably take the next step which is going ahead and doing intrautriene insemination now we have to be also wary about the fact that you know there could be other factors playing in the infertility as well like the patient may have a tubal package or she may have it associate uterine problem or there could be semen problems in the husband so we have to take care that we have seen all these things as well when we are not just going ahead and you know giving ovulation induction to these patients that is one thing to look into now there is a typical problem which we see in while treating these patients especially when we are doing ovulation induction or what we call as ovarian stimulation where we want two or three follicles instead so the typical problem is that they have something called as a very narrow window so which means that say for example I want to give her an injection to get her ovulation happening now the dose of injection is 75 international units so when I give 75 international units nothing happens her ovaries are completely you know stagnate but when I make it double the next dose is 150 so when I make it double there is an explosive response so this is the typical problem which we see in a lot of PCOS patients so IVF when we do IVF the question is that if this kind of problem comes up if we are repeatedly seeing with whatever we are trying we are not able to get to one two or max three follicles we are getting an explosive response then is the one time we want to do IVF for this kind of patient if we have tried several cycles of natural trying which we have tried you know IUIs for these patients and nothing has worked out we don't know what is the cause but we know that there is an inherent PCOS problem that is when again we want to go ahead with you know IVF or else you know there is some other factor playing as well that we know that there is a tubal abnormality which could be a problem or there is some male factor which could be corresponding along with the PCOS it is so in these situations we would want to go ahead with an IVF not routinely first step always will be to go ahead and give them an ovulation all right that makes sense doctor thank you so much coming to Dr. Gita now you know PCOS can happen anytime so how to treat PCOS in teenagers in reproductive age and in pre menopausal age as you know all the doctors have already talked about since we don't know what is causing the PCOS it's difficult to treat the cause of the PCOS so our management at all age groups is basically we are looking to manage the symptoms with which they are presenting and as we have already talked as Dr. Arneema rightly mentioned there can be a lot of anxiety and depression in these patients so you have to look at the patient as a whole they need both the most important support they need is a psychological support to allay their anxiety and fear regarding the PCOD that is the foremost thing because and also to you know remove the myth that anyone treatment is going to completely cure them or get rid of PCOD for the lifetime you know we get a lot of patients who have visited a lot of other doctors and have been told ok you take the medications for 3 months you will be completely alright and that when it doesn't happen that leads to more anxiety and more of depression in these patients so we have to tell them there is nothing like a lifelong cure for PCO so as long as we are managing the symptoms we manage as she said when infertility patient our goal is to get them pregnant and once they have delivered the symptoms of irregular cycles can come back so it is first to reassure them there is nothing like a lifelong cure for the PCOD we are going to manage with whatever problems you are presenting at particular time that you are seeing us so looking at the various age groups now as the doctors have mentioned the main the connoisseur management is the weight management as many of the PCO as rightly said are OBs so the management of obesity remains the first focus for the treatment of these people with PCO because what we have seen is even about a 5% reduction in their weight will lead to a large extent it will help in regularizing the cycles even without medication so even if they manage to lose about 5-10% the cycles will go back to a normal pattern it will also reduce the various other risk factors that we associate with PCOD like diabetes their cardiac risk factors and of course it is going to improve their feelings of anxiety, depression, their own body image issues so it is a big help the first thing is to look at the weight management now in the teenagers usually the most common thing is irregular cycles and the unwanted hair and the acne that is what the teenagers usually present to us with going to the irregular cycles now typically do we need to bleed every month again that is a myth from a health point of view a cycle once in 2-3 months is fine as far as the uterine health is concerned now why 2-3 months we do not want to leave beyond that because the lining of the uterus then tends to build up that is what we call it endometrial hyperplasia and that can lead to further complications so we want the women to bleed at least once in 2-3 months in 2-3 ways the worst first as we talked about is the weight management a good loss of weight might itself help to regularize the cycles and when we look at the medications the common medications we use are either the contraceptive pills so in people who do not have any contraindications who in whom we can safely use them you know for now there are some people who have got a history of clot in the legs or lungs they have had jaundice they have migraines in these people we cannot use the contraceptive pills they can be safely used contraceptive pills are a very good method to keep the cycles regular and on time because as Dr. Monica rightly said the body seizes it's the external hormones that we are giving that takes over and keeps the cycles regular if they do not want contraceptive pills another method we use is progesterones just one half of the contraceptive pills so that in fact awards the side effects due to the estrogen so the main side effect that we see is due to the estrogen component so we just use progesterones for let's say about a week or so once in 2-3 months to make sure that the woman bleeds so this is where the irregular cycles this is how we manage the irregular cycles now coming to the unwanted hair of course the contraceptive pills also help and as Dr. Monica said it takes about 4-6 months of the pills we have got special pills which we use for the PCOD but in the second half so a estrogen and a progesterone component that can be the first line of management if we do not see any results with the conventional contraceptive pills we also use some other kind of pills which have got anti androgens that is the anti male hormone there are different things like citrotone acetate which is added along with the estrogen which also gives very good results in the treatment of acne and the hair setism so maybe a 6-9 month course of these pills will help to reduce the hair growth the other way they can look at this to go for the cosmetic the laser hair removal or the electrolysis which is quite common these days and as Dr. Arunima mentioned there is another drug metformin which is actually an anti-diabetic drug which helps to balance the hormones in the PCOS and can also help in these particular situations finally we are also looking at infertility which is the main problem in the reproductive age group and that Dr. Arunima has dealt it in detail how we can get this woman to overlay and help them to receive and again in the perimenopause age group it's always the problem with the irregular cycles more often and as I've already mentioned so in all this we also have to remember that PCOD is associated with other risk factors like diabetes and the other cardiometabolic disorders the cardiac so the overall life stage you know and to encourage them to adapt a healthy lifestyle will remain the cornerstone of management for these people alright thank you Dr. Geeta I'd like to move to Dr. Monika right now and I want to ask you can anybody start a laser therapy for hair growth in PCOS and is it going to be less effective in reducing hair growth laser therapy is one of the cornerstone of therapy for hair reduction that we use in PCOD but unfortunately in case of PCOD patients generally not as effective till your hormones that the underlying hormonal dysfunction is controlled so normally what we advise is that the patient need to be on a good hormonal therapy it can be an antrogen it can be a an estrogen progesterone pill it can be a progesterone pill they need to be on some medication for at least 3-4 months before they start undergoing the laser sessions see laser therapy destroys the hair and it destroys the hair follicle either by a concentrated beam of light like for the laser or for electrolysis electric current is passed through that destroys the hair follicle now this helps in reducing the amount of hair growth and reducing the rate of hair growth ultimately with the destruction of the follicles because of the repeated sessions there is reduction in the hair growth the important thing to know is it is reduction in hair growth it is improving so it does not completely go away but it reduces so that's how there is a reduction in the hair growth but for that underlying hormonal therapies need to be taken regularly for a couple of months at least before initiating your laser sessions because until the underlying hormones are controlled what happens is that even if you do take the laser the hair just comes back because the veil hormones that are circulating in the body of a PCOD woman they promote more terminal hair growth that is think dark hair growth they promote these hair growth so the laser therapy will ultimately not be very effective if you do it it won't be long lasting if you do it without controlling your hormone levels first alright make sense Dr. Monica coming to Dr. Navanita Saha and this is my favourite question that I'd like to ask you is does one need to avoid gluten and dairy in PCOS and if they have to would there be any alternatives for it so this is very controversial questions like many people ask me so of course those who are sensitive to gluten or dairy or it is lactose they definitely have to avoid it if somebody is having celiac disease for example or if you have non celiac gluten sensitivity or gluten intolerance you don't have to be celiac always but there could be a sensitive to gluten in that case of course avoiding gluten will reduce your symptoms and what happen in PCOS is there will be as I said earlier also there will be inflammation and stomach disorder and it will trigger lot of other sensitive sensitivity that patient will become sensitive to lot of things and they are not aware of it sometimes there will be intolerance to lactose or say dairy or to gluten or wheat products and they are not aware so what I ask them if you have not checked it your intolerance can avoid it for certain period of time say example 3 4 weeks to 6 weeks and see how it helps you are your symptoms are coming down and if you are feeling fine there is no change and gradually you can again start taking it but if your symptoms say example like your blotting or rushing to toilet immediately having food all those are coming down and you are feeling better your energy levels have improved it could be a sign that you are intolerance to gluten or dairy products also so if you are sensitive then there are other alternatives you can go for gluten free cereals millers are very good examples all the millers are gluten free that include your ragi, chowar, bajra banyard, millet kinva, rice you can go for brown rice or red rice depend on what you prefer so those are the healthier options that you can go for coming to dairy there are a lot of studies which says that there is a direct link of acne with including more of dairy products so if you leave them for a certain period of time and if your kidneys are reducing and you feel better again blotting and all are not there there could be a sign that you are intolerance to dairy products so also in milk there is a hormone called IGF1 it's called insulin like growth factor and it mimics insulin so what will happen if you are taking more of dairy and having this particular hormone your ovaries will secret more of testosterone because there will be a lot of insulin running in your blood and it leads to insulin resistance and your body producing ovaries producing more of male hormones and aggravate your PCOS also if you are taking this example there are many studies saying in dairy also if you are taking well which one better low fat or high fat full fat so taking many of us will prefer taking low fat dairy products toned milk, low fat curd fat free cheese so it says that low fat dairy have producing more androgen it increase your androgen levels it aggravate your PCOS as compared to high fat dairy products so if you have to choose dairy I will suggest first preferably go for full fat dairy products if you cannot eliminate dairy completely because it also have good source of calcium vitamin D phosphorus all other nutrients are there also choosing other dairy products like cheese, yogurt which won't show or increase your androgen levels are good options for you again there is something called A1 and A2 casein protein that comes in the milk so there is lot of saying going on that A2 milk is better because it's local cows just the daisy cows milk so A2 milk is a preferable options compared to A1 which will be increasing your inflammation so my says go for full fat A2 organic milk and dairy products limited to 1 cup of milk per day you can include cheese, paneer, yogurt preferably a full fat Greek yogurt would be a healthier option if you want to go dairy completely because of example of you want to reduce your kidneys you have lactose intolerance or other problem then you can have other alternatives like you can go for almond milk you can have coconut milk oats milk all those other options are available this all you can have it so again case to case you need to first understand whether you are sensitive to it whether you have any intolerance and if it is you can eliminate for some time to see if your symptoms improve and then if it doesn't have any effect on you then you gradually bring them back to your diet thank you so much for throwing some light on that and giving us a little bit of clarity on what to eat what not to eat and coming back to Dr. Geeta what is COS associated with any other condition like is it inheritable yeah a clear when you talk about inheritance it is like whether from the mother definitely will the daughter have it too so yes it has been seen in the families that the irregular cycles in the PCOD runs but I think a clear genetic pattern of this is how it runs hasn't been identified and whether it is associated with other disorders PCOD is a part of what we call the metabolic syndrome you know where all wherein we have the obesity and which is a part of the PCOD the other metabolic disorders like hypertension, the cardiac risk the diabetes they all come under the umbrella of the metabolic syndrome and the PCOD is a part of it that is why when we are trying to manage the PCOD patients the goal is not only to make the cycles regular or to make them conceive you look it at a entire holistic way so that they reduce the weight so that it reduces the risk for all these. Now another important association with PCOD is when they do not have cycles for a very long time as Dr. Murnika had mentioned they have an excess of estrogen in their body so this promotes the build up of the inometrial lining which also increases the risk of inometrial carcinoma in these particular patients so it is so you know PCOD is just not about managing the cycles or making them conceive it is associated with a lot of other medical disorders and we have to look at these patients in view of all the things that they are prone to and you know advise and manage them accordingly all right thank you Dr. Gita Dr. Arunima the question I'd like to ask you is we spoke about difficulties in conceiving in some of the patients right what are the tests that may be needed to that the PCOS patient have to do before they plan on conceiving. Okay so basically from the fertility point of view apart from all the fertility related tests which we do there are certain specific tests which we do in relation to PCOS one is the FSH and the LH which is done on the day 2 FSH is follicular stimulating hormone and LH is the luteinizing hormone this along with estrogen is done on the second day of the period so why are we doing this test we are trying to see how severe is the PCOS by looking at the LH-FSH so that is one thing the other thing which probably is not given in the guidelines but lot of infertility specialists will be wanting to do it is called something called as the AMH or the anti-mullerian hormone this hormone typically tells us what is the current reserve of eggs in the ovary so in PCOS we expect it to be really high now if it is really high say the normal range is approximately up to 3.5 2 to 3.5 is what we call as the normal range now if it is beyond that it comes in the PCOS range if it is beyond 3.5 that is if it is really high say 7, 8, 10 we understand that the PCOS is going to be very difficult to treat in that situation you know we know how much to titrate the drug how low to start the drug with as I said that you know we have something called as a very narrow window in PCOS so it is very important that we do this particular test apart from this a regular scan of trans vaginal sonography is something which is very important in this situation to understand how you know how severe the PCOS has gone with whether the something called as the ovarian stromal thickness has increased a lot or not do we require eventually if possible we may require a surgery for these patients you know to make them ovulate that is not routinely prescribed but do we need that that is something which we have to decide so these are the tests which we usually do from the fertility point of view apart from the normal fertility tests when we are looking at the PCOS patient. Alright thank you Dr. Arunima I'd like to talk to Dr. Modika right now and I'd like to ask is there a natural way to manage PCOS I think Dr. Anitha has already discussed quite a lot about this the most natural way to manage PCOD will be to attain and maintain a 5 to 10 percent weight loss that has been shown consistently to reduce just circulating insulin level now insulin we know has been involved in the pathogenesis of PCOD these patients are not diabetic per se they do have an increased risk for future development of diabetes but they are not diabetes what they do have is an impaired glucose tolerance or an impaired fasting glucose along with they have an increased insulin levels so these insulin levels they act on the ovary they act also centrally on the what we call hypothalamus in the pituitary and they lead to the metabolic they have a link to the metabolic disturbance that leads to PCOD so that's why when we know some PCOD patients when they manage to and maintain the weight loss of up to 10 percent they can even manage to eliminate their need for medication of PCOD they can resume their normal mences possibly because of the lowering of the insulin levels which has a direct effect both centrally as well as peripherally that is both on the brain as well as on the ovaries itself so that reduces the might have any effect that we are not completely aware of as yet that how it reduces the androgen secretion it also resumes the disordered LHFSH pulses that are present in the brain of a PCOD patient so that's how we can manage PCOD by a natural way rest all some patients do well with gluten free diet some patients do well with lactose free diet this is all as per the patient what the patient the diet soothes the patient as of now what we recommend is a diet filled with complex carbohydrates low fat diet without any trans fat and without any fast foods that is the soft drink, cold drink all that should be avoided that is all otherwise on this diet the patient can maintain and reduce 10 percent of weight loss with an increased physical activity then that is perfect now how much physical activity is required in PCOD normally for diabetics what we recommend is around 30 minutes per day for PCOD it's around 45 minutes per day of moderate intensity physical activity a moderate intensity physical activity is something that raises your heart rate so it should be a little bit out of breath and you should have a difficulty in talking normally if you are exercising at a moderate intensity what we recommend around 5 days a week at least 45 minutes regular physical activity can lead to a sustained weight loss but it is to be noted that the sustained weight loss begins only after about a 3 month mark of regular physical activity so the patient have to maintain and motivate themselves at least for the first 3 months before they start to see any results thank you Dr. Monica and before we go to questions from the public this is the last question I would like to ask Dr. Navanita and the question is how to deal with PCOS related depression with diet and nutrition okay so depression and anxiety is very common in PCOS if anybody already suffering from PCOS they will be knowing that in their lifetime they felt severe mood swings sometimes they feel like crying without any reason they get angry on just suddenly they feel all those kind of change in their temper so and also there is so many studies which shows that PCOS women will have 6 full of chances of having depression or mental health and as we all know PCOS is related to insulin resistance and which will lead to high androgen levels which give you all the symptoms of obesity having acne having facial hair infertility so you can understand a teenage or a young woman having all those symptoms where she cannot lose weight even she is eating very small quantity right and she is trying to conceive where all her friends are having children so this all factors are enough to have depression and most of the time they will not be so open like because as also in lean PCOS as I said you cannot make out they are having PCOS right so they are not very open to people they don't have those support system so this all cause lot of anxiety depression among them and the right way to manage it is to have talk to your doctors talk to your nutritionist ask for support follow a good healthy PCOS diet as I have explained follow more of complex curve have food at their natural best avoid packet food as much possible include good fats healthy fats like fatty fish like salmone tuna, mackerel, sardines right include healthy oils like you can include olive oil cold pressed coconut oil canola oil you can have even little bit of ghee also avoid deep fried food food which contain trans fat right so include protein of oil avoid all that include more of fruits and vegetables which we miss it I don't know how many of us will eat fruits on a daily basis right so include one or two fruits on a daily basis include you can all your nutrients vitamins and minerals which they will be undeficient of make sure you expose yourself to sunlight at least 20 minutes of sunlight if not ensure that you take vitamin D supplement so having some vitamin supplement like vitamin D if you are vegetarian not eating enough food which are rich in omega 3 you should include omega 3 supplements right even for vegetarian you can include walnuts right black seeds which are good source of omega 3 include healthy nuts, oily seeds include more good proteins right so as I said follow a healthy busy diet exercise regularly also supplement in a form of vitamin D omega 3 which is a vitamin B complex this all shows to improve your symptoms including your depression and anxiety alright thank you so much doctors I'd like to now ask you question ask you the questions sent by the public I'll start off with doctor Arunima there's a person who says that my periods are regular how can I have PCOS okay so there is a possibility that when you have regular periods you may have PCOS see PCOS we have various what we call as phenotypes phenotypes means the outward look of PCOS may be different for different people there were three symptoms which doctor Gita had mentioned one was anovillation that is not developing any follicle the second one was hyperandrogenism that is abnormal hair in the body third was ultrasound related features now you may have something called as an ovulatory PCOS where you have just the hyperandrogenism and the ultrasound features so that is one possibility the other thing is that some anovillatory PCOS may also bleed fairly regularly probably because of something called as estrogen withdrawal so that is a possibility rare possibility but most of the time these kind of patients are ovulatory PCOS so that's a good thing in a way because from my point of view from the fertility point of view because in spite of the fact that you have PCOS you are ovulating so that's good for me alright thank you so much doctor the next question is for doctor Gita and the person asks what is the age group that PCOS is seen in yes you already mentioned we see across the spectrum right from the post-menaculate group till the perimenopausal so we have teenagers coming in with these common problems of acne heresitism, irregular cycles we have got women in their child bearing age coming with the problem of infertility then we later see people again in the parties coming again with irregular cycles into the city so there is no particular age group it can be seen in all the women after alright I hope that answers your question the next one is for doctor Navanita I think you have spoken a little bit about it but just for this person what are low GI carbs that people can consume okay so low GI 4 which have GI less than 69 normally those are moderate and less than 50 comes are low GI those 4 which will after taking will not shoot up your sugar levels so all your complex carbs example your millets, your whole grains your brown rice whole pulses fruits, vegetables all come under this but a high GI food if I want to tell you is various of processed foods for example your white bread your maida products then your food juices or cold drinks sweet, sugar, any kind of weighty product this all comes under high GI food and need to be avoided because this will shoot up your sugar levels this increase your insulin levels in your body and then as your insulin resistance all it will aggravate your PCOS symptoms right thank you doctor Navanita and the last question actually the second last question I'd like to ask is doctor Monica what are the long term side effects of hormonal pills so these hormonal pills that are given they basically have two components they have an estrogenic component and a progesterone component so major side effects are from the estrogen component and regular bleeding is induced by the progesterone component so as such the long term side effects have not been studied in PCOD patients but we did have a study of most menopausal patients that was done in the 2000's that was done to see what the effect of hormonal replacement therapy for patients was who were already had attained menopause so these similar kind of pills were used for hormonal replacement therapy as well and therein we found that there was a borderline rise in certain parameters of the metabolic kind so there was an increased risk of dyskepidemia or cholesterol that might increased borderline increased risk in the ovarian cancer there was also an increased risk of dementia but I want to see, empathize that this was done in patients who were above 60 years of age and they already had some of these you know some of these disorders and baseline so there is no clear cut but based on these studies what we do is that we do not give these hormonal pills continuously to any patient of PCOD we normally have a gap period so normally if the patient does require these hormonal pills and they do not menstruate at all without them then what we give is, we give a regular treatment for these patients to induce regular cycles for around 1 year and after that we give a gap for around 3 to 6 months where we see whether they have resumed their normal cycles or not and after that if they have resumed we want to keep them off the pills it's important to realize that these pills are only for symptom management and they do not specifically have any role on the etiopathogenesis of PCOD so we only give them on the need basis so if it is needed only then we give it, if the patient is menstruating normally without the needs of these then obviously we do not like it as such there are certain minor side effects like nausea, vomiting, deranged labor profile that is managed within the OPDI itself and rarely it has leads to anything very severe alright thank you so much Dr. Monica now this is a question I'd like to put it out open to all anybody who'd like to take it up and answer there's a person who says hi ma'am I was just 38 kgs and was diagnosed as lean PCOS and increased weight to 45 what would you like to tell I would like to know the BMI of that patient that was she underweight before and now has she become normal weight on these on the medications or has she tried to gain weight because of the PCOD diagnosis because if she was underweight then even an underweight patient can have something called as hypothermic immunoria and they may not menstruate normally if they are very underweight because there is a hormone that is secreted by a fat cells called leptin that permits normal menses so the PCOD diagnosis itself might need an update now that the patient is of normal weight just based on weight that is all I think we cannot say alright I hope that answers all your questions I would like to thank all the doctors on the panel today for coming out and speaking to us about PCOS showing a lot of light and hoping that we all have a healthy lifestyle from here I definitely have made lots of mental notes a lot of things that I don't have to do which you guys have mentioned but thank you thank you so much for the FAQ sessions with the doctor thank you to doctor Namnita Sahar doctor Geeta Kumar doctor Arunima doctor Monika Sharma and all the listeners who have joined in this session which is truly helpful for everyone thank you doctor thank you so much