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

KEYPOINTS

• 01

  PCOS is common and mostly missed

  Aliabadi calls polycystic ovary syndrome the most common hormone disorder in women of reproductive age. It affects about 15% of US women and more than 20% in some Middle Eastern countries. Studies say about 70% of cases go undiagnosed, and she believes over 90% are either undiagnosed or wrongly treated, often with birth control alone. About 75% of patients gain weight while 25% are lean, and she estimates 60–70% of her PCOS patients have disordered eating, which she says eating-disorder clinics often miss.

• 02

  Diagnosis needs two of three criteria, and a normal testosterone result does not rule it out

  The criteria are: signs of excess androgens (acne, oily skin, facial or body hair, male-pattern thinning); ovulation problems (cycles longer than about 35 days or roughly eight periods a year); and polycystic-appearing ovaries. That last one means 20 or more follicles in a 'string of pearls' pattern, not cysts. Since 2023 a high AMH or egg count can count as the third criterion. A normal blood testosterone does not exclude PCOS, so a daughter on spironolactone or Accutane for acne who also gets laser hair removal may already meet the criteria.

• 03

  Four PCOS phenotypes explain why it looks different from patient to patient

  Some patients have all features. Others have regular periods yet 70–80% of PCOS patients still do not ovulate, because that bleed comes from estrogen withdrawal, not ovulation. Others have no androgen symptoms at all. Lean women, women without acne, and women with regular cycles can all have PCOS, which is why Aliabadi says diagnosing it takes clinical pattern recognition.

• 04

  Insulin resistance drives much of PCOS

  About 80% of PCOS patients are insulin resistant, often from birth and including lean women. Excess ovarian androgens worsen insulin resistance. High insulin then pushes the ovaries to make more androgen, stalls ovulation, lowers sex hormone-binding globulin so free testosterone rises, and promotes visceral fat. That fat releases inflammatory cytokines, creating a self-reinforcing loop that also affects mood.

• 05

  A high AMH can be a warning sign, not reassurance

  A rough rule: each 0.1 of AMH equals about one follicle, so an AMH of 1 means about 10. Thirty follicles at age 40 suggests PCOS, which affects egg quality. At 25–28, about three eggs make one embryo; at 40 it may take 10–15, so an AMH of 0.5 could mean two or three egg-freezing cycles. She notes that 50% of US counties have no OB-GYN.

• 06

  Treat the root causes, not just the symptoms

  Birth control raises SHBG, which binds testosterone and controls acne, hair and cycles, but it is only one tool. Her approach starts with 10–15 minute walks after meals, sleep, stress reduction, an anti-inflammatory diet with less processed food, adequate protein, and resistance and high-intensity exercise. Then come insulin-sensitizing supplements (inositol, vitamin D, curcumin, chromium), metformin, and GLP-1s. Berberine she uses only in short pulses, not long term.

• 07

  Painful periods are not normal

  Pain that makes you miss school or work, cancel plans, or go to urgent care is a warning sign, as are pain with deep penetration, constant bloating, painful bowel movements, and repeated 'UTIs' with negative cultures. She says these mean endometriosis until proven otherwise. It is the top cause of chronic pelvic pain and a leading cause of infertility. She says patients often get colonoscopies or opioids like Norco and Percocet instead of a diagnosis.

• 08

  Endometriosis is often missed on imaging and in surgery

  A normal ultrasound or MRI does not rule it out, though an endometrioma ('chocolate cyst') shows up immediately and signals roughly stage 3 disease. Laparoscopic excision, cutting lesions out rather than burning them, is the gold standard for diagnosis but not the first treatment. She says only about 1 in 100 gynecologists is trained to do it well. Stromal endometriosis appears as thin fibrous lines rather than dark spots and can take her 15 minutes to find.

• 09

  Endometriosis can take eggs early

  Inflammation damages egg count and quality, scars the fallopian tubes, and makes the pelvis hostile to sperm and embryos, raising the risk of ectopic pregnancy and miscarriage. She has seen 30-year-olds with almost no eggs and 14-year-olds with the egg count of a 40-year-old. She estimates more than 20% of women have endometriosis and that about half of PCOS patients have it too, possibly fueled by PCOS-related inflammation, though she calls this her own hypothesis.