Understanding PCOS and obesity with Dr. Emilia Huvinen

– Welcome back to “Scale Up Your Practice,” the podcast from Obesity Canada. I’m Dr. Roshan Abraham, family physician and associate professor at the University of Alberta.

– And I’m Michelle McMillan, a lived experience advocate, and a member of Obesity Canada’s community. This podcast is where we bring together research, clinical expertise, and lived experience to explore how obesity care can be more compassionate and evidence-based.

– Today’s episode is supported by an unrestricted educational grant from Eli Lilly Canada.

– In today’s conversation, we’re diving into one of the most common and often misunderstood conditions in women’s health, polycystic ovary syndrome, or PCOS, and how it interacts with obesity. As someone who lives with this condition, I’m personally very interested in discussing and learning more about this topic today.

– PCOS effects between 6 to 13% of women of reproductive age globally, with up to 70% of women remaining undiagnosed. PCOS is the most common cause of ovulation dysfunction and the most common hormonal disorder in women. It’s linked to increased risk of diabetes, cardiovascular disease, MASLD or M-A-S-L-D, and even sleep apnea.

– And as a woman who has lived with PCOS since puberty, but wasn’t diagnosed until I had difficulty conceiving my second child, I sympathize with the 70% of women who are undiagnosed. However, it’s not just a reproductive condition, as I can attest to. At its core, PCOS is deeply tied to metabolism, to insulin resistance, adipose tissue dysfunction, and the complex interplay of hormones and inflammation.

– Joining us to explore this connection is Dr. Emilia Huvinen, gynecologist researcher and associate professor at the University of Helsinki, whose research and clinical work explores the intersection of obesity and women’s health. Dr. Huvinen, welcome to the podcast. It’s great to have you here.

– Oh, thank you so much. I have to be really honest, I’m honored to be here, and of course, it’s great that women’s health and PCOS get all this attention that they truly deserve.

– Thank you so much again. Let’s start with the basics. For clinicians who may not treat PCOS every day, can you walk us through what’s happening biologically and how it connects to obesity, metabolic health, and reproductive health?

– Oh, yes. This is actually, to be honest, something that I explain also to all my patients at the first visit, if they come with PCOS or I diagnose that. Because even the name says polycystic ovaries syndrome, and many patients come with the thought that my ovaries are somehow wrong or abnormal or damaged. And also for clinicians, maybe it draws our attention to the more gynecological side of PCOS. But actually what’s at the core is like Michelle already stated, it’s insulin resistance. And it’s like it’s in the middle. And I explain my patients that it’s just your body doesn’t react to insulin as it should, and therefore, to control the blood glucose, the body just secretes more insulin. Well, the insulin goes to the brain, to the hypothalamus and then disturbs the production of GnRH and therefore sending a strange signal to the pituitary gland, which then sends a wrong signal to the ovary. So it’s actually the insulin that causes the cycle. And then the ovary just produces a lot of eggs, a lot of little follicles, and then not an ovulation. So that’s where the polycystic, so they’re not cysts, they’re just many little follicles. That’s where it comes from, and no ovulations. In addition to that, insulin actually goes straight to the ovary, and then it stimulates theca cells that are on the surface of those follicles to produce testosterone. So again, it’s the insulin that causes the appearance, it causes the secretion of testosterone. And then of course, the testosterone interferes at cycle level more, and then it produces the symptoms that comes from testosterone. So there’s acne, hair loss, hirsutism, so a lot of hair growth. In addition, higher insulin and higher glucose, they go to liver, interfere with the production of proteins and namely sex hormone binding globally. And there again, it has a job to bind free testosterone. And when there’s less binding protein, there’s more free testosterone again, adding into this cycle. So with this picture, I draw it always for every patient, and I can tell you, 100% of my patients ask, “Can I take it with me?” And then they take it as a souvenir.

– Yes, I wish that when I was diagnosed, it had been explained that way. Trust me, love, love, lovely fertility doctor, but did not explain it as clearly in half an hour as you just did in like five minutes. So thank you so, so much.

– It works really much better, the picture, but I hope you got the idea.

– Absolutely. As I know from myself, and as I know from many women living with PCOS, there is an interaction with obesity and PCOS. Now, you’ve mentioned it, obviously it goes with the insulin resistance, but I’d be interested, you know, that relationship that you’re seeing between PCOS and obesity and how, I don’t know which one is, as we would say here, the chicken and which one is the egg, but I’m so curious about your thoughts about that.

– Yes, of course. As the core pathophysiological feature is insulin resistance, the obesity is of course increasing insulin resistance, and even adding to the inflammation in the adipose tissue. Whether that’s what is the chicken and the egg question? Well, they’re tightly connected. The Mendelian randomization studies show that at least obesity is driving a PCOS. So that at least that we know. But from my clinical practice, I have to say, definitely, it seems that women with PCOS truly have difficulty in losing weight. And that is seen also in, they did like a questionnaire for women with PCOS, and it came on a really, really high level that that is exactly what women want help with, is weight loss, is weight management, help with their obesity. So it seems to be more difficult, but like to be exact, at least we know that obesity is causative of PCOS, probably not the other way around, but it’s difficult.

– That’s good to know because we often, you know, in the world of obesity, you know, what’s a cause and what’s an effect? And we also do know that, you know, treating obesity may help relieve many of these other comorbid disorders. So given what you said about this, that it’s more than just cycles and fertility and those kind of things, how do you see treatment changing with this new information around PCOS? What do you advise your patients with PCOS to move forward living with this condition?

– As I told, I always draw this picture, and I think that guides my treatment because, and it’s also for the patients, it’s clear we know now that what we are treating is not the cycles. It’s because they are like, it’s a symptom more. It’s not the acne, it’s not the hirsutism, but it is insulin resistance, and therefore, it’s very easy to explain, okay, we have many ways how we can treat your insulin resistance. Then we start with lifestyle. Like, that forms the basis. And then we talk about different ways of lifestyle, how we can help your insulin resistance about. Moving more. If there’s something, finding a way which is a good for you, which you enjoy talking about diet, which are the beneficial maybe ways of helping your weight management, helping your insulin resistance. Then we talk about the second level, which I think is metformin, which is, it’s a very easy access, cheap, pretty well tolerated, and then go to the further, further levels to like the GLP-1 GIP medications. And I also talk about myo-inositol, although the scientific evidence is not that strong, but it’s also, we know it’s safe and some women want to try it. And I don’t think that there’s nothing wrong with that. So it kind of starts from there. And of course, the typical, let’s say more old fashioned ways of just, what we did, like just get you a regular period or give you acne cream. Of course, that is there as well, because we’re doctors. We want to treat the symptoms. And I don’t blame anyone for that, of course, that is important, but it’s kinda like, we start building the treatment from treating the pathophysiology and thereafter then just go, what’s what we have left?

– I think that’s actually a really powerful statement about how early and integrated care can make such a difference. And I’d have to say that that was even before my work with Obesity Canada. That was always my approach with PCOS, even when diagnostic clarity wasn’t always there. From a practical standpoint though, and I know a lot of listeners might find this helpful, what are those first steps for primarily in identifying and managing PCOS when a patient is also living with obesity?

– So for diagnosis of PCOS, we need two of the three criteria. So we need irregular periods, or it’s anovulation, atory failure in a current guideline. Typically, it’s an irregular period. The second one is high androgen levels. It’s either her systems are clinical signs or a laboratory test. And the third one is ultrasound, multi follicular ovaries or in high AMH. So you don’t need a gynecologist to make a diagnosis, so that’s for sure. And I do hope that more clinicians come in because 10% of women have PCOS, so, like, yeah, so too many stay undiagnosed. I think that like how to really start, after making the diagnosis, I think patient information is the first. Then if there is irregular periods, of course, I do recommend starting a combined contraceptive because if there is long periods without menstruation, there is a risk of endometrial hyperplasia. And we know that women with PCOS are at an increased risk of cancer as well. So that is truly important. For hirsutism, typically, it resolves in a very long, it requires a long time. So therefore, that’s probably not one of those first we weighed how it reacts to the treatments. But of course, but that is kind of like I would start with metformin if we’re talking about obesity, It’s indicated for everybody with PCOS and BMI 25. So even with with overweight. So everybody with metformin, go through how slowly you started to reduce the side effects and then to see whether how the periods are coming and then talk about contraceptives.

– Absolutely.

– Of course, when we talk about contraceptives, we have to remember that there is an increased risk of thrombosis also with obesity and the combined contraceptives. But I mean, there are progestin-only pills available, so one can use those as well. So if there’s obesity. And of course, I don’t know about Canada, but in Finland, we do have many women prefer using a progestin IUD and then that’s absolutely perfect.

– It’s quite common as well here.

– Prevents cancer, yeah.

– Now in primary care and gynecology, and especially when we think about from the con context of primary care, PCOS is complex, the experience of living with it can be even more complicated. So many patients describe years of bouncing between specialists before getting a diagnosis, and this likely ties into some bias, not just from a weight stigma standpoint, but what do you think makes PCOS so easy to overlook or misinterpret in practice?

– I’ve been thinking about this a lot. Honestly, it’s a really good question. I do believe that it comes down to the fact that the symptoms are so varying. So it’s not always a typical, you know, like facial hair kind of, anovulation and infertility. But it can be because it’s almost, I mean, the prevalence of depression is more than 40%. Anxiety, almost 40%. I mean, there’s psychiatric illnesses. There’s a sleep apnea. I mean, they can end up with a sleep doctor or they can have bad acne. They end up with a dermatologist. So it’s kinda like, and when they go with one bad symptom, it’s truly understandable because this condition has been so ovary focused and really, like for the gynecologist, for fertility. And then I think that there just needs to be more awareness, not that everybody needs to treat PCOS, but to maybe then guide them to somebody who can make a diagnosis and treat. But it’s because the symptoms come from so many different areas. Psychological, sleep, metabolic, gynecology, skin, hair. So probably, that is one of the reasons. And of course, it doesn’t help that it is associated with obesity, which has the related stigma. So yeah, I think that’s enough of a mess.

– Yeah, yeah, yeah. Really complex. And you know, I’m going to throw one more thing under the bus, it’s women.

– I was going to say that too.

– Absolutely true. It’s absolutely true.

– If this was happening to men, it would be very different.

– Absolutely. And it’s also because then, the diagnosis, I mean it’s about like, okay, maybe that and maybe that. And then it’s like, and then you have to rule out the other causes and because it is. There are other causes for hirsutism, there are other causes for irregular periods, there are other causes for acne. I mean, probably that’s because you do have to connect the dots. And then there’s always obesity that you can just blame like, “Oh, just eat less.”

– Correct. Yep.

– Yeah. And you know, I think, you know, myself and other women that I’ve talked to with PCOS, you know, we often feel a little dismissed, you know, particularly we get the, “If you just lose weight, all of your symptoms would go away. Like, we wouldn’t have to worry about metformin or doing scans or anything.” And the reason I raised that is because it fuels the self-blame piece. And as you’ve spoken about it, it is not easy when you have insulin resistance to lose weight. It is significantly more difficult than someone who doesn’t have it. So you’re already asking someone living with a lot of, you know, not great symptoms, like no woman wants hair on her chin, acne at 40 really sucks. Right? Like, there’s a lot of things. And I loved your initial thoughts about a first conversation, but I think I’d like to delve a little deeper into that. Like, what would be your recommendation? Because we have a lot of healthcare professionals who listen to the podcast. What would be your advice to them about that first conversation with a patient that you probably think has PCOS? Like, how would you gently raise it with them moving forward?

– I would probably, if it would, okay. Because I think that in many cases, unfortunately, it seems that the patients are more aware than the doctors, but if it is so that the doctor has the thought, patient doesn’t have a clue. Honestly, I would just ask, have you ever heard of polycystic over syndrome? Just to kind of ask, probe a little bit. If there’s like, “Oh, yes, no, I’ve heard it’s horrible,” or, okay, so then you know how to put your next words. And maybe it’s like, “No, never heard.” So there you can start from a fresh whiteboard, like, okay, well it’s this condition where you have insulin resistance and so on. So I would absolutely start from there and then start to explain, okay, tell my story about insulin resistance and thereafter explain that yes, these can be the symptoms. Go through the ovulatory part, what it can mean for your fertility. Go through the metabolic complication. Like, I never want to like scare my patients and I always try to put, when we’re talking about future risk, I do think that we need to kind of watch the steps that we take, right? So it’s not about, oh my, yeah, you have like a threefold diabetes risk or no, but it’s more like we should take it as a crystal ball. Like yes, there is an associated, like a threefold risk or three to ninefold risk of diabetes, but now that we know it, we can do things to prevent it and then monitor you so that if you get it, we diagnose it early because then the prognosis is better. So kinda like put it this way, like, okay, it’s actually good that we know that you’re in this higher risk of, because then we can monitor you every one, two to three years for your cardiovascular disease, for your liver, and for your sleep, for your diabetes. So that’s kind of where I would start to start to build. And then what I typically tell my patients is that yes, there is a risk because I think fertility is, for young women. It of course depends on the age. So someone in their 20s or 30s. I do say yes. There can be problems with fertility. If there are no ovulations, it is possible that weight loss brings you ovulations. But if not, it is the easiest thing, easiest infertility to treat. So typically, the medications for ovulation, they work really well. And according to studies, women with PCOS get as children as they want. So their fertility is, we can’t say that it’s the same, but typically, they get as many as they want. They might need a ovulatory induction, but then, but they still get the child.

– Yes, I can concur. I wanted two, I got two. It’s all good.

– Absolutely, so.

– So we’ve highlighted some important skills, I would say in those first conversations. From your perspective, shifting to gaps and addressing those gaps, especially when obesity or insulin resistance are part of the picture, what are some of those gaps in how we assess and manage PCOS?

– Hmm. Yeah, I think that’s, it’s like I said before, it’s understandable. I think that the gap, truly the biggest gap is going straight to treating the symptoms.

– Right.

– Mm, yeah.

– So we’ll go into acne, we go into hirsutism, we go into, well, of course, they’re important, but we kind of miss the insulin resistance and the obesity part. Where actually by treating that, you know, you might not need to even treat the symptoms because the symptoms will ease. Because we know that that weight loss does help. It does help with insulin resistance, it does help with hyperandrogenism and it does help with psychological health, gynecological health, and metabolic health, so.

– So you’ve painted a really powerful picture of how the system shapes care, not just biology. How much of this comes down to bias or assumptions, even unintentionally in how we see and talk about obesity and PCOS?

– Hmm. I think that does play a big role. And it’s not only the bias and the assumption of the healthcare professionals, but there’s a lot of internalized bias. And I do see that very often. And there’s probably, if we think about the HCP role, there’s probably a lot of, maybe it’s like, okay, a physician might think, okay, I know that it’s related to obesity, but oh my God, I don’t know how to treat obesity. It’s like, oh, it’s so difficult or something. And then that is one of the reasons like, okay, I don’t even want to go there. Maybe, you know, I’ll just give the contraceptives and that takes care.

– [Roshan] Interesting.

– Or then for the women, I mean, it’s like they don’t want to probably even, yeah, they’ve maybe had enough times when they’ve been told, “Eat less move more,” Or, “Just lose weight, you know, it will cure your PCOS.” Or, I mean, I have a lot of patients that have been like, no, no, no, no, no. Or they might even go to a gynecologist and then they do ultrasound and then they’re told, “No, no, no, your ovaries look good.”

– Yes.

– You don’t have PCOS. And I’m like, no. So that is like, so that is so… What I’m seeing a lot is that the women are more educated, so they know that they could have, but then someone just orders a scan and then there’s like, “You don’t have it, so forget.” And then I’m like.

– Yeah, there’s so much bias here. So much bias. And it can be so deflating too. I’ve seen it in my patients is, and hearing about the scan from a specialist or another physician, and it can be literally deflating. Because they do know what’s going on with them and they’re being told something completely different. And a big part of it is bias, yeah.

– And it truly kind of, how would we say in Finnish at least like, kind of pulls the rug under your feet is like, okay, I was trying to find help. I was trying to find support and, okay. So that’s…

– And I think that thought in the question also lead into what we like to call our bias break. So we like to take a point at the podcast every time to ask our experts for them to reflect on how bias, even unintentional right? Can shape how you care for people living with obesity and PCOS and reproductive health concerns. You know, there’s a whole list. So I’m wondering if you could share a moment as a clinician where you witness the bias, experience the bias, your patient perhaps told you about something that happened to them with another specialist so that we can kinda understand what’s going on out there and share it with our audience.

– Yeah, there’s tons of stories in my mind, yes. I think that I witness it every week. Women, you know, the first coming, especially if we’re talking about PCOS, coming with the concern, like, “Please, could you do the ultrasound and check my ovaries because I’m worried that I will never have children.” And there’s this horrible, horrible worry and blame. And so that’s definitely one which definitely and interferes with their health and how they care for themselves. Of course, then there is all these women who tell about these stories about, “Okay, no, you don’t have it.” Or I was just told that I will never have children. And then you have to just lose weight. And how that it is been like, I hear so many stories and I actually just recently now comes to my mind. Last week I met this woman, she was now 35, and she was told when she got the diagnosis when she was 20 that she can’t have children. So she has basically lived her life thinking that she can never have children, not using any contraception, luckily did not get unintentionally pregnant. But now she learned that actually that is not true. And now she’s like, she’s coming to me, she’s crying like I’ve lost all this time. And now luckily, she has a good partner. And now we were thinking about, okay, how do we do with the weight management, how do we do it best? But that is like, that moment. But that was like also for her seeing, the pain when she was thinking of the past, but then still thinking like, okay, she’s only 35, so she probably has still the chance. So, also two sides of that story.

– Yeah, I mean, the story is heartbreaking, but it speaks to so much stigma. Like she was told it, she internalized it. I don’t want to put thoughts in her mind, but you know, I’ve spoken to my friends who are just like, have been told that and then had been told if they lost weight, they could have children. And so they try to lose weight. They lose some weight. Even since significant weight, they still don’t get pregnant. Again, internalizing that stigma and bias, it’s all my fault. I didn’t lose enough weight. I did, I, I, I. And that’s so, so sad. We can’t support people when they really need supporting.

– I do. I mean, I do think that’s horrible. And what I’ve seen, it was during my years of residency, how, you know, couples with a higher BMI were basically told like, “Oh, okay, you just go home and lose weight. You know, try to find some nice activity that you can do together and maybe you should not eat in McDonald’s so often, so call us when your BMI is less than 35.” Nothing else. That is like, how can you? That is so unfair and so hurting for the people, so.

– Is there a moment, I guess, that we’ve talked a lot about how bias sort of intersects with PCOS and obviously obesity as well. Is there a moment or example that stayed with you, one that really highlights what can happen when a patient feels truly hurt or supported in their care? I mean, you mentioned one patient who at least started that journey with you. Are there any other instances that would be helpful to share with our listeners?

– I have to say, I’m, I’m grateful that I get to experience these moments of like relief every day. It’s typically comes in form of tears. It’s a moment when like, oh, finally. The first moments come when I draw the picture of PCOS and they look at it like, “Wow, so it’s not my ovaries?” And then when I explain that it’s in your genes or it’s in your intrauterine life, and they’re like, “Oh, it’s not my fault?” And then come the tears like, “Wow, finally, somebody understands me, somebody’s on my side.” And that’s like, and I think it truly moves me every time. Every time I get to be there. Because it’s so big and it’s so empowering for the women. And I see all these, this, the history of stigma and the years of shame kind of crumbling and then how empowered they feel. And then I’ve seen truly how big difference it makes. I mean, we don’t have to even speak about any change. We don’t have to even agree any changes in lifestyle, but it can be just the conversation. Just addressing, just giving the freedom of that shame and stigma and the bias. It can be that the next time we meet, it’s like, “I don’t know what happened, but I’ve lost three kilos.” And I feel like, I mean, it is so powerful.

– Yeah, I agree. Super powerful. And thank you for sharing that because sometimes, you know, I’m not a clinician, but you know, sometimes you know, you address a stigma and a bias and you actually get the result that you were looking for. And that’s such an important message to get out to the community.

– Absolutely.

– So speaking of management, when we’ve talked about it in bits and pieces, for our listeners to just sort of bring it together, what does evidence-based care for PCOS look like today? Particularly when obesity is part of that picture? So sort of bringing it all together.

– I would say especially, yeah, if there’s obesity, so for sure. It starts with metformin. Combined contraceptives or some kind of for hormonal. So if that’s possible, probably what the progestin-only. So treat if there is amenorrhea or oligomenorrhea so long period breaks. Take care of that. It be a cyclic progestin as well. If somebody doesn’t want the contraceptive. Then of course, it’s lifestyle and psychological care. So it is exercise, it is a healthy diet, whatever that is. It of course, should be truly individualized. Exercise goals are quite, how should I say? 150 to 250 minutes per week. So we do know that exercise is good in fighting insulin resistance, but that is a big goal. So it’s a big goal. Up to 250 minutes per week with two times strength training. And then support and weight management. And of course we have luckily now, the stronger obesity medications. And from them, there we do have evidence. Okay, the current guideline from 2023 says GLP-1 agonist can be used. So still the scientific evidence is growing, I should say. The studies have been done mainly with liraglutide, with small doses, 1.2 to 1.8. Very short periods, like two to three months. Okay, that’s not how you treat a chronic disease. But even those show superiority to metformin.

– Oh, wow.

– So, yeah. So I think that that kind of gives an idea that if you would use, I mean, there’s one study with three milligrams and it is pretty good. And you can imagine like if you put them stronger, possibly stronger medications, and at least if they help with weight loss, then that at least. But so they truly, I mean they’re of course, in my daily toolkit, but if we look at like PCOS scientific evidence, they are like, you can use them. But I would say from my clinical experience, I think that they truly are part of PCOS care.

– I mean, you’ve gave us some great ideas about how, you know, it doesn’t have to be dramatic, you know, impacts. Yeah, 250 hours, 250 minutes a week plus two one hour sessions of strength training. That’s a lot to ask of anyone, whether you have PCOS or not.

– Absolutely.

– I challenge the general population that most of the general population isn’t meaning that, but if we put that aside.

– No, no.

– No.

– I don’t think that is like, it’s crazy.

– Yeah, I’m not meeting it. I won’t throw Roshan under the bus.

– Oh, I don’t. I don’t meet it either. And I have a no.

– Me neither.

– I have a family history of heart disease and I still need to, that’s why I’m working on that now. Actually, as an aside, I did a community talk to men of South Asian descent recently, where there is, where we know from an ethnic standpoint, there is an increased risk for heart disease. And even talking about that and finding ways to just introduce small amounts of that and specifically sort of smashing that myth, because so many of them, even afterwards were saying, “Oh, we gotta do it to lose weight.” And I was like, you know, “First of all, let’s like sort of dismantle this whole idea that it’s all about weight. Let’s just talk about your heart, which is the most important thing here for our ethnic group. Let’s forget about weight, let’s just talk about your heart.” And I think that’s what’s really powerful when we talk about these conditions because of our society and the way that we look at weight. And we automatically assume that if you exercise more, therefore you will lose more weight and address the obesity. Let’s just take a step back and say there are so many benefits to this from an insulin resistance standpoint, from a cardiovascular standpoint, and all that matters is that we start low and try to find a way to sort of increase that. Because very few people are reaching the 150 mark for our cardiovascular guidelines. Very few people.

– That is so true. And I think that you really brought the main, main, main important thing. It’s like exercise. I always say like, exercise is not there to lose weight. It is important. Okay, 250 is like, okay, who could do that?

– 250.

– Okay, that’s crazy. But it’s there in the guidelines. But I mean, I’m sure it’s beneficial, but it’s crazy. But anyway, like I think that then come, we come back to my picture of insulin resistance. But then again it goes like, I’m not saying like, okay, you have to exercise to lose weight. No, no, no. Because then again, if you say that, then it’s like, “Oh, I went to the gym and I did my even 250 and I did not lose weight. Oh, I’m going to stop.” So it is not the motivation to keep on doing. And therefore, I mean, I always start like, okay, first, reduce sedentary time. Just keep on moving whatever you like doing. And then, you know, as active as you are, that’s the best. And then you can, you know, let’s then take care of your muscles, but is not about weight loss, it’s about wellbeing, it’s about insulin resistance, it’s about recovery, it’s about feeling good and therefore, I think that keeps the motivation up a lot better than, but it is, people always think. “I don’t lose weight because I don’t exercise enough.”

– And that’s probably a whole different podcast about the shift from let’s move our bodies because it’s fun to do like we’re doing things we enjoy and they’re fun. And because reframing it as I’m doing this terrible, awful task that I hate doing so that I can lose weight and then I don’t lose weight. Who’s going to keep doing that? No human being, we’re just not biologically set that way, it’s not happening.

– Nope. Right.

– So we’ve just had a great discussion about how, you know, it doesn’t have to be dramatic. You don’t have to spend your life at the gym, right? So I’m curious from your perspective, you know, small shifts, how do you see those impacting your patients, their metabolic risks, their hormonal things, their emotional health, just with small shifts? I’d be curious what your thoughts.

– Yes, I think that’s very important to see the small changes because that keeps your motivation, keeps supporting you. And I always actually, especially when treating obesity or when obesity is involved, I ask about the individual goals. Like, what would you like to achieve? And where are we going? Where do we want to go with this treatment? And whether that is regular periods or whether that is going the stairs without feeling heavy in the breath or whether that’s putting nail polish in your toes. And/or not feeling tight in your clothes. And then those are some like really practical things where you might see the change. Of course, what I also want to, when talking about obesity, I always also ask about how do you build during the day? And maybe it is just eating a bigger breakfast, which gives like, “Oh my God, I have so much energy during the day, I don’t have these cravings in the afternoon or the crash,” or I mean, so, it can be in your eating behavior, in your energy levels. It can be sometimes when we modify the diet to have more fiber, less sugar spikes. Many women say, I have less brain fog because of the smoother glucose levels. It can be. I mean, of course then when we have, well, I mean it can be improvement in your sleep. Sometimes you start a medication and that’s like, I’ve seen it both, with metformin, both with GLP-1s, you start a medication and bang, you have regular periods. It can be like right there. But I think that the most are like the energy levels, less brain fog, better sleep and better like satiety and like less thinking about food during the day. I think these are like, when you go get into the good like. And I’m not saying good habits, I’m saying the habits that are good or the best for that individual. So I think that is truly important I think in our caring for our patients is not to be kind of giving like, okay, this is what you need, like using the 250 minutes as an example. Like, here I am, the doctor who knows everything and then you should go and do this. But it is like, okay, I know you’ve done everything well and you must be eating according to all the guidelines, but now we are just trying to find a better way for you to feel better. So it’s kinda like these tiny subtle changes that are like individually good for you.

– It’s just so powerful. I love the fact that you put forward just your simple words. You’re probably eating properly, but we just want to tweak some things.

– Yes.

– Because people living with obesity get the opposite all the time.

– Yes.

– I know you must be eating three meals a day at McDonald’s and sitting on your couch. Well maybe there are people like that, but I don’t know any people living with obesity that that’s their lifestyle. So I love that you said that because then that opens a conversation with me like, yeah, okay, I think I’m doing okay, but maybe we could tweak some things so that things are better. So thank you so much. That’s such a powerful statement.

– Thank you. But I do think that that is so because I see that, and of course I hear and I see how people have been blamed. And, unfortunately, I have to say, I also hear from my colleagues how the prejudice and the bias thinking. Oh, but I mean, if they have all that weight, they must be eating a lot. Like, you know? there’s like this kinda like, but how can they be so fat if know, I’m sure that they are snacking all the time and drinking soda. And, no. So I think that being a doctor, I kind of, I have to, there’s also bias towards me because of course, I think that Michael Wallas said it really well, like, you have to remember that when the patient comes, they must think that we hate them. So I have to kind of come from that standpoint and prove that I don’t hate them. So I think that I have to work a little bit more because many people have worked against me, my colleagues. So that’s why I think it’s truly important to show that I am beside you. I am not against you. I’m not above you. I’m beside you, next to you showing, I mean, and I know I trust what you say. You say you eat three meals. You eat five meals, okay, you say you don’t eat candy, that’s perfect. And I know that you know how you should eat and I know that you’re doing your best. And it’s kinda like just going there. Like we’re individual. Like some of us likes candy, and then some of us likes chips and some of us like herring or whatever. So also our bodies do need different kinds of approaches. So kind of be there like, let’s be detectives. That’s kinda my, I always say, let’s be detectives together and find the best way for you.

– I think the curiosity piece is something that I’ve learned as a really powerful antidote to the power differentials that we see in medicine. Not to mention that to really emphasize values and goal-based care, which is what you’re highlighting. The one thing that I always try to emphasize in the podcast is that, and this is to break some bias as well, all of these recommendations don’t just apply to obesity. All of these recommendations apply to everyone living with a chronic disease, which is so many of our patients when it comes to small progress, when it comes to how we talk about chronic disease in general. So it’s not just isolated to obesity, it applies to all chronic disease. And every time we have these podcasts, I think about, now I work at an academic site about how we can improve access to care for all of our patients with chronic disease with that simple mindset at the back of our head. Which is that everyone deserves this care. Everyone deserves to be free of bias. Everyone deserves to have their goals and values as a priority so that we actually get to the issue that they need to address in the right amount of time. But that’s not always possible to do as an individual. And so oftentimes, you need a team-based approach. PCOS care really benefits from that team-based approach. What have you seen work best in coordinating that sort of team-based care?

– I think it starts in the individual, of course, individual basis. It’s not everybody who needs a psychologist. It is not everybody who needs a dietician. And it kinda starts in finding that each of the challenges. Maybe someone benefits from a dermatologist. And so it kinda like talking with the patient, seeing what are the challenges, starting with baby steps from my point of view, like, what are the medications and lifestyle? And then start building the blocks. Okay, what’s our first? Should we now start with the psychologist? And then we do the dermatologist later if there’s any need even. And then kinda like ask about the patient’s priorities and then build the team around and not like, okay, we have this track that everybody goes first to a dietician because we know that you don’t eat properly and then you go to a psychologist because we know that you have trauma and so and so on. And so I don’t believe in one size fits all.

– Thank you so much for that comprehensive look at treatment and really something a bit aspirational I would say for all of us as we have these conversations about treatment and care for chronic disease in general. We’ll get back to our conversation in a moment, but first, we want to tell all our listeners about something big coming up next year. The Canadian Obesity Summit in 2026 is happening between March 25th and 29th in Montreal. This is Obesity Canada’s flagship scientific Congress on Obesity, bringing together researchers, healthcare professionals and policy leaders from across the country and around the world. It’s five days of learning, collaboration, and community, all centered on this year’s theme, Obesity Across the Lifespan, Connecting Research to Real World Care. If you’re planning to be there, now’s the time to get your tickets. Early bird registration is open until November 30th, 2025. So don’t wait to secure the best pricing, learn more and secure your spot at the link in the show notes or by scanning the QR code on the screen if you’re watching on YouTube. So looking ahead, what gives you hope, Dr. Huvinen, about where PCOS and obesity care are heading? Whether that’s in research, clinical education, or how we talk about these conditions?

– Hmm. I do see a lot of hope. I have hope now in bringing the awareness. There’s I think there’s a lot more conversation and I think when we have awareness, we also bring strength to our women with PCOS because they know what they can ask for. And also the awareness is around physicians finding education. And everybody wants to be a good doctor. So once we have education in its place, I do think. So awareness is absolutely number one. Number two, I have to say as an obesity doctor, that I do see that the new obesity medications offer a good tool for helping our patients both with PCOS and obesity. So I do think that that is an excellent step that gives hope because it is a biological chronical disease and in many cases, lifestyle is not enough. Even though lifestyle forms the basis. But then to have these medications that are effective, I think that really brings hope because with weight loss, it can be that fertility improves dramatically. And then having a child that is, as Michelle that explained, I mean, it’s a very big prize. So I think that that’s my hope.

– That’s really hopeful. So, you know, for clinicians, who might feel uncertain about managing PCOS and obesity, and for some of them, it might be today might be the first time, you know, truly understanding that link between those two chronic diseases. I’m going to ask you the impossible, but what’s one step that our listeners can take to start improving their care for these patients tomorrow? What would be your one key tip that you’d like to just give to them to walk into their office tomorrow that you know, they can put first and forward when they see a patient tomorrow with PCOS?

– You’re putting a really good question.

– I know, it’s the impossible question. It’s unfair.

– It’s actually a really good question.

– I would probably say like the one thing is, yeah, come down and sit next to your patient and then think and help. Sit in their shoes and then try to think like, how could you, from their perspective, help their insulin resistance best?

– Excellent. Simple, straightforward. Thank you.

– And that’s a tall task. As for patients, especially those who have been told to just lose weight. Again, we’ve talked a lot about that. What message, parting thoughts, message would you want them to hear instead?

– Hmm. It’s absolutely is not your fault. It’s not your ovaries, they’re not damaged. It’s insulin resistance, which is based on your genes or your intrauterine life when you were a fetus. And it can be treated. So just find yourself a doctor who can help you.

– Dr. Huvinen, thank you for helping us understand how PCOS and obesity intersect. And for reminding us that early recognition, integrated care, empathy, and addressing bias can improve patient outcomes.

– Thank you for inviting me. It’s been a pleasure.

– And to our listeners, if you found this episode helpful, I’m sure you did because I certainly did, share it with a colleague or a friend. And don’t forget to subscribe to Scale Up Your Practice wherever you get your podcasts so you’re notified when the new episodes are available.

– Until next time, stay curious, stay kind, and keep scaling up your practice. This podcast is intended for informational and educational purposes only and does not constitute medical advice. The content shared in this podcast should never be used as a substitute for professional medical advice, diagnosis, or treatment. Always seek the guidance of a qualified healthcare professional with any questions you may have regarding your health or a medical condition. The information and treatments discussed in this podcast are based on Canadian guidelines and approve practices As of the time of recording. If you’re listening from outside of Canada, please consult your local healthcare professional to ensure compliance with your region’s medical standards, guidelines, and recommendations. The creators of this podcast disclaim all liability for any decisions or actions taken based on the content discussed. Listening to this podcast does not establish a professional or patient-client relationship.