#167 – PCOS 101 (Polycystic Ovarian Syndrome): Unique symptoms & metabolic health | Doc Talk w/ Azure Grant

PCOS, commonly known as polycystic ovarian syndrome, is a condition with multiple epigenetic components and a number of symptoms to look out for, including irregular menstruation and excessive hair growth. While prescription medication can help people deal with PCOS symptoms, diet and lifestyle have massive impact as well. Learn how to treat PCOS naturally with diet and lifestyle changes in this Doc Talk with Levels Research Design Lead Azure Grant and Cissy Hu.

02:21 – What is PCOS?

PCOS (polycystic ovarian syndrome) affects nearly a quarter of women and is the leading cause of ovulatory infertility.

PCOS stands for polycystic, that’s the P and the C, ovarian, that’s the O, syndrome, that’s the S. And so it affects somewhere upwards of 10%, maybe as much of a quarter of women, and like you said, is the leading cause of ovulatory infertility. It’s actually something that’s pretty complex and it’s not totally known where it comes from, but it seems to be a multi genic disorder, have a lot of epigenetic contributors, maybe have something to do with in utero testosterone exposure. And then on the slightly brighter side, it also has a lot to do with lifestyle and diet, so there are a lot of things that people can do to impact it and make it better.

03:14 – What are the signs and symptoms of PCOS?

PCOS has to do with fundamental hormone imbalances and excess production of androgens and results in unpleasant symptoms.

Unfortunately, it can be really hard to diagnose PCOS and it often takes a long time, but there are some pretty clear signs. It has to do with fundamental hormone imbalances and often the excess production of androgens. These are hormones that we typically associate with male reproduction, even though women happen too, like testosterone. One of the common hallmarks of PCOS will be excess production of testosterone. It also commonly presents as symptoms of menstrual irregularity, so that will be things like absence of menstrual periods or very long cycles, things like more than 35 days long or evidence of missed ovulation in people who might track something like their LH or luteinizing hormone. They might see that they’re going a long period between menses and not seeming to have any ovulation at all. And then there are some secondary symptoms too, excess levels of androgens and those are things like excess hair growth, also called hirsutism. And then finally, give them a name, the last bucket of symptoms is cysts on the ovaries. And then to connect that to metabolic health, it’s also really common to have insulin resistance in PCOS. And the majority of women with PCOS are obese. Not surprisingly, this is actually a really big umbrella category syndrome that might comprise several unique subtypes.

05:11 – What are the criteria for a PCOS diagnosis?

There are three criteria for PCOS, though you only need two of the three for a diagnosis: too much androgens for a female, ovulatory dysfunction, and ovarian cysts.

Most people are diagnosed with PCOS in adulthood, but because the three criteria for PCOS diagnosis are a little bit different from each other, and because you only have to meet two of them for a diagnosis, it is possible to get one quite early. Those three criteria are evidence of too much androgens for a female. And so those are the things like high testosterone, can lead to excess hair growth, ovulatory dysfunction is one of them. Obviously if a person is not yet having menstrual cycles, they’re not going to be able to demonstrate ovulatory dysfunction. And then the third one is the presence of cysts on an ovary, which you have ovaries your whole life. Theoretically, and this does happen sometimes in the pre menarchial stage, girls as young as 10 have been diagnosed with both too much androgen production and cysts on the ovaries. However, the point that you bring up about time to diagnosis in PCOS. The average length of time it takes to diagnose PCOS is two years and three doctors and often more than that, so it takes a really long time.

06:36 – The impact of delayed diagnosis

It takes a lot of time and money to get a PCOS diagnosis, which is why so many women go undiagnosed.

There are a lot of impacts of delayed diagnosis, and I think the first ones are probably under diagnosis. At the beginning, we gave this big range of probably at least 10% of women. I think one of the recent figures was 13% of women 18 to 49 have received a PCOS diagnosis already, but maybe up to a quarter, meaning that a lot of people are falling off the wagon and not getting diagnosed. And to understand when that happens, think about going to the doctor in the US and you need to prove that you have two of the following, too much testosterone or body hair growth, ovulatory dysfunction, meaning you need to have shown that you’re not ovulating. You need to have maybe tracked your cycles for months to show that they’re long or unstable. And although more and more women are tracking their cycles, many still don’t, so that takes time. And then determining whether or not you have polycystic ovaries requires going in for an ultrasound. At this point, you’re looking at blood work, you’re looking at potentially multiple months of self tracking, different providers, different appointments. And for a lot of Americans especially, that means a lot of time to try to get in to see these different people and a lot of expense and without a lot of background or maybe a lot of frustration about, what is this problem that I’m having and why can’t they figure it out faster, you can imagine a lot of people might stop somewhere along the way.

11:40 – Can diet help PCOS symptoms?

There have been many studies about diet and PCOS which shows that certain diets can help with PCOS symptoms.

Something that is a really positive takeaway with PCOS, is that a lot of different diets have been studied with respect to PCOS. One of the first things that doctors want to do with these patients is to help them get some weight down if they’re overweight, which most of these patients tend to be, and any number of dietary interventions that you might expect, including Mediterranean diet, the hypertension diet, old fashioned caloric restriction, supplementation, including with things like CoQ10, all of these things seem to help PCOS. Anything that is going to result in a pretty big drop of weight or to help initially lower blood glucose levels if done consistently over time, really seems to help with PCOS.

12:38 – Don’t just rely on food

While food is a great way to help reduce PCOS symptoms, things like exercise can also be a great way to lose weight and get your insulin sensitivity down.

Food seems to be the one that it’s studied really consistently, but exercise like you might expect, leading to weight loss and in particular things like endurance exercise habits, can be really good for getting that waist to hip ratio down and improving insulin sensitivity. One other thing that I want to mention is that it doesn’t seem to be just the impact of things like restricting carbs or restricting calories, but one of the things we talk about a lot of levels, is the importance of things like phytonutrients in having an overall healthy diet. And so this has been studied actually pretty recently. There was a 2020 study of women who did kind a combo keto, Mediterranean style diet, that was supplemented with some phytonutrients for a few months and lost an average of 20 pounds, improved their lipid panels, seemed to lose a lot of fat and lower insulin. It seems like when you combine a diet that allows you to narrow the time window in which you’re eating, consume fewer carbs, that supplementing that diet with nutrient rich foods makes the impact even bigger.

13:51 – What are phytonutrients?

Phytonutrients are particles and molecules found in plants which help your metabolism work more efficiently.

Phytonutrients are little particles and molecules found often in plants, and these help our metabolism work more efficiently. They give our cells things that they need to do to help burn fat more efficiently. It’s like a big and growing field of research because often old fashioned diets were designed to focus on the three main macronutrients and their ratios of consumption. But as you might expect, especially plant rich foods and naturally occurring foods, are filled with all kinds of vitamins, minerals, enzymes, active compounds that have a lot to do with helping us have a healthy metabolism.

14:46 – How intermittent fasting can help PCOS symptoms

Time-restricted eating, also known as intermittent fasting, can help people with PCOS lose weight and regulate their insulin levels.

Time restricted eating is something that does seem to be really helpful for weight loss generally, but also for weight loss in PCOS. Time restricted eating or it’s also called intermittent fasting is a related set of practices, but this means A, eating your food during the daytime and B, setting your food hours to a certain number of hours during the day. The minimum that seems to kick in for benefits is 12 hours, which most people can pull off. But if people can work up to it, something more like 13, 14 hours of fasting per day, can have really good benefits. And this has to do in part with the biological rhythms we have in our body, including in our glucose and insulin sensitivity. People tend to be more insulin sensitive during the earlier hours in the day, so think especially mid-morning, to early to mid afternoon, and then to be a little bit more reactive later at night. A lot of these diets focus on shifting the eating window so that you’re not having that late night dessert. Maybe you’re having a little bit of an earlier dinner and a slightly later breakfast, or some people omit breakfast altogether. It does seem to be very effective. It can be hard for people to jump into cold turkey and get rid of a lot of habits that they love, but it is something that can be worked up to over time, for good effects and allow people to maintain a little bit more of the typical content of what they were eating and just change the timing.

18:37 – Characterizing glucose phenotypes

There are subgroups of people with PCOS who have different disorders from one another, but both still fall into the PCOS category.

I think there’s a lot of basic work to do in characterizing the glucose phenotypes in women with PCOS. Separate from that, it seems pretty clear that there are subgroups of people with PCOS who might have pretty different disorders from one another. Imagine someone who does or doesn’t present with cysts or someone who does or doesn’t present with excess androgen production. Both of these people could still fall under the same diagnosis and might typically clinically get similar feedback. But really, if you’re a person who has high testosterone as a woman and a person who doesn’t, you have very different things metabolically going on. Similarly, some people with PCOS aren’t overweight, that’s probably a different phenotype and maybe needs a different set of treatments in it and advice than someone who is overweight. I think the top couple of studies that I would want to do are a general population characteristic of what the subtypes of PCOS are with some continuous data to back that up, and then a deep dive on what are the features of the shapes and the timing of glucose excursion in PCOS and how those correlate with things like symptom severity or improvement over time if someone goes on a particular diet. I think the common theme among those is I think we have a lot of time series data now, that is easier for people to acquire than it was in the past, and it’s really on us to make the most of every single minute that’s in that dataset.

Cissy Hu (00:06):

There are a lot of impacts of delayed diagnosis, and I think the first ones are probably under diagnosis. Think about going to the doctor in the US and you need to prove that you have two of the following, too much testosterone or body hair growth, ovulatory dysfunction, and then determining whether or not you have polycystic ovaries, requires going in for an ultrasound. At this point, you’re looking at blood work, you’re looking at potentially multiple months of self tracking, different providers, different appointments. And for a lot of Americans especially, that means a lot of time to try to get in to see these different people and a lot of expense.

Ben Grynol (00:52):

I’m Ben Grynol, part of the early startup team here at Levels. We’re building tech that helps people to understand their metabolic health. And this is your front row seat to everything we do. This is a whole new level.

(01:08):

Recently we started this series called Doc Talk, and the idea of it was to break down technical concepts and health and wellness and make them more accessible and digestible. For this episode, Azure Grant, part of our research team and Cissy Hu, part of our community team sat down and discussed PCOS, polycystic ovarian syndrome. PCOS is the leading cause of ovulatory infertility in women today. It’s a very important issue and it’s quite complex. It’s not necessarily well understood, but there’s more and more research coming out that allows us to understand how metabolic health and things like glucose and other biomarkers pertain to PCOS. Anyway, no need to wait, here’s the conversation with Azure and Cissy.

Cissy Hu (02:10):

Why don’t we just kick it off with the basics. For our listeners who aren’t familiar with PCOS, can you share a brief overview of what PCOS is?

Azure Grant (02:19):

Absolutely. PCOS stands for polycystic, that’s the P and the C ovarian, that’s the O, syndrome, that’s the S. And so it affects somewhere upwards of 10%, maybe as much of a quarter of women, and like you said, is the leading cause of ovulatory infertility. It’s actually something that’s pretty complex and it’s not totally known where it comes from, but it seems to be a multi genic disorder, have a lot of epigenetic contributors, maybe have something to do with in utero testosterone exposure. And then on the slightly brighter side, it also has a lot to do with lifestyle and diet, so there are a lot of things that people can do to impact it and make it better.

Cissy Hu (03:03):

Got it. How does PCOS typically manifest in the body? How might someone notice or realize that they might have PCOS?

Azure Grant (03:13):

Unfortunately, it can be really hard to diagnose PCOS and it often takes a long time, but there are some pretty clear signs. It has to do with fundamental hormone imbalances and often the excess production of androgens. These are hormones that we typically associate with male reproduction, even though women happen too, like testosterone. One of the common hallmarks of PCOS will be excess production of testosterone. It also commonly presents as symptoms of menstrual irregularity, so that will be things like absence of menstrual periods or very long cycles, things like more than 35 days long or evidence of missed ovulation in people who might track something like their LH or luteinizing hormone. They might see that they’re going a long period between menses and not seeming to have any ovulation at all.

(04:08):

And then there are some secondary symptoms too, excess levels of androgens and those are things like excess hair growth, also called hirsutism. And then finally, give them a name, the last bucket of symptoms is cysts on the ovaries. And then to connect that to metabolic health, it’s also really common to have insulin resistance in PCOS. And the majority of women with PCOS are obese. Not surprisingly, this is actually a really big umbrella category syndrome that might comprise several unique subtypes.

Cissy Hu (04:45):

Interesting. You mentioned that typically PCOS is challenging to diagnose. It sounds like you need to have gone through puberty, in order to diagnose whether or not you might even have PCOS and so much of it is connected to the reproductive system. How and when is it typically diagnosed, and is there any impact of a delayed diagnosis if it takes years to diagnose somebody with PCOS?

Azure Grant (05:08):

A really interesting question. Most people are diagnosed with PCOS in adulthood, but because the three criteria for PCOS diagnosis are a little bit different from each other, and because you only have to meet two of them for a diagnosis, it is possible to get one quite early. Those three criteria are evidence of too much androgens for a female. And so those are the things like high testosterone, can lead to excess hair growth, ovulatory dysfunction is one of them.

(05:41):

Obviously if a person is not yet having menstrual cycles, they’re not going to be able to demonstrate ovulatory dysfunction. And then the third one is the presence of cysts on an ovary, which you have ovaries your whole life. Theoretically, and this does happen sometimes in the pre menarchial stage, girls as young as 10 have been diagnosed with both too much androgen production and cysts on the ovaries. However, the point that you bring up about time to diagnosis in PCOS. The average length of time it takes to diagnose PCOS is two years and three doctors and often more than that, so it takes a really long time.

Cissy Hu (06:23):

Is there any negative impact of delayed diagnoses or does it not really progress from the time you begin to show symptoms of PCOS?

Azure Grant (06:34):

Right. Good question. There are a lot of impacts of delayed diagnosis, and I think the first ones are probably under diagnosis. At the beginning, we gave this big range of probably at least 10% of women. I think one of the recent figures was 13% of women 18 to 49 have received a PCOS diagnosis already, but maybe up to a quarter, meaning that a lot of people are falling off the wagon and not getting diagnosed.

(07:04):

And to understand when that happens, think about going to the doctor in the US and you need to prove that you have two of the following, too much testosterone or body hair growth, ovulatory dysfunction, meaning you need to have shown that you’re not ovulating. You need to have maybe tracked your cycles for months to show that they’re long or unstable. And although more and more women are tracking their cycles, many still don’t, so that takes time. And then determining whether or not you have polycystic ovaries requires going in for an ultrasound. At this point, you’re looking at blood work, you’re looking at potentially multiple months of self tracking, different providers, different appointments. And for a lot of Americans especially, that means a lot of time to try to get in to see these different people and a lot of expense and without a lot of background or maybe a lot of frustration about, what is this problem that I’m having and why can’t they figure it out faster, you can imagine a lot of people might stop somewhere along the way.

Cissy Hu (08:08):

That makes a ton of sense. Sounds like an uphill battle.

Azure Grant (08:12):

Yeah, absolutely. And as you suggested, these seem to have really bad downhill consequences, meaning the longer that someone goes living with PCOS that is diagnosed, the more likely they are to either have more trouble with fertility and also to go on to develop things like type 2 diabetes. It’s something like your 7X more likely to develop type 2 diabetes if you have PCOS.

Cissy Hu (08:39):

Wow. Tugging on the metabolic health thread there, the type 2 diabetes, can you talk a bit more about the insulin resistance or lack of insulin resistance for women with PCOS? How are metabolic health and PCOS related?

Azure Grant (08:55):

Right. Insulin resistance or having too high insulin seems to be very common in PCOS, so it’s up to 70% of women who are diagnosed also demonstrate insulin resistance on something like an oral glucose tolerance test. And more than half of those women, so not only do they have insulin resistance, but more than half go on to develop type 2 diabetes by a pretty young age, by about 40. It’s also thought maybe that when people come in initially and they receive a type 2 diabetes diagnosis, they can then go on to get a PCOS diagnosis.

(09:35):

How are these related? It’s still something that is actively being studied and it seems like it’s a combination of in utero and genetic factors, so things you can’t control that already happen, that make an individual more likely to be insulin resistant. But there’s also this kind of vicious cycle of having high insulin leads to increased appetite, can lead to more carb cravings and cravings for other sweet foods, which can perpetuate the problem of higher glucose, higher insulin.

(10:07):

In addition, having high insulin can impair fatty acid oxidation or fat burning in the mitochondria, which can make it even harder to lose weight. And then there’s a really interesting interaction between cells and the ovaries and insulin receptors themselves. In the ovaries, insulin receptors are found on these things called theca cells, and those cells when they make androgen, which is higher in PCOS, can get more insulin receptors.

(10:40):

And moreover, insulin can increase the number of theca cells that a person has and we can go on and on. Having high insulin can lower the production of something called sex hormone binding globulin, something that would normally bind testosterone and help take it out of circulation. Obviously if you have less of that, you’re going to have even more testosterone around. And on top of that, the elevated androgen levels themselves can contribute to more fat deposition in women. It’s really unfortunately a process that if it doesn’t get interrupted by something like a lifestyle intervention or first thing first, a diagnosis, then it can get worse and worse over time.

Cissy Hu (11:24):

From the perspective of a lifestyle intervention, can you talk a bit about any research that’s been done around monitoring things like your glucose levels to manage PCOS, any specific research that’s been done in that space?

Azure Grant (11:39):

I think this is something that is a really positive takeaway with PCOS, is that a lot of different diets have been studied with respect to PCOS. One of the first things that doctors want to do with these patients is to help them get some weight down if they’re overweight, which most of these patients tend to be, and any number of dietary interventions that you might expect, including Mediterranean diet, the hypertension diet, old fashioned caloric restriction, supplementation, including with things like CoQ10, all of these things seem to help PCOS. Anything that is going to result in a pretty big drop of weight or to help initially lower blood glucose levels if done consistently over time, really seems to help with PCOS.

Cissy Hu (12:26):

Got it. Mostly you just talked on dietary changes. Any lifestyle changes that have been studied that have made a positive impact on managing PCOS?

Azure Grant (12:37):

Yeah, I would say food seems to be the one that it’s studied really consistently, but exercise like you might expect, leading to weight loss and in particular things like endurance exercise habits, can be really good for getting that waist to hip ratio down and improving insulin sensitivity. One other thing that I want to mention is that it doesn’t seem to be just the impact of things like restricting carbs or restricting calories, but one of the things we talk about a lot of levels, is the importance of things like phytonutrients in having an overall healthy diet.

(13:13):

And so this has been studied actually pretty recently. There was a 2020 study of women who did kind a combo keto, Mediterranean style diet, that was supplemented with some phytonutrients for a few months and lost an average of 20 pounds, improved their lipid panels, seemed to lose a lot of fat and lower insulin. It seems like when you combine a diet that allows you to narrow the time window in which you’re eating, consume fewer carbs, that supplementing that diet with nutrient rich foods makes the impact even bigger.

Cissy Hu (13:49):

What are phytonutrients?

Azure Grant (13:51):

Phytonutrients are little particles and molecules found often in plants, and these help our metabolism work more efficiently. They give our cells things that they need to do to help burn fat more efficiently. It’s like a big and growing field of research because often old fashioned diets were designed to focus on the three main macronutrients and their ratios of consumption. But as you might expect, especially plant rich foods and naturally occurring foods, are filled with all kinds of vitamins, minerals, enzymes, active compounds that have a lot to do with helping us have a healthy metabolism.

Cissy Hu (14:35):

Got it. Makes a ton of sense. You mentioned restricting calories. Has there been any research around how the impact of fasting on managing PCOS?

Azure Grant (14:45):

Yes, time restricted eating is something that does seem to be really helpful for weight loss generally, but also for weight loss in PCOS. Time restricted eating or it’s also called intermittent fasting is a related set of practices, but this means A, eating your food during the daytime and B, setting your food hours to a certain number of hours during the day. The minimum that seems to kick in for benefits is 12 hours, which most people can pull off.

(15:16):

But if people can work up to it, something more like 13, 14 hours of fasting per day, can have really good benefits. And this has to do in part with the biological rhythms we have in our body, including in our glucose and insulin sensitivity. People tend to be more insulin sensitive during the earlier hours in the day, so think especially mid-morning, to early to mid afternoon, and then to be a little bit more reactive later at night. A lot of these diets focus on shifting the eating window so that you’re not having that late night dessert. Maybe you’re having a little bit of an earlier dinner and a slightly later breakfast, or some people omit breakfast altogether. It does seem to be very effective. It can be hard for people to jump into cold turkey and get rid of a lot of habits that they love, but it is something that can be worked up to over time, for good effects and allow people to maintain a little bit more of the typical content of what they were eating and just change the timing.

Cissy Hu (16:23):

The good news here is that it sounds like there’s a number of different ways that you can manage PCOS from a dietary perspective. You can try keto, you can try fasting, calorie restricting, all these different ways. The good news that it sounds like it’s not a one size fits all solution.

Azure Grant (16:42):

Yeah. And one thing that we didn’t talk about as much, birth control and metformin, which is a diabetes drug, are also pretty common frontline treatments to treat PCOS. And I’m not the clinical useful kind of doctor, so I’m less good for commenting on those. But they do help a lot, especially in the beginning to help restore insulin sensitivity and to help break the cycle of excess androgen production. But I think personally, and we often tend to advocate, there’s a lot that you can do non-pharmaceutically, to either supplement the medication that’s prescribed or to break the cycle in PCOS just through the foods that you choose to eat and through more exercise.

Cissy Hu (17:34):

From the role that you sit in, so there’s a lot of different experiments to women with PCOS can experiment with. If you could wave a magic wand, what are one to two studies that you would love to work on to better understand PCOS as it relates to metabolic health?

Azure Grant (17:51):

Okay, super fun question. I love it. Studies that I would love to work on to understand how PCOS and metabolic health are related. Well, the first one is really simple and it’s getting a lot more CGMs on women with PCOS and then taking that CGM data that’s collected every 5 to every 15 minutes and looking at all of the nitty gritty, complex, fun features like the size of the spikes after meals or the shape of the spikes after meals, are they pointy, are they curvy, when they happen, how often people eat? All of that really detailed data so that we’re not just looking at something like, what was your mean glucose over the day or what was your response over two hours to a single oral glucose tolerance test?

(18:37):

I think there’s a lot of basic work to do in characterizing the glucose phenotypes in women with PCOS. Separate from that, it seems pretty clear that there are subgroups of people with PCOS who might have pretty different disorders from one another. Imagine someone who does or doesn’t present with cysts or someone who does or doesn’t present with excess androgen production. Both of these people could still fall under the same diagnosis and might typically clinically get similar feedback. But really, if you’re a person who has high testosterone as a woman and a person who doesn’t, you have very different things metabolically going on.

(19:18):

Similarly, some people with PCOS aren’t overweight, that’s probably a different phenotype and maybe needs a different set of treatments in it and advice than someone who is overweight. I think the top couple of studies that I would want to do are a general population characteristic of what the subtypes of PCOS are with some continuous data to back that up, and then a deep dive on what are the features of the shapes and the timing of glucose excursion in PCOS and how those correlate with things like symptom severity or improvement over time if someone goes on a particular diet. I think the common theme among those is I think we have a lot of time series data now, that is easier for people to acquire than it was in the past, and it’s really on us to make the most of every single minute that’s in that dataset.

Cissy Hu (20:13):

The interesting thing that you’re talking about is that even with someone who’s in the same subset, so say it’s someone who has higher testosterone levels. And multiple people with higher testosterone levels, their solution could be multiple different things. It’s not just because you both have higher testosterone levels, like fasting might be the direction you go in. Because everyone’s body is so different, the solution to managing PCOS could be things like fasting for one person and keto for another person. Is that generally correct?

Azure Grant (20:47):

I think it’s possible. I don’t know if high testosterone would be the difference between those two. I think when it comes to dietary choice, my guess, I don’t know, is that the main goal is to reduce insulin levels, restore insulin sensitivity and reduce glucose levels and that anything that does that, that works for a given individual lifestyle-wise, is probably going to help their PCOS at the same time. I think whether or not someone has high testosterone, is probably going to contribute to how much or how far that person has to go to restore their insulin sensitivity.

(21:27):

But one cohort comparison that would be really interesting is if someone is presenting with really irregular ovulatory cycles and cysts on their ovaries and they’re not overweight, what could they do lifestyle-wise, in order to improve their outcomes if it doesn’t seem like they’re having as many of the symptoms of high insulin as someone else. And having a chance to see with glucose data, if you’re someone with PCOS, whether or not your blood sugar is falling into healthy ranges or not, could be a really interesting first step to help them know, do I really need to focus on improving my insulin sensitivity or is maybe there’s something else going on here.

Cissy Hu (22:08):

Got it, so much work to do in this space. Before we wrap, is there anything else that you want to share with our listeners on PCOS as it relates to metabolic health or just PCOS more broadly?

Azure Grant (22:20):

I guess I would just make a plug for you. Cissy hasn’t said much about herself today, but she’s our community lead and she’s been doing a great job reaching out to different people in the community and having them bring their questions to us. I would say to anyone who is a listener and a part of the Levels community, if you’re interested in PCOS or other reproductive health topics and you have questions for us, or you have things that you want us to study or you want to share your experiences with us, please don’t hesitate to reach out because one thing we want to do, is make sure that the research that we do, within Levels, is really closely tied to what you need.