online, in this session, which is called, Who's Really Driving the Bus in PCOS? My name is Joop Laufen. I'm a reproductive endocrinologist based in the Netherlands, in Rotterdam, and I'm your moderator in this session. We have two eminent speakers today, both members of an elusive and exclusive club. They call themselves the Peacocks, and they are longstanding members of that club. Before the debate is going to start, you have to scan the QR code and vote for one of the two speakers. They are mentioned by name in there. So it's either Andrea de Nijf or it's Ricardo Aziz. It's not Joop Laufen because I'm the moderator and I'm not participating in the debate, just only moderating it. Both speakers will have exactly 25 minutes. If they exceed the time, then their last slide will automatically flip up. Then there are two rounds of five-minute rebuttal for each, and then we will vote again by scanning the QR code, and then we also will see the poll who is granted the driver's seat in the bus. So I can't stress this enough. Ricardo and Andrea, you have to stick to your timetable. And if you do that properly, then we have also 15 to 20 minutes at the end to ask questions and provide answers to that. Having said that, I proposed ladies first, but Ricardo decided to start. So Ricardo Aziz is an internationally recognized physician, scientist, executive. Currently he is the chief science officer and EVP operates strategy commissioner for the Lundquist Institute. He commutes quite a bit through the U.S. between New York and the West Coast. He is renowned for what he has done in the PCOS field and especially in terms of hyperandrogenemia definitions. He is in the International Guideline Group, which is dealing with diagnosis and screening. So Ricardo, the floor is yours. Good morning. I want to start in a hurry here because I got 63 slides to review in 25 minutes. Let's see if we can get this moving. My slides are not reacting. There we go. Oops. Went to the end. Yes, that's helpful. That's not very helpful. A few disclosures. History pays me enough to say different things, but you should be aware of it. We need to recall that really the first observation in modern polystic ovary syndrome of hyperinsulinemia and metabolic dysfunction in PCOS occurred in this study by Bergen, Gibbons, and Katabchi. In fact, it was a study that was not designed to study metabolic dysfunction in PCOS at all. It was actually meant to study androgen excess in women. And of course, they thought, ooh, a good model of androgen excess in women is going to be PCOS, and so we're going to study them. And of course, they were surprised to find the level of hyperinsulinemia. In fact, that has been corroborated multiple times in the study by, in fact, Andrea sitting at the other side of the table. That also corroborated hyperinsulinemia in individuals with polycystic ovary syndrome, in this case, really highlighting the impact of obesity on metabolic dysfunction. Now, the question that we have to answer today is, is insulin the driving the bus in polycystic ovary syndrome? And of course, I am speaking in favor of that, and I will show you convincing data that will allow you to have no doubts that insulin is driving the bus. So this is a study, 89, by Jeff Chang and colleagues, looking at the correlation between insulin levels in the system and testosterone. And you can see there's a beautiful correlation between insulin and testosterone, indicating that insulin was driving, in this case, testosterone. But this is an association study. A number of years later, John Nessler, following on Barbieri's early work, noted that insulin in theca cells of polycystic ovaries actually stimulated androgen production by the theca cells of polycystic ovary syndrome to a much greater extent than that in normals, again, indicating that insulin is driving androgens, in this case, in the ovary. Subsequently, John did a study in which he suppressed insulin for a short period of time, of course, using diazoxide, and noted, again, that as you suppressed insulin, androgen levels also dropped, again, indicating that insulin is driving the androgen bus. Many years later, we did this very large study with a number of individuals here in the audience and on the podium, in which we studied the impact of troglitazone, a thiazolidinedione insensitizer on androgens in polycystic ovary syndrome, and you can see that it was a very nice dose-related association in the suppression of testosterone by thiazolidinedione, again, indicating that insulin action was driving the androgen bus. Now, in regards to the phenotype of polycystic ovary syndrome, you can see, for example, here, a very nice linear correlation between the severity of menstrual dysfunction and the degrees of insulin resistance measured, actually, by hyperinsulinemia in about 500 polycystic ovary syndrome patients, again, indicating that even the phenotype of PCOS is heavily related to hyperinsulinemia. When you looked at hirsutism, and this is, again, a study in about 750 or so polycystic ovary syndrome patients, consecutive adult patients, you will find that the strongest predictors of hirsutism in women with polycystic ovary syndrome were actually fasting insulin, HOMA, and in this case, body mass as a secondary index. Not androgen levels, interestingly enough, but insulin and measures of insulin action, again, indicating that even the phenotype of polycystic ovary syndrome is principally driven by hyperinsulinemia and insulin metabolic dysfunction. Now, if you're not convinced by clinical data, then let's look at the molecular data. This is studies looking at adipose tissue, adipocytes in particular. We use that as a model tissue to determine, if you would, metabolic dysfunction and polycystic ovary syndrome, and you can see that here, the glucose uptake into adipocytes is much suppressed in polycystic ovary syndrome patients, and in fact, glucose, GLUT4 expression, which is the principal glucose transporter, is also very suppressed in polycystic ovary syndrome adipocytes. If you were to look at mechanisms potentially explaining this dysfunction in glucose uptake in polycystic ovary syndrome adipocytes, we look to epigenetics, among other markers. We studied microRNA93, and we'll talk a little bit more about that at a seminar, at a symposium on Monday, but nevertheless, it's important to note that microRNA93 suppresses GLUT4, and was found to be elevated in all the patients with PCOS that we studied, whether they were lean or not, and also in insulin-resistant individuals. Furthermore, the concentration of microRNA93 was negatively associated with GLUT4, and of course, positively related with HOMA-IR, in other words, measures of insulin action. So this is, again, in the tissue, in adipocytes. We are observing that microRNA93, in this case, as a model, was related to metabolic dysfunction in PCOS. But what's interesting is that when you proceeded to overexpress microRNA93 in human-differentiated adipocytes, you also got the same response. MicroRNA93 increased, and then GLUT4 expression and protein decreased. If you then did this, and you suppressed microRNA93 with antisense microRNA93, you would see that the microRNA gene expression would decrease, but GLUT4 would increase. All of this indicating that this is a model for studying how this primary target could cause metabolic dysfunction in polystegory syndrome. So how does this relate to the question about what is driving the bus? Well, this is a primary metabolic target impacting on GLUT4 expression. When you overexpress microRNA93 in a transgenic mouse, what you find is, in fact, a number of other expressions, including the overexpression or concentration of androgens, as well as CYP17A1 or alpha-1, indicating that this, again, is driving androgen dysfunction in this model, murine model of polystegovory syndrome. Again, a metabolic hit driving androgens in that regard. Well, supposing you don't like animals, and you don't think that models of polystegovory syndrome in animals really work, well, let's take a look, then, at what happens in adolescents and in children, because one of the indicators, clearly, of what's driving the bus is what first changes in our lives in individuals who are at risk for polystegovory syndrome. These are studies from Teresa Sir Peterman, many years ago, indicating here that in daughters of PCOS women in the pre-pubertal and post-pubertal period, this is the pre-pubertal period here, the first thing that they observed was an increase in the two-hour insulin. There was no change in androgens at that time. Androgens came later in the post-pubertal period, again, indicating that the first abnormality observed before you had any hyperandrogenemia was actually hyperinsulinemia, again, giving us proof that insulin is driving the bus. Well, how about other changes? Well, this is a later study of theirs, looking again at insulin, and this is Tanner staging at the bottom, if you would. This is testosterone here, and this is insulin, and you can see that insulin was already elevated in Tanner stage 1 daughters of women with PCOS, but androgens really were not and did not increase until much later in Tanner stages. If you look at the adipose tissue, we looked at adipose tissue earlier, and you looked at insulin resistance, you could see also that insulin resistance in adipose tissue was already elevated in polystegovory syndrome patient in girls who were first-degree relatives of women with PCOS. So again, insulin dysfunction seems to be driving the bus in androgens just from a chronologic age perspective. How about genetics? Well, you know, gene GWAS is something that we've been doing for some time. Lots of investigators have looked at this, and clearly one of the targets identified, one of the 11 loci identified by GWAS has been near or approximate to the insulin receptor gene. Now, a caveat here, of course, we don't really know that it's the insulin receptor gene, but it is a loci close to the insulin receptor gene. So all of this data really does support this model for the pathophysiology of polystegovory syndrome where you have insulin resistance perhaps due to adipose tissue dysfunction, insulin post-receptor abnormalities, and made worse by obesity. This level of insulin resistance results in significant hyperinsulinemia because in general the beta cell function in polystegovory syndrome patients is relatively well preserved until later in life. This level of hyperinsulinemia, this excess insulin drives the androgen bus by suppressing SHBG from the liver, stimulating ovarian theca to overproduce androgens resulting in hyperandrogenism. So yes, insulin is driving the bus. So in conclusion, insulin drives the bus in PCOS because there are measurable hyperinsulinemia present in the majority of PCOS patients. Insulin stimulates androgen secretion by the ovary. The suppression of insulin decreases androgens and improves ovulation. Hyperinsulinemia is associated with phenotypic features of PCOS. Insulin resistance is present at the tissue level. An animal model overexpressing a microRNA that suppresses the principle insulin-mediated glucose transported, GLUT4, leads to PCOS-like features including hyperandrogenemia. Hyperinsulinemia and abnormalities in insulin-mediated glucose transport and beta cell function precede the development of hyperandrogenemia, and GWAS studies have identified PCOS loci near the insulin receptor gene that may indicate a relationship. So insulin does drive the bus. Now there is a caveat. While hyperinsulinemia may drive the bus in most PCOS women, elevated insulin alone may not be sufficient to result in the phenotype of PCOS. We have done studies in diabetics and prediabetics, and again, insulin resistance alone and associated hyperinsulinemia is not enough to produce PCOS. So other permissive factors are likely required, including abnormalities of androgen, stereogenesis, and metabolism. And furthermore, we must remember that PCOS remains a heterogeneous syndrome, possibly encompassing various disorders. But in general, insulin does drive the bus. Thank you very much for your attention. These are some of my colleagues who have been generous in their time in helping support these studies. Thank you. Ricardo, thank you for sticking to the timetable. It's an equally honor to introduce the next speaker to you. That's Andrea Dunaev. She's a former president of the Endocrine Society. She's currently the chief of the Division of Endocrinology, Diabetes, and Bone Disease for Mount Sinai Health System, and she is holding the Lillian and Henry Stratton Chair of Molecular Medicine at the Icahn School of Medicine, Mount Sinai in New York, where she moved about five years ago, and she has a longstanding history. Before that, in Chicago at Northwestern University. Andrea, the floor is yours. Thank you very much, and I thank my learned opponent for his very eloquent presentation. I took this question to mean who is initiating the bus, who's taking it out of the depot, not who's keeping it going once it's out on the streets. So let's see, this slide doesn't want to advance. There we go. We're going to skip that. So here is, in the United States, the most famous bus driver, Ralph Cramden, and I think I will convince you in the next approximately 20 minutes that it is androgens that are driving the bus out of the depot and the essential causal factor in PCOS. So we're going to talk about androgen elevations in PCOS, experimental manipulation of androgens in humans to actually test this hypothesis, animal models, phenotypes in families, developmental origins in humans, and then genetic analyses. And some of the same slides will come up that Ricardo showed, but perhaps with a different interpretation. So while the distinguished Jim Givens, Bergen, and Katapshi were describing hyperinsulinemia, they also had a very large body of work on what are the features of PCOS that characterize it, the hormonal features. And this is the first of many publications showing the most common hormonal abnormalities elevated free testosterone levels, and this has been repeated many times. And then moving ahead several decades, these are studies that actually demonstrate Koch's postulates that something is causal. And the first set of studies are from John Marshall's group, where they were able to show that giving flutamide to women with PCOS restored the normal feedback sensitivity of the hypothalamic pulse generator. So you could correct the disordered LH secretion and have normal feedback to estradiol if you took away androgen action with flutamide. So therefore, testosterone has a direct effect to antagonize estrogen action at the pulse generator. A few years later, Renato Pasquale's group showed that if you antagonize androgen action while you also have weight loss intervention, you will get more loss of fat. So further proof that androgens contribute to the alterations in body composition we see in women with PCOS and particularly increase fat mass. Meanwhile, back at the ranch, and this is literally at the ranch because a lot of these studies were done in animals, there was a seminal insight by Dave Abbott and Dan Domezic, and they looked at macaques who had received androgens, the mothers, during gestation, and they found that the offspring of those dams had all of the features, both metabolic and reproductive, of PCOS. So you actually could create an entire phenocopy of PCOS in our relatives, the non-human primates, just with transient androgen exposure during development. And this has been summarized in a lovely review recently by Lisa Stirner-Victorian and colleagues, and you can do this in multiple animal species, and it's now very well established that you get all of the features of PCOS. So also, in about the same time, this is the late 90s, we were beginning to do much larger genetic analyses in PCOS. The technologies had become available where you could really interrogate the entire genome. As the first thing we decided to do in these studies, we decided to prospectively phenotype relatives of women with PCOS, reproductive-age women, to ask the question, what is the underlying phenotype in these families? And what we found was that about 40% of these reproductive-age sisters had elevated testosterone levels. And in fact, this is completely untransformed data, this is just the distribution of those testosterone levels in these sisters, and you can see that there is a bimodal distribution, that there's one group within the normal range, and a second group who have elevated androgen levels. And what this suggests is a variation of a gene regulating androgen levels that's contributing to this, and that this variant is with higher androgen levels. And then we asked, what about the men? And it turns out that the brothers of women with PCOS also have elevated androgen levels. They have elevated DHEAS levels compared to age and weight match controls. So hyperandrogenemia is an underlying phenotype in PCOS families, which strongly argues that it's an inherited primary abnormality. Now I will give my learned colleague, I will give all of the data, and we did find that in the individuals with higher androgen levels, they also tended to have higher insulin levels. So the metabolic and the reproductive abnormalities, at least in the families, tend to track together. What about this idea of developmental origins of PCOS? Can we find evidence for that in humans for prenatal androgen exposure? Well, first thing is, where is the androgen coming from? And we know that the placenta has tremendous aromatase capacity. So it is unlikely that androgen from mom is crossing the placenta to affect the offspring. What about the offspring, the fetal ovary, making testosterone? And the fetal ovary is, for decades, thought to not do anything. But if you look in fetal ovaries, you can start to see the expression of P450C17, which is the rate-limiting enzyme for androgen biosynthesis, so by early in the second trimester. So the enzymatic machinery is there. And what is there for evidence that androgens are actually increased prenatally? Well, when we and others have looked at cord blood, we didn't find elevated androgens. But that doesn't disprove the hypothesis, because that's reflecting androgen levels late in gestation. But anogenital distance is a sensitive marker of androgen exposure in female offspring. And it's been shown by a number of groups that daughters of women with PCOS at birth have increased anogenital distance. Now, there are contrary studies. But this is pretty suggestive data that there may be androgen excess in utero coming from the fetal ovary. We would say it's due to genetic variation in androgen biosynthesis. Now, here's the same data that Ricardo showed you. This study, interestingly, here we have the testosterone. Here we have two-hour insulin. And both the insulin and the androgens, at least by Tanner 4, were increased. But I agree with Ricardo. It looks like maybe the insulins are increased a little earlier. But these studies were done using not a very sensitive androgen assay. These were not liquid chromatography mass spec assays. So when we repeated this research and used more sensitive androgen assays, we found, indeed, that in Tanner 1 to 3, daughters of women with PCOS, there was evidence for androgen excess, total and bioavailable. So it's a very early defect. Also some evidence for hyperinsulinemia. But then we were able to go back even earlier and look in urinary metabolites of androgen in collaboration with Wiebke-Arlt. And we found that there's evidence for increased 5-alpha reductase activity, which is the enzyme that converts testosterone to dihydrotestosterone, in these infant daughters. So very, very early evidence for androgen excess. Now, it's hard to assess insulin sensitivity, insulin action at this time. So I think I haven't totally answered the question there. Now, on to the genetics. And these are genome-wide association studies, which allow you to interrogate the whole genome and to look for loci that are associated with the PCOS phenotype, as well as with its quantitative traits. And here is where I think my opponent was a little bit selective, because he didn't show you all the data. And in addition to the insulin receptor, which was a signal in Europeans, there is a gene, DEND1A, which we'll talk about in a couple of minutes, which is a strong signal both in Chinese and in Europeans. And as a matter of fact, I'm sorry. Insulin receptor is in Han Chinese, not Europeans. And then, to be fair, this gene, Theta, is a diabetes susceptibility gene, which is present in both populations. The rest of these genes, none of them at this point are known to affect either insulin sensitivity or androgen biosynthesis. And what this sharing means is that the genetic variation was present before the East Asian population diverged from the European population, which is probably about 60,000 to 100,000 years ago. So very evolutionarily conserved. And I don't have a slide of this, but even in primates, we're finding that there is DEND1A that may be important in androgen biosynthesis. So very old pathways. And Jerry Strauss and Jan McAllister did studies with DEND1A. And they have shown that it's a major regulator of androgen biosynthesis and theca cells. Its expression is increased in the theca cells of women with PCOS. And that if you overexpress it in a normal theca cell, you can create a PCOS phenotype. So very definitive in vitro proof that DEND1A plays an important role in androgen biosynthesis in women with PCOS. So this is another genetic approach different from GWAS. This is using whole genome sequencing and looking for rare genetic variants. And we're very interested in rarer genetic variants because they're more likely to have larger effects. And these are studies where we have many families where we're able to look at both parents. And this is a great family because we have affected and unaffected daughters. And we're able to look at the transmission of genes in these families. And what we found is that 50% of the families had rare variants in DEND1A. And so this is an important gene in families with PCOS. And here we're looking at LH to FSH ratio by the individuals who do and don't have variants. This is PCOS phenotype with and without, and then even unaffected sisters. And you can see if you have the DEND1A variants, you have higher LH to FSH ratios, more features of PCOS. So finally, I want to tell you about a very powerful technique. And a lot of data were shown by my honorable opponent that looked at association. And we all know that association does not give us causation. So how can we start to get to causal inferences? And this technique, called Mendelian randomization, you take genetic variants that are highly correlated with your exposure of interest. Could be BMI, could be testosterone levels, that you have to have variants that aren't associated independently with the outcome causing PCOS and are not causing your outcome by affecting another variable. But if you meet those criteria, which you can test, then if your genetic variants associated with what you're interested actually are significantly associated with your outcome, you can draw causal inferences. Because it is the DNA that's not infected by the environment that is associated with your outcome of interest. And why it's called Mendelian randomization is that it's like a randomized clinical trial. So in a randomized clinical trial, you might be giving a drug and looking at LDL, versus in controls and looking at outcomes. And here, you're looking at genotypes that affect your exposure of interest. And let's say genotypes A is associated with lower LDL levels. And in those individuals with those genotypes, they have fewer cardiovascular events compared to people with the genotype that doesn't affect LDL levels. So this is a powerful piece of evidence on disease causality. And using Mendelian randomization, and there are now several studies, it's been possible to show that genetically predicted testosterone is causally associated with PCOS. And interestingly in women, genetically predicted testosterone is also associated with type 2 diabetes. So evidence that testosterone can cause not only a PCOS, but a metabolic disorder. So to summarize, the data to support that androgens are driving the bus from the depot are that they're the most common biochemical feature of PCOS, that we can actually show in interventional studies that they contribute to alterations in GNRH secretion and fat mass, that hyperandrogenemia is a core phenotype in families with PCOS, that there's evidence for increased anogenital distance in daughters of women with PCOS, consistent with the hypothesis that there's prenatal androgen excess. There's evidence from infancy for increases in androgen production in PCOS. A major PCOS susceptibility gene, DEND1A, that's in populations as diverse as Han Chinese and Europeans, plays a key role in androgen biosynthesis. It's upregulated in PCOS theca cells. 50% of families have rare variants. And then finally, genetically determined testosterone is causally associated with PCOS. I rest my case. Thank you. Thank you, Andrea. Well, my fine feathered peacocks friends, it's time to raise your tail feathers. So I would like to invite Ricardo in this theater, and Andrea in that one. You have five minutes, Ricardo, to define your rebuttal. Very good. Start now. I'm going to time it. You're going to time it? OK. Tell me when to go. You're ready to go. So I think it's important to understand that, again, my noble opponent has been selective in some of her data. Let's look at the Mendelian randomization. Mendelian randomization is an interesting tool. It appears that everything is being now Mendelian randomized. But I will tell you that Mendelian randomization may be a little bit premature to use in a disorder like polystic ovary syndrome. We wrote an editorial about this maybe six or eight months ago. This is a heterogeneous disorder. In fact, you have to have a fairly defined endpoint phenotype when you're talking about Mendelian randomization. You have to have a very good idea of what you're looking at from a pathophysiologic point of view. And we don't have either one of those things for Mendelian randomization. So I do think that the use of Mendelian randomization is a bit premature in polystic ovary syndrome, although I'd like to see that. The issue is, does androgens cause PCOS? And we know, for example, that, in fact, androgens alone don't cause you to have polystic ovary syndrome. Now, for example, we have patients, male transgender patients who receive androgens. And they may develop somewhat polycystic ovaries in their appearance. But yet, when you stop androgens, they revert to normal. This is not a permanent change. So I think it's very important that we understand that androgens themselves, by themselves in isolation, don't really end up generating the polystic ovary syndrome phenotype. And to be fair, probably doesn't insulin alone either. You need polystic ovary syndrome. It's a multiple hit disorder. We're just beginning to understand the multiple hits. Clearly, it appears in most patients with PCOS. Again, not all. Most patients with PCOS, whether they're obese or not obese, insulin dynamic abnormalities, including free fatty acid abnormalities, begin to precede hyperandrogenemia. But again, to be fair to my opponent, androgens do play a role. Whether permissive or not is unclear yet. Thank you, Ricardo. So first to deal with some of your evidence, all of the many elegant studies you presented in adipocytes, or really any study in acutely isolated target tissues, insulin-sensitive target tissues, are affected by the in vivo environment. So we know that hyperinsulinemia downregulates insulin receptors, glucose transport. So once somebody has an established insulin resistance, which we both agree that adult women with PCOS have, your studies that you look at what's going on in the target tissues, you can't tell what's acquired and what's intrinsic. In order to ask questions about intrinsic abnormalities, you can perhaps use studies with cell cultures and ask if abnormalities persist. And that's been controversial in PCOS. In fact, we've shown in pre-adipocytes in culture from PCOS that the insulin signaling abnormalities completely resolve, suggesting that they're acquired defects. I think there's general agreement that not all women with PCOS are insulin resistant. And certainly when it's measured by euglycemic clamps, there are even populations where there's no evidence for decreases in insulin action. Now, one can say perhaps insulin acts abnormally even in individuals with normal insulin levels in PCOS. And insulin is pleiotropic and has mitogenic actions as well as glucose metabolism actions. So perhaps that's going on. In terms of giving androgen and not creating PCOS, first, there are certainly situations where you can create a complete PCOS phenotype with androgens. And my first paper with Bill Crowley as a fellow was an androgen-secreting luteoma of the ovary where the woman had disordered LH secretion in high androgens and everything resolved when the androgens were removed. Secondly, I think the current hypothesis is that it's developmental exposure to androgens. And so one, a lot of these are organizational effects and that you need to have them at critical periods of development. So the studies in transgender individuals don't really go to the point. And whether we want to both come up with more global hypotheses than it's androgens or insulin, I think we could. But our charge here was to defend our assigned bus drivers. OK, Ricardo. We have a final five minutes. Final five to shake your tail feather. So I think, really, that part of the issue that we're having is we're talking about PCOS as a single disorder. But having said that, even in PCOS, not all individuals are hyperandrogenemic. In fact, we have defined phenotype D in PCOS, which is by definition not hyperandrogenemic. And that accounts for about 20% of PCOS subjects, whether you actually encounter them in the clinic and you encounter them in the general population. So by definition, androgenemia or androgen excess is not synchronon with polystic ovary syndrome. Two, I think that the many studies that we have of insulin intervention, metformin, triclitazones, et cetera, the thiazolidinediones, a number of other newer drugs, all of those demonstrate that androgens decrease. Now, it is cause and effect, yes. But that doesn't necessarily mean that it's causal. However, if we do the flip side and study the impact of androgens in women, as that early study by Kitabchi and colleagues tried to do, you will find that the impact of androgens in women on metabolic dysfunction is extraordinarily modest. So again, I will stick to my point. Insulin drives the bus. Don't want to get too philosophical about it. Thank you. Andrea. So the early studies by Kitabchi were, again, correlation and not causality. I think studies administering androgens show that you can, in normal people, alter body composition and increase central adiposity. And so you do get some insulin resistance. And again, we think that it's probably the developmental exposure in partnership with the ongoing exposure. The genes that have been discovered so far, so I think your criticism of Mendelian randomization is really not accurate. We do PCOS defined the same way for all GWAS studies. These are the GWAS in which the major hits have been discovered for PCOS. And so whatever this quotes loose definition, it is associated with genetic signals. And one of the strongest genetic signals that we have for PCOS is an androgen gene. And the insulin receptor is only in limited populations. So I think both genetically, physiologically, animal model wise, we have much stronger evidence for androgens driving the bus, my dear. OK. When you have to say my dear, you know you've lost. But that's another story. Could I ask you to sit here next to me, both of you? I'm sorry? Could you sit here? Ricardo and I. So the final verdict is to the audience. Could we have the QR slide back again, please? Is it up there? Yeah, there we go. All right, there it is. So Ricardo, Aziz, insulin is driving the bus. Andrea, the knife. Androgens are driving the bus. So, what's the verdict? We should have a poll result here. It's not working? No, there's no poll. Okay. There's no poll. That's interesting. Well, then let's do it in a different way. Could I see raised hands for Ricardo Aziz, Insulin is driving the bus. It's hard. Yes. Be bashful now. Raised hands for Andrea de Knijff, Androgens are driving the bus. I think the verdict is quite clear. Ricardo, don't you think so? I think so. All right. This was, as far as the debate was concerned, since we have two eminent experts on PCS sitting here behind the table, there's also room for questions from the audience. And what I would like to propose is that you do that one by one, and I have also questions from the people which are in the virtual room. So I want to start with the first question from the virtual platform, that is, I feel in my heart that PCS is actually multiple diseases that we lump into some thin, predominantly hyperandrogenic women and some obese, predominantly hyperandrogenic women. In my heart, I feel that some of them may have a form of non-classical congenital adrenal hyperplasia that we have not yet discovered. How do you feel about this, Ricardo? So I think that's a good question. However, I think that if one follows the current diagnostic guidelines and considers that polystic ovary syndrome is a diagnosis of exclusion and proceeds to exclude, among other things, non-classical adrenal hyperplasia, I think that we could be very comfortable that we're dealing with polystic ovary syndrome. Again, the most common type of non-classical adrenal hyperplasia is 21-hydroxylase-deficient non-classical adrenal hyperplasia. There are very clear ways of screening for this, just a baseline 17HP. In the past, we've studied 3-beta-HSD and 11-hydroxylase-deficient non-classical adrenal hyperplasia. Those are extraordinarily rare, rare enough to become extraordinarily uncommon. So I think today, in today's evaluation, if you follow the guidelines, you will not confuse non-classical adrenal hyperplasia with PCOS. Andrea? So our construct of PCOS is totally based on expert opinion and not data. And what we're seeing as we move into having access to huge data sets from electronic health records, from multiple genotyping, and this is very similar to what our colleagues in cancer have been doing for about 10 years, is the ability to look at disease aggregation based on features in an agnostic way and ask the question, through machine learning, what of the features aggregate together? And these are clustering methods. And when you do this with the features of what we now call PCOS, you indeed do get multiple disorders. You get a disorder that is characterized by high LH, lower body mass index, higher SHBG, which is a more reproductive subtype. You get a metabolic subtype. And proof of principle is that these subtypes are associated with distinct genetic loci. We have posters on that at this meeting. Kelly Brewer, if you want to see some of our subtyping. This is true in PCOS of diverse ancestries, so East Asian PCOS, PCOS from all over Europe. And then there's sort of a background group that has some of the features of the reproductive genetic susceptibility, such as FSH beta, that have already been identified. So I think our future is going to be going to data-driven approaches rather than smoke-filled rooms where people just pontificate. All right. Please state your name and where you're from. David Ehrman, Chicago. I was hoping the gloves would come off. Maybe they will soon for this debate. But I wanted to comment. I think part of the issue is that the clinical evaluation of women with PCOS is fraught with difficulties both in defining the clinical features and hormonal abnormalities. And probably the most well-defined feature is the androgen elevation. Insulin levels are very fraught with problem. They're influenced by body weight, body fat distribution. And so it's very difficult to define the phenotype by insulin levels, even in response to stimulation. It seems to me that the approach looking at subphenotypes and looking at the genetics that underlie the subphenotypes might be a better approach. So when Andrea says agnostic, in other words, looking at the genotype and then correlating it blindly with the phenotype rather than looking at the phenotype and trying to determine whether it's genetic or not. If I'm making myself clear, I hope so. And Andrea, maybe you want to expound a little bit on the approach with the cluster analysis. Yeah. I think, you know, number one, that's a very important point that you about the difficulty in a clinical situation characterizing insulin resistance. I think the American Diabetes Association recommends against doing insulin assays for clinical utility. They've never been able to standardize them. There's wildly different results. So measuring an insulin level really isn't informative. Fasting insulin levels reflect insulin clearance in addition to secretion. So I think that's an important message for people. In a research setting, I think you can use consistently well-measured insulin levels as one of your traits and then do these analyses. Now we have big enough sample sizes. So there's been a large meta-analysis looking at the different PCOS diagnostic criteria, asking the question, do the NIH criteria differ genetically from the non-NIH Rotterdam criteria versus self-reported PCOS? And the answer is no. All of these different, what we call the PCOS phenotypes currently, they're genetically identical. The clustering algorithms have shown, and this is used now, those of you who are following the diabetes literature, there have been subtypes identified of type 2 diabetes with distinct genetic architectures. So this is what's happening now with PCOS. And the data, I think, are very, very compelling, because you can show that this is in any population of women. It's not just a European phenomenon. Next question over there. Hold on for just a second. So I do think we need to understand a couple of things, and I think that Andrea's comments are well-placed, except to say the following. We're getting very confused between definitions and phenotype. The studies, for example, looking at whether definitions had similar genetic profiles do not take into account that the vast majority of patients, really, in those studies are phenotype what we call A and B, right, classic NIH, the vast majority of them. So we have to be very careful as we talk about patients clinically, right? What are we talking about? Are we talking about the hyperandrogenemic phenotype, right, or are we talking about the non-hyperandrogenemic phenotype? So I still suggest that we be very careful about how we look at PCOS patients. We don't look at them in a uniform way, because if we do that, we're going to have difficulty. The second thing is, of course, the diabetes literature is beginning now to look at subpopulations of patients based on genetics, but they've identified more than 300 different loci. And PCOS efforts right now, it's only somewhere between 11 and 19. So we still are far away from being able to actually do that. It's a work in progress, and I have to agree with Andrea that it'll eventually, hopefully, will be there. Okay, next question over there. Troy Zahidi, New York. I listened attentively, and I'm still not convinced that there is not a third driver carrying both of them. For example, AMH is elevated in these patients, and why not? I mean, you both correctly mentioned that association is not causation. Also improvement with intervention is not causation. And there are so many genes close to each other that interact and have to do something with something that if you want to look, you will always find something that is close to something else. So I'm still not convinced. And then the other question is, I didn't understand the concept of genetic randomization. If you put everybody who has some kind of a phenotype in one group and everybody else in the other group, it's not really randomized. So the randomization is talking about at birth, your alleles assort. So you randomly get either alleles from mom or alleles from dad, and that's at the time of conception. And so what you're looking at is genotypes from conception that aren't affected by the environment, and if you have a genotype that's associated with your outcome of interest, you can use the genotype as a proxy. So the idea of calling it randomization is just the randomization of maternal and paternal alleles. I have another question from the audience. If insulin is driving the bus, why doesn't everyone get type 2 diabetes? Question for Ricardo. That's a very good question. And we have been studying diabetic patients, diabetic patients with PCOS and PCOS patients who are not diabetic to understand that question. It's very clear that PCOS patients, again, there's a heterogeneity in the response, but the large proportion develop significant hyperinsulinemia to levels that are greater than that of diabetes, even though their levels of insulin resistance as measured, say, by the FSIGTT or even the clamp are similar or higher than diabetics. And that's because, in fact, at the end of the day, to actually cause a patient to be PCOS, it's not a single hit. And I think if we want to, and again, we have a debate today about insulin versus androgens, but that is a simplistic argument, as you've already heard. There are multiple hits, and it's not enough to be insulin resistant to actually develop PCOS. You actually need to have other hits that are either permissive or determinative, depending on what they are. Another question from the audience for Andrei, I guess both of you. Given that a new sufficiently large population studies of PCOS that have been done have now clearly indicated that PCOS is a complex genetic trait, how can one hope to single out any predominant bus driver, since the current data indicate genes like DENDI1A, THADA, have much stronger genetic association than either insulin or androgens, yet aren't even mentioned? Isn't the question like trying to single out a single gene in type 2 diabetes whose complex genetic status is now established? Andrei, could you comment on that? So, you can resolve some of the heterogeneity of complex traits by subtyping. And so there are several different ways people do it. There's soft clustering, which has been done by Miriam Udler and Jose Flores and Emma Alkvist also doing subtyping diabetes. And yes, there are many, many susceptibility alleles, but what you find is different families of susceptibility variants are associated with the different subtypes. And I think we had a heuristic concept here to argue insulin or androgens, but I clearly agree, and as does Ricardo, that this is a heterogeneous trait with many, many susceptibility contributors. But even within that, you can resolve PCOS and type 2 diabetes into more homogeneous, not completely homogeneous, subtypes. And what those subtyping does is it increases your power of your genetic analyses because you're reducing the background noise. You're dealing with a pure entity. And Andrea is absolutely correct. I mean, the more careful you phenotype, and again, I'm going to speak on the clinical side of phenotyping patients, the cleaner your data. For example, much of our data using adipose tissue, for example, and despite the fact that, you know, we use actually pre-adipocytes, so we do see the defects in pre-adipocytes, but you have to have very clean phenotypes at the beginning. If you just take, say, Rotterdam as a whole and you say, I'm just going to include Rotterdam, you have absolutely no idea what you're including in your studies. So again, you know, genetic phenotyping and subgrouping, phenotypic subgrouping, et cetera, will allow you to become and get better answers. Okay, Gordon Cutler. My question is, why can't the answer be that there be both, and that there are two ways to get into what is a common phenotype at the end? And the clinical experience that caused me to think this is, first, as a fellow taking care of the extreme insulin-resistant patients of Jeff Flier, Ron Kahn, and Jesse Roth, and all of those women had very high insulins. They all had high ovarian androgen. They all had what I would call a PCOS or even more extreme hyperthecosis-type phenotype. But the other side is I worked on a unit where there were lots of adrenal patients, and I saw patients with non-classic CAH, which, like the DEND is another gene that's very clearly associated with elevated androgens from the fetal on. And some of these patients, as they went through puberty and adolescence, they looked absolutely like classic PCOS in every way until you measured their basal or stimulated 17-hydroxyprogesterone. So I thought, it seemed to me like you can get here either way, and there's nothing wrong with that, so why not accept that as a dual pathway that can get you to the same phenotype? So I think I would totally agree. We find in our genetic analyses with identifying subtypes, a metabolic and a reproductive subtype, in fact, and if you look through puberty, so we're now doing prospective studies in early postmenarchal girls, it's clear that there's one subset that appears to be LH-driven and another subset that appears to be insulin-driven. So I think that's, you know, absolutely an evolved way to look at it, and we were asked to sort of do an artificial construct and wanted to be good debaters and stick to our orders. Thank you, Gordon. You know, that is probably their realistic supposition. I do think we have to be careful, though, because when you look at metabolic dysfunction, it correlates very tightly with androgen excess. Now again, these are correlations, causality, et cetera, but the phenotypes are very intertwined. I think we have to be a little bit careful, and you're absolutely correct. I mean, we have the non-classic model, which we've used for many of our studies as a model of primary hyperandrogenism external to the ovary, right? And we've used, actually, the insulin-resistant model as well. So you're absolutely correct, but I think that we don't want to fall into the trap of lumping all PCOS together into either an insulin, an androgen, or a combined bus, because in fact, we're not there yet. Bill Crowley from Boston. This is an interesting debate, although somewhat of a theoretical construct here of diverting into two things, but I have to give you the experience now of 40 years having tried to phenotype these patients, doing a fairly heavy job of phenotyping, and being completely frustrated that we could never publish anything that was uniform. At the time, I didn't understand why, because it was working so well in other diseases. The other diseases we were looking at were purely monogenic diseases. And you can define a phenotype, you can give its variants, you can discuss how penetrant the variant is, and that's how we as endocrinologists think. It's got to be this, or it's got to be that. It's got to be insulin, or it's got to be... And in fact, Andre was the first person to see that the type 2 diabetes, that the complex trait genetics would apply here. And I have to say, I doubted it initially, but the more I looked at this and became acquainted with it, I realized that she had something here where we were arguing about how precise the phenotype should be. And I was in the school that you just outlined, and Andrea said, no, there's a much bigger picture to look at this, and she was absolutely right. And the model here, of course, is type 2 diabetes. No one would be sitting here arguing, gee, is it the GLUT2 receptor, or is it the TSCF7-alpha? By the way, it took 12,000 people in Iceland to see the TSCF7-alpha. It took it 18,000 people for the Broad to see it, and you only had two genes, and you've only got 10,000 cases. So now type 2 diabetes is up to 185 genes, and that's because they've studied hundreds of thousands. So we're the blind men and the elephant here, and we have no idea the size of the elephant because we keep looking for single factors. We keep looking in small populations, and they're not translatable. And the field and money is being wasted doing this when this is a complex genetic trait. There's going to be dozens of genes here. There will be many pathways to it. And which ones to intercept will be important because these associations that we do in small groups probably reflect other things. But the idea of Mendelianizing the DENT1 gene, it was the first step of Andrea's subtyping, and I think that's what happens in these complex trait genetics. Rather than start with a phenotype and look for the genotype, you take the genotype and look for the phenotype, but you've got to know the genotypes. And you can't get there any other way but through large GWAS, Mendelian associations, and large populations. And it will be funny to look back upon this discussion in five or 10 years as to how dated we were when, in fact, the diabetes people are showing us clearly where we have to go with this disorder. And it's large populations, large collaborations, and we have to stop wasting our time on small aspects of this because we're wasting money and time. Type 2 diabetes and type 1 diabetes, where the genetic structure's all known now, are the way to lead this. And I think anything else is just folly. Thank you for that comment, and I think both debaters will agree with you on that. Next question, please. Hi, so just a question about Mendelian randomization. Is there a statistical control in place for the fact that humans do not mate randomly? That's a very good point. No. And, you know, that comes up every so often in commentary. And there is actually specific terminology for it, which I'm forgetting. I mean, it's not completely assortive. And so... Thank you. There's a specific question for Dr. Aziz here. Could you comment on the PCOS in type 1 diabetes patients' role of insulin? Yeah, it's an interesting model. There's a number of reports indicating that PCOS, the prevalence of PCOS is higher in type 1 diabetes patients than, say, the general population. And whether that is because the treatment involves levels of insulin that are not as well regulated, say, in a non-diabetic patient, or whether there's actually a primary issue in type 1 diabetes is unknown. I tend to favor the therapy impact type of thought. But I don't have a lot to say except to say that that is a bit odd from just a purely metabolic point. Okay. And a question for Andrea. Any evidence of androgen receptor blockade improving PCOS symptoms beyond excess hair growth? So there are studies that have shown that combined with weight loss, antagonizing androgen receptor with flutamide does facilitate greater loss of visceral adiposity, so suggesting that androgens contribute. Then there's very fascinating data from Lourdes Abenas in Barcelona that a combination of spironolactone, metformin and pyoglitazone can prevent or can reverse PCOS in early postmenarchal girls. And sort of that's our holy grail is if we could come up with a time where we could actually intervene and prevent or revert the syndrome. And her data are exciting. I don't know if anybody is planning to replicate that. So there are intriguing data out there. Yeah. Then we have a question here. Do symptoms of PCOS improve post-uni or bilateral ophorectomy? For example, in patients who have had kids and don't desire pregnancy anymore. I think you would not promote us. Yeah. We would not promote ophorectomy. We would not. But we've actually studied a number of women who have had polycystic ovary syndrome and have undergone a hysterectomy or bilateral ophorectomy, particularly to study the impact of the ovary on the adrenal. And I could say certainly their symptoms improved dramatically, right? Their androgens sources are removed. That's a big chunk of where they're distressed. We have not really been able to follow them up at this point in regard to their metabolic dysfunction and whether that's improved significantly. But certainly their androgenic symptoms do improve. Andrea? Well, I think all of these studies we have to remember, and Professor Lavin has reported this. So PCOS reproductive phenotype improves with age, with ovarian aging. And so it's hard to look at these studies, which tend to be older studies in that nobody is doing this anymore, to know if there was really improvement due to the intervention or if it's just the natural evolution of the reproductive features of the disease. Yeah. And just to add to that is most of these interferences, what is now very popular and popping up again is laparoscopic ovarian drilling in which you just destroy quite a reasonable amount of ovarian tissue in these women. You reduce their ovarian reserve. Their FSH go up. Their AMH levels go down. And it's questionable whether that's a thing which you should promote in these women. And actually, indeed, they regain normal menstrual cycles most of the time somewhere between 35 years and 45 years of age. And they're also quite fertile between 40 and 45 years of age. So we should keep that in mind before we are going to embark on these very invasive-like procedures. Another question, what about emotional associations in PCOS? Anyone who emotional associations in PCOS? Well, I think there is a fair amount of data. And we have a poster. We had an oral at the Androgen Excess Society on Friday and a poster looking at the economic impact of emotional mental health disorders in PCOS. And it's very clear that PCOS women tend to suffer greater incidents of anxiety, depression, eating disorders, and postpartum depression. Anuja Dokras has done a lot of these studies as well as others. So I think there is very little doubt that patients with PCOS have decreased quality of life and increased risk of mental health disorders. Exactly the pathophysiology behind the increased risk of mental health disorders I think is a little bit difficult to figure out whether it's a perception, whether it's a stigma, whether there is a biological cause. But no doubt, they're definitely at greater risk. So genetically, there's tremendous genetic correlation between psychiatric disorders and a PCOS. So that means that some of the same genes are causally implicated in both disorders. There's some Mendelian randomization studies, though not all, that suggests that PCOS is causally associated with depression. And then some of the animal models with prenatal androgen administration can show in the offspring that there's the mouse equivalent of anxiety. I don't know if they eat a lot of cheese or something. Do you recommend to monitor androgen levels after starting OCPs for anti-androgen therapy? Andrea? No. I think once you've established a diagnosis, you monitor clinically. And is the patient feeling her, if you're treating for hirsutism or whatever, getting better? Okay. So you just manage the clinical symptoms? Yep. Ricardo, do you do it differently? I agree. No, I totally agree. I mean, you manage the clinical symptoms. You're wanting to see these patients get better. And monitoring androgens is of no value unless you are concerned about a, you know, androgen-decreasing tumor that you mistakenly confused with PCOS. But that's the rare entity. So I would do that only if the patient is getting worse in despite your therapy. What about the different clinical phenotypes that have mainly clinical androgen excess on the one hand, and others have mainly oligomenorrhea and PCOM on the other hand? Could you comment on that? Whether there are any difference between these? Well, I mean, you know, so from a clinical point of view, we still are using the four phenotype approach, AB, which is really classic PCOS. Then the ovulatory PCOS, which is what we call phenotype C. And then the non-hyperandrogenic PCOS, which is phenotype D. And if you're going to use that kind of thing, you obviously will have these different kind of phenotypes that have different androgen levels. It's very clear that phenotype D has a significantly less risk of metabolic dysfunction. Now, whether it's zero or the same as the renal population, the populations are not big enough to study. But again, phenotype D, non-hyperandrogenic PCOS, much less metabolic risk. Phenotype A and B, much greater metabolic risk. Andrea, would you say something about that? So I think the phenotypic features such as hirsutism, that's an independent genetic trait having to do with your number of hair follicles and 5-alpha reductase capacity of the hair follicles and androgen receptor sensitivity. So almost, I think, Ricardo, in your troglitazone study, 40% of the women who had circulating androgen levels and oligomenorrhea didn't have hirsutism. So I think people need to remember that. And that's why kind of tailoring your therapy clinically. I think for endocrinologists, and why I argue against this focus on polycystic ovarian morphology, for endocrinologists we're worried about metabolic risk, symptoms of androgen excess, and so, you know, the anovulatory group are at higher metabolic risk. They have androgen excess symptoms, we treat them. The ones with, you know, the phenotype C has regular menstrual cycles, but if they have androgen excess that's symptomatic with hirsutism, then we treat them like hirsutism patients. And trying to use the ovarian morphology to further stratify, I think, is just daunting for internists and endocrinologists and leads to poorer outcomes because patients aren't seeing doctors who feel comfortable taking care of them. I can't agree more. I mean, I think it's a, using polycystic ovaries is helpful in the world of infertility and IVF. It's much less helpful outside of that, so. Another question from the audience, virtual audience in this. Is there any data regarding OCPs reducing insulin resistance? Well, actually, there's data indicating that OCPs actually worsen insulin resistance. Modestly, let's be very clear, not dramatically, but measurably. So we don't really use OCPs to improve insulin resistance, although we should feel comfortable treating insulin-resistant patients with OCPs because the impact is relatively modest and the impact on other things, androgens and other benefits of OCPs is significant. But no, it won't improve the insulin resistance. There is a recent, relatively recent study showing that women on OCPs had reduced risk of type 2 diabetes. Now, I don't remember the details of that study if it's, you know, a selection bias that only the women who were considered at low risk for diabetes were put on the oral contraceptives in the first place, but. There's a lot of epidemiologic data, both in PCOS and otherwise, that the health benefits of being on birth control pills significantly outweigh any kind of risk. I'm always impressed with endocrinologists, particularly pediatric endocrinologists, who sort of refuse to put their patients on oral contraceptives because God only knows what will happen with the patients long-term. Actually, the patients will be better. They will have less androgenic symptoms over time. They will have less risk of, you know, colon cancer, ovarian cancer, often diabetes, et cetera. So we certainly advise patients that that should be considered as a first-line therapy for individuals who are not trying to get pregnant and who have androgenic symptoms as a complaint. They don't all tolerate it, about 80% to 90% do, but nevertheless, it should be a first-line therapy, and I say that to endocrinologists who sometimes are reluctant. A question which has been posed by a lot of people in the virtual room is, would first-line therapy now be a GLP agonist rather than metformin? And please comment on that in lean PCOS women and obese PCOS women. So the studies, I think we have to be very clear that most of the studies that have looked at, for example, or not most, but many of the studies have looked at molecular abnormalities, for example, of insulin action in tissues, adipose tissue, for example, have actually used lean women, and I think there is very good data, even from clamp studies, and I think, Andrea, you have some of those early studies, you know, demonstrate that actually lean women with PCOS also are metabolically abnormal compared to match, to BMI match control. So BMI, lean and obesity certainly doesn't save you from being metabolically affected. It certainly, the degree is much greater in obese individuals, and obesity adds a whole layer of metabolic dysfunction to PCOS. Now, as first-line therapy, you know, obviously metformin is a very modest drug. It's not vitamin M. Many endocrinologists seem to give every single PCOS patient that walks in through the door without any assessment of metabolic function, et cetera, metformin, which I think is wrong because, A, it's a lifelong drug whose only outcome will be nothing happens, right? I mean, the only thing you're going to be giving these women is metformin in the hopes of nothing happened, and so to do that, you actually have some better data. Now, would I use GLP-1 as first line? No, I would not. I mean, I'm using GLP-1 as second or third line, but certainly not GLP-1 as first line. I don't know if Andrea, you're using it as first line or? So I think we have to define what we're using it for, and as far as I know, it hasn't been demonstrated to have direct reproductive benefits, that its benefit is that they're very potent for weight reduction. There are very few studies with the weight-reducing doses, so most studies are with loraglutide at 1.2 milligrams, not the 2.4. So there certainly need to be more studies, but I think what we need to do for weight management in our obese PCOS women is that they should be taking advantage of these newer therapeutic agents, and the idea that you should give somebody metformin to lose weight is not serving the patients well, except in adolescence. Unfortunately, the companies that make GLP-1 receptor agonists are absolutely refusing to support PCOS trials, and I've had numerous, numerous discussions, but I think that clinical take-home message is if they meet criteria for obesity to be on these agents, these agents are very effective for weight loss. I have to agree with that, and unfortunately, there is a bias in the pharmaceutical world against research with PCOS patients, and this primarily basically has to do with many PCOS patients are obviously of reproductive age. How do you study a drug and ensure that whatever teratogenic and litiginous effects are controlled? So that is a real issue of always studying reproductive- aged women who are not on a contraceptive, because, of course, in this case, it would offset it. But there are ways of getting around it, and I share Andrea's frustration with the industry. Dr. Edelman. Yeah? There we go. Just a comment. I don't want to go into paroxysmal anecdotal tachycardia, but we've used the GLP-1 receptor agonists, mainly semaglutide, in these women with PCOS who either are pre-diabetic or obese or both, and also with non-alcoholic fatty liver disease, and there's a great potential there. And like you, maybe, Andrea, we proposed a study that they didn't see fit because they thought we wanted to treat PCOS per se, the reproductive aspect of PCOS. But we're looking at the other phenotypic components, including liver disease, which is really rampant. Actually, it's really common in PCOS, twice as common as you would expect for women of same age and weight. So I think long-term, we're going to have to see into this and try to convince the pharmaceutical companies that this is a population that would benefit from those pharmaceutical agents. Anybody wants to comment on that? Then the last question over there. Please, go ahead. Thanks for the great debate. I had a question about, I think, something that Dr. Aziz asked earlier or mentioned earlier about the life course of PCOS. What are your opinions about the interactions between the reproductive and metabolic axes in PCOS with age, especially with kind of like the diverging phenotypes of improving reproductive phenotypes and then the worsening cardiometabolic phenotypes? Well, I think it's important, and it's a very good question. Let's talk a little bit about, just for a second, and Andrea has done this very interesting study separating reproductive and metabolic phenotype. Unfortunately, in the clinic, and again, we have to be able to distinguish cluster analysis type and analysis from what's in the clinic. In the clinic, most patients who come in for infertility are also metabolically challenged, right? And so, I think we have to be clear about that. There is evidence, as you know, from metformin and various other drugs that there appears to be an improvement in the IVF in vitro fertilization outcomes using insulin sensitizers, for example. Not dramatic, but measurable differences in that regard. So, I think that really it is this picture where you have metabolic dysfunction, hyperinsulinemia, drives androgen excess in the ovaries, does impact on ovulatory function, does impact, and subsequently, obviously, on fertility from that point of view. So, there is a metabolic impact on the reproductive access, which we need to take into consideration as these women become pregnant. Also, in their pregnancy risk is going to be higher as well for gestational diabetes and a number of other complications. That's been fairly well demonstrated in larger populations as well. So, it's a little hard to tease out both the reproductive and the metabolic axes, if you would, when you're dealing with patients at clinic, particularly in the infertility clinic. So, I answered your question, but maybe not. Our distinguished chair is really the leader in this field, but a lot of the genetic variants that are coming up in PCOS have to do with ovarian aging and DNA repair, and women with PCOS appear to go through menopause later. They have, you know, they do start to have normal ovulatory cycles and their fertility in the later 30s, and so the idea that it may be some sort of these gene variants may be something that preserves reproductive lifespan, I think, is very intriguing. Okay. Due to time limits, we have to close this session. Unfortunately, we could not answer all the questions from the virtual space. We will do our best to do that afterwards and see whether we can provide some answers. I would like to thank you as an audience, and a special thanks to these two eminent, finely feathered PCOS experts who did the debate. Thank you very much. Thank you all. Thank you very much. Thank you.

polycystic ovary syndrome

PCOS

diagnostic criteria

phenotypes

insulin

androgens

genetic studies

metabolic health

oral contraceptives

GLP-1 receptor agonists

ovarian surgery

reproductive health