女性激素健康、多囊卵巢综合征、子宫内膜异位症、生育能力与乳腺癌 | Thaïs Aliabadi博士

这在科学领域确实如此，在医学领域也尤为明显。

And this is true in science, and very clearly true in medicine as well.

事物的命名可能非常有用，但也可能严重限制理解。

What things are named can be very useful, but it can also really limit understanding.

令人困惑。

Confusing.

是啊。

Yeah.

如果今天的讨论能带来什么改变，希望我们甚至能在PCOS中的'C'旁边加个星号或直接去掉它。

If anything, today's discussion, hopefully, we'll maybe even remove or put an asterisk next to the c in PCOS.

你知道他们想改名，但我个人反对，因为二十五年来我一直在说PCOS、PCOS、PCOS。

You know they want to change the name, but I personally am against it because I've spent twenty five years saying PCOS, PCOS, PCOS, PCOS.

我感觉就在最近几年，越来越多人开始关注——就像过去没人谈论更年期，现在人人都在讨论更年期。

And I feel like just in the past few years, more and more people you know, like people didn't talk about menopause, now everyone's talking about menopause.

希望PCOS能成为下一个热点话题。

I feel like PCOS is the next topic, hopefully.

如果你们去改名字，那我就得从头再来一遍了。

And if you go and change the name, then I feel like I have to start all over again.

不。

No.

但你说得很有道理。

But you make a very good point.

我们也不希望发生这种情况。

We don't want that to have to happen.

我同意。

And I agree.

但他们正在尝试这么做。

But they're trying to do it.

公共卫生领域有个奇怪现象，需要长期积累巨大的压力才能推动改变。

There's strange thing in public health where there needs to be a ton of hydraulic pressure over time.

看来今天是我可以稍微政治不正确的一天。

Like, I guess today's my day to be only slightly politically incorrect.

五年前，如果你提到'肥胖'这个词，或者说'这个人有健康问题是因为他们肥胖'。

Five years ago, if you said the word obese or you said, this person has health issues because they're obese.

当时说这种话的人甚至会因此丢掉工作。

It was considered I mean, people were losing jobs for making statements like that.

现在我们明白了肥胖确实对大脑和身体健康构成严重威胁。

Now we understand obesity Is it a serious risk to brain and body health.

是的。

Yes.

这是一种疾病。

Medical condition.

我认为GLP类药物某种程度上帮助改变了现在的观点，因为有了医疗手段。但肥胖对人有危害这个事实始终成立。

I think the GLPs have kind of helped shift the view now because there's a medical treatment, but it was always true that obesity was dangerous for people.

但现在你可以公开这么说了。

But now you can say it.

所以我认为这方面确实需要持续施加巨大的社会压力。

So I do think that there needs to be a lot of hydraulic pressure behind that.

现在你们对多囊卵巢综合症也采取了同样的态度。

And now you're doing the same for PCOS.

我有几个关于头发稀疏、痤疮等问题。

So I have a couple of questions about the thinning of hair, acne, and so forth.

我能想象很多女性听众会想：我确实有点痤疮问题。

I could imagine that a number of women listening to this are thinking, well, I've got a little bit of acne.

我的头发比五年前稀疏了。

My hair is thinner than it was five years ago.

但这是轻度多囊卵巢综合症吗？

But is this mild PCOS?

这些症状能说明患有多囊卵巢综合症吗？

Is this indicative of PCOS?

我的意思是，每个人都应该最了解自己的身体状况。

I mean, everyone knows that Hopefully knows their body best.

但痤疮或头发稀疏要到什么程度才算严重呢？

But how bad does the acne or the hair thinning have to be?

有多快？

How rapid?

在你可能会说，你知道，可能只是头发看起来变薄了。

Before you might say, you know, it's maybe just the hairs seem to be thinner.

痘痘稍微多了一点。

There's a little bit more acne.

是背部的痘痘，而且整个周期都有吗？

It's back acne, but and is it throughout the cycle?

是的。

Yes.

整个周期都有。

It's throughout the cycle.

这些通常是来诊所寻求帮助的患者。

And these are patients who usually come to the office asking for help.

他们会说，我的痘痘一直消不掉。

They say, I can't get rid of my acne.

我常说，如果你超过25岁还在为痘痘困扰，来我诊所点名要螺内酯和异维A酸，那肯定有问题，对吧？

I always say, if you're older than 25 and you're struggling with acne and you come to my office and you're asking for spironolactone and Accutane, something's not right, right?

如果你有脱发问题，比如梳头时掉一大把头发。

If you have hair thinning, like you brush your hair and you lose tons of hair.

我是说，这类患者你一看他们的头皮就知道在脱发。

I mean, these are patients you could look at their scalp and you know they're losing hair.

我说的不是产后脱发那种情况。

I'm not talking about the hair loss that you get postpartum.

你知道那种是暂时性的，大概9到12个月就能恢复？

Do you know what that's transitional and it recovers in like nine to twelve months?

这些是持续存在的症状。

These are symptoms that persist.

随着这些患者年龄增长，症状会变得越来越明显。

And as these patients get older, it becomes more and more and more significant.

但我之所以说这么多，是因为我总会综合考虑其他因素。

But the reason I gave that big picture is I always look at other factors.

他们减肥有困难吗？

Are they having a hard time losing weight?

他们有情绪障碍吗？

Do they have mood disorder?

他们是否有饮食失调的历史？

Do they have any history of eating disorder?

他们服用过异维A酸吗？

Have they been on Accutane?

他们是否每年要去激光脱毛两次，因为无法摆脱体毛？

Do they go and laser their hair like twice a year because they can't get rid of it?

这是一种你会识别的模式。

It's a pattern that you will know.

这不是一点点症状。

It's not a little bit of this.

这些患者。

Are patients.

正在听我讲话的患者们会说：是的，我就是这样。

Patients who are listening right now to me, they're going to say, Yes, I have this.

我符合所有症状，每一项都能打上勾。

I have every symptom, and I put a check-in front of it.

多囊卵巢综合征的问题在于它有四种不同的表型。

The problem with PCOS is there are four different phenotypes of PCOS.

这就是为什么医生诊断多囊卵巢综合征时如此困惑。

That's why it's so confusing for doctors to diagnose PCOS.

最常见的经典表型患者同时具备以下三个特征。

The most common classic phenotype is a patient that has all three.

超声显示多囊卵巢样改变、有高雄激素症状或血液检测显示睾酮/雄激素水平升高，以及月经不规律。

PCOS looking ovaries on ultrasound, elevated testosterone symptoms or high testosterone or androgens in the blood, and irregular period.

第二类B型患者有高雄激素症状。

The second type B patients have the high androgen symptoms.

她们确实存在排卵功能障碍伴月经不规律，但超声检查显示这些患者的卵巢是正常的。

They do have dysfunctional ovulation with irregular periods, but these patients have normal ovaries on ultrasound.

所以在这类患者中，你不能仅凭超声检查说你的卵巢看起来不像多囊卵巢，就断定没有患病。

So you can't, in this group of patients, you can't do an ultrasound and say your ovaries are not PCOS looking, you don't have it.

第三种表现型是排卵型多囊卵巢综合征。

Then the third phenotype is the ovulatory PCOS.

这让人非常困惑。

It gets very confusing.

这类多囊卵巢患者实际上至少有时会排卵，因为你知道，70%到80%的多囊卵巢患者是不排卵的。

This group of PCOS patients actually ovulate at least sometimes because, you know, seventy to eighty percent of PCOS patients don't ovulate.

70%？

Seventy?

80%的患者不排卵，即使她们的月经周期规律。

To eighty percent do not ovulate, even when they have regular cycles.

所以在20%到30%能排卵的患者中——怀孕需要排卵——这类C型患者有时会排卵且周期规律。

So of the twenty, thirty percent who ovulate, you need to ovulate to get pregnant, this C phenotype, these patients are ovulating sometimes with regular cycles.

这些多囊卵巢患者去看医生时，超声显示卵巢呈多囊样，有痤疮、脱发、面部毛发、体毛增多、情绪问题等症状，但月经周期却是规律的。

So these are PCOS patients who go to the doctor, they have PCOS looking ovaries on ultrasound, they have acne, hair loss, facial hair, body hair, mood, all of that, but their periods are regular.

即便是这些患者，很多时候也没有排卵。

Even these patients, a lot of times are not ovulating.

你所看到的规律周期其实是雌激素撤退导致的。

That regular cycle that you're seeing is estrogen withdrawal.

这并非源于排卵后的孕激素作用。

It's not from the progesterone of ovulation.

如果你想了解的话，我们会深入探讨所有这些内容。

And we're going get into all that if you want to.

第四类患者基本上没有任何睾酮或雄激素升高的症状。

And the fourth category, these are patients who basically don't have any elevated testosterone or androgen symptoms.

他们没有痤疮、体毛增多或面部/身体毛发脱落的问题。

They don't have acne, hair, lost facial hair, body hair.

她们只是排卵不规律，且超声显示卵巢呈多囊样改变。

They just don't ovulate regularly and they have PCOS looking ovaries on ultrasound.

想象一下这四种表型，对吧？

So imagine these four phenotypes, right?

再想象一下所有的胰岛素抵抗和其他这些潜在病症。

And imagine all the insulin resistance and all these other underlying conditions.

这使得这些患者的整体情况、形象变得如此不同。

It makes the big picture, the image of these patients so different.

他们来就诊时的表现各不相同。

They all present differently to the office.

这就是为什么医生们会感到困惑。

That's why doctors scratch their heads.

这就是为什么医生不愿意诊断多囊卵巢综合征，因为他们真的不理解所有这些表型。

That's why doctors don't want to diagnose PCOS because they really don't understand all these phenotypes.

他们不明白你可以完全瘦弱却患有多囊卵巢综合征，并非所有多囊患者都必须有体重问题，你不一定会有痤疮、脱发、面部或体毛问题，在某些表型中甚至不需要有多囊样卵巢。

They don't understand that you can be completely thin and have PCOS, that not all PCOS patients need to have weight issues, that you don't have to have acne, hair loss, facial hair, body hair, that in some phenotypes, don't need to have a PCOS looking ovaries.

有些患者月经周期是规律的。

There's some that have regular cycles.

所以，这就是为什么它会变得如此令人困惑。

So, that's why it gets so confusing.

确实令人困惑。

It is confusing.

不过，我认为当人们听说存在不同的指标时——显然如此——听起来像您这样经验丰富的从业者能够看出哪些指标相互关联的整体轮廓。

And yet, I think when one hears that there are different indicators, obviously, and it sounds like a skilled practitioner like yourself can see the contour of which ones fit together.

我的意思是，这属于模式识别。

I mean, it's pattern recognition.

是的。

Yes.

临床模式识别。

Clinical pattern recognition.

没错。

Yes.

这对AI搜索来说非常困难，或者说根本不可能实现。

Which is very difficult to do from an AI search or from a it's impossible, really.

我想我还有几个问题要问。

I mean, I think I have a couple of questions.

首先想到一个与情绪障碍相关的问题。

One is just leap to mind as it relates to the mood disorders.

我能想象其中一些障碍是通过抗抑郁药、SSRIs这类药物来治疗或尝试治疗的。

I could imagine that some of these disorders are treated, or they attempt to treat them through antidepressants, SSRIs, things of that sort.

是否有迹象表明，针对这些情绪障碍的药物治疗会与我们讨论的激素相互作用，从而加剧多囊卵巢综合征？

Is there any indication that the drug treatments for these mood disorders interact with the hormones that we're talking about in a way that exacerbates the PCOS?

我的意思是，我们知道血清素、多巴胺等物质都与这些激素存在反馈和相互作用。

I mean, we know that serotonin and dopamine, all these things have feedback and interaction with these hormones.

还是你认为这完全是另一回事？

Or do you think that that's a separate thing entirely?

要回答这个问题，我认为最好先告诉你多囊卵巢综合征症状的根本驱动因素，以及这些因素如何影响情绪。

In order to answer that, I think it's better for me to tell you the underlying drivers of the symptoms of PCOS and how those can affect the mood.

通过治疗根本病因，有时无需使用舍曲林或艾司西酞普兰等药物就能改善情绪变化。

And by treating the underlying conditions, sometimes you can address mood changes without having to give them a Zoloft or Alexapro.

当然，有时可能还是需要用药的，对吧？

You might have to, right?

但据我所知，并没有证据表明这些药物会导致多囊卵巢综合征。

But there's no evidence, from what I understand, that those drugs are actually causing No.

好的。

Okay.

我只是想从根本上排除这种可能性。

I just wanted to essentially rule that out.

没错。

Right.

好的。

Okay.

很好。

Good.

听你这么说我就放心了，因为那些

I'm relieved to hear that because those

我是说，据我所知这些药物很常见。

drugs I mean, are commonly too my knowledge.

我从未经历过

I've never experienced My

我这次相当认真的网络搜索显示没有关联，但我想向你求证

not so cursory web search on this said no, but I want to verify with you.

那么情绪障碍的成因是什么？

So what is the cause of the mood disorders?

你提到睾酮水平轻微偏高

You're talking slightly elevated testosterone.

所以所有男性听众都会觉得，哦，听起来很棒

So all the males listening are like, Oh, sounds great.

当然，现在给更年期女性补充睾酮已经成为一种流行趋势

And of course, supplementing with testosterone in women in menopause has now become kind of a trendy thing.

对多囊卵巢综合征患者完全可以这样做，这个我们可以稍后讨论

And you can absolutely do that with PCOS patients, we can get to that.

不过我可以先讨论基础原理吗？

But is it okay if I discuss the underlying pillars?

因为这非常重要，我认为这正是人们所不了解的。

Because it's very important, and I think that's what people don't understand.

根据我至少过去25年临床实践中的观察，我发现这正是关键所在。

And I think that's what I've observed in my practice, at least over the past twenty five years.

理解这一点至关重要，因为如果不明白原理，就不知道如何治疗多囊卵巢综合征。

And it's so important to understand it because if you don't understand it, then you don't know how to treat PCOS.

那样你就不会只是简单地用避孕药来应付。

Then you don't just throw birth control pill at it.

这就是为什么这些患者感觉不到好转。

And that's why these patients don't feel better.

导致多囊卵巢综合征症状的根本支柱有几个。

So there are underlying pillars that drive the symptoms of PCOS.

首要问题是大脑-垂体-卵巢轴通路，我相信你已经烂熟于心了。

The number one issue is the brain pituitary ovary access, which I'm sure you know it by heart.

但如你所知，我们的下丘脑会释放一种叫做促性腺激素释放激素（GnRH）的激素，它以脉冲方式刺激分泌。

But as you know, our hypothalamus releases a hormone called GnRH that stimulates in a, it fires in a pulsatile fashion.

它基本上会刺激脑垂体释放一种名为FSH的激素，这种激素会刺激卵巢中的卵泡。

And basically it stimulates the pituitary gland to release this hormone called FSH, which stimulates the follicles in the ovaries.

每个月一个卵泡，随着卵泡受到刺激并开始生长，它就会开始释放雌激素。

As the follicles, one follicle per month, as the follicle gets stimulated and starts growing, it starts releasing estrogen.

当雌激素水平在48小时内达到峰值时，它会刺激同一个脑垂体释放一种名为LH的激素。

When the estrogen peaks really high for forty eight hours, it stimulates that same pituitary gland to release a hormone called LH.

而LH激素负责触发排卵。

And LH is responsible for ovulation.

它的作用是基本上削弱卵泡壁。

It comes, it basically weakens the wall of the follicle.

它会引起炎症反应。

It causes inflammation.

它会导致血管变化等一系列反应。

It causes vascular changes, all of that.

这样卵子就被释放出来了。

So the egg gets released.

卵子排出后，剩下的卵泡组织就形成黄体囊肿，开始分泌黄体酮来支持胚胎着床。

Once the egg gets released, whatever's left of that follicle is the corpus luteal cyst, which starts releasing progesterone to basically support implantation.

这是正常情况下应该发生的。

This is what's supposed to happen.

这就是人们怀孕的过程。

And that's how people get pregnant.

这个机制多美妙啊，对吧？

It's such a beautiful mechanism, right?

确实非常美妙。

It's so beautiful.

那些被FSH刺激的细胞会产生一种激素，反馈抑制FSH的分泌并促进LH的分泌。

Very cells that are stimulated by FSH produce a hormone which feeds back to shut down the production of FSH and bring in the LH.

我是说，这基本上就是一套精妙的分子齿轮系统。

I mean, it's a beautiful molecular set of gears, basically.

太美妙了。

It's beautiful.

我是说，虽然不想过于简化，但仔细想想确实令人难以置信。

I mean, not to make it too reductionist, but it's truly incredible when one thinks about it.

正如你提到的，这个机制从大脑一直延伸到卵巢。

And as you mentioned, that it spans from the brain all the way to the ovary.

到子宫，是的，

To the uterus, Yeah,

这真是一系列惊人的相互作用。

it's a spectacular set of interactions, really.

要知道卵泡刺激产生的雌激素会让子宫内膜变得丰厚多汁，为怀孕做好准备。

And you know that estrogen that the follicle is stimulating gets the lining of the uterus nice and juicy, ready for pregnancy.

然后当卵子排出后，黄体酮开始发挥作用，它能稳定子宫内膜，让胚胎可以着床并发育成可爱的宝宝。

And then when the egg ovulates and now the progesterone comes, the progesterone stabilizes that lining so the embryo can go and implant and turn into a beautiful baby.

通常在前十二周孕期里，那个黄体囊肿会持续释放黄体酮，简单来说就是帮助胚胎牢牢固定在子宫壁上。

And usually that cyst, the corpus luteal cyst during the first twelve weeks of pregnancy is helping release the progesterone to help the pregnancy really stick to that wall of the uterus in simple terms.

没有一丝浪费。

Nothing wasted.

毫无浪费。

Nothing.

但女性真是不可思议。

But women are incredible.

我们难道不神奇吗？

Aren't we incredible?

这太令人惊叹了。

That's amazing.

我是说，确实，确实如此。

I mean, it's Indeed, indeed, they are.

没有任何浪费。

Nothing's wasted.

那些原本会被丢弃的卵泡部分，实际上是关键激素的来源。

The portion of the follicle that would otherwise be discarded is actually a source of critical hormones.

这太神奇了。

It's incredible.

这真是太不可思议了。

It's It's incredible.

但让我告诉你多囊卵巢综合征患者的情况。

But let me tell you what happens in a poor PCOS patient.

这就是问题所在。

That's the problem.

还记得下丘脑分泌的GnRH吗？它开始超快速脉冲式释放。

The GnRH, remember that secretes from the hypothalamus, it starts pulsating super fast.

这样一来，就改变了FSH和LH的平衡。

By doing that, it shifts the FSHLH balance.

所以FSH下降而LH上升。

So FSH goes down and LH goes up.

LH会刺激卵巢中的这些细胞。

LH stimulates these cells in the ovary.

不知道你是否记得卵巢中的卵泡膜细胞，它们开始大量分泌雄激素，对吧？

I don't know if you remember the theca cells in the ovary and they start pumping androgens out, right?

当卵巢中有大量雄激素时，这些雄激素会阻碍那个正在发育准备排卵的美丽卵泡的生长。

And when you have a lot of androgens in the ovaries, the androgens block the growth of that beautiful follicle that's growing to ovulate.

于是卵泡被冻结，无法排卵。

So it freezes the follicle and it prevents it from ovulating.

卵泡仍在分泌雌激素，但始终无法达到高峰值，对吧？

The follicle is still secreting the estrogen, but it never gets to that peak high, right?

它仍在刺激子宫内膜，但排卵并未发生。

And it's still stimulating the lining of the uterus, but the ovulation doesn't happen.

所以当排卵没有发生时，多囊卵巢综合征，你会看到卵巢中这些卵泡。

So when the ovulation doesn't happen, polycystic ovary syndrome, you start seeing these follicles in the ovary.

那么是缺乏足够的LH吗？

So is it lack of sufficient LH?

是LH太多了。

It's too much LH.

LH太多了。

Too much LH.

因此，多囊卵巢综合征（PCOS）患者的LH与FSH比例会发生逆转。

So, PCOS, the LH FSH ratio flips.

也就是说，LH的水平是FSH的两倍。

So, the LH is twice as much as the FSH.

于是这种持续分泌的LH会不断刺激卵泡膜细胞大量产生雄激素，对吧？

So, you have this constant secretion of LH that stimulates these theca cells to just pump androgens out, right?

所以卵泡被冻结无法排卵，持续滞留在卵巢中。

So the follicle freezes, doesn't ovulate, the follicle stays in the ovary.

研究人员注意到，PCOS患者的卵巢对LH异常敏感——无论出于何种原因。

And one thing that they've noticed with PCOS patients for whatever reason, their ovary is super sensitive to the LH.

这就像火上浇油。

It's like adding fuel to the fire.

就像一种正反馈机制。

It's like a positive feedback.

我之所以询问LH调节机制，是因为正常情况下LH峰是触发排卵的关键信号，对吗？

The reason I asked if it's how LH is adjusted, the LH surge is what triggers ovulation normally, correct?

但并没有LH激增的情况。

But there is no LH surge.

我脑海中形成的画面是，强力的杠杆拉动实际上只是一系列小杠杆被反复拉动。

What I'm getting a mental visual of is that the strong pull of the levers is just a bunch of smaller levers being pulled repeatedly.

但子宫内膜仍然会脱落，对吧？

But there's still shedding of the uterine lining, right?

仍然会有月经。

There's still menses.

有可能。

It can be.

所以这就是为什么对于没有明显PCOS症状的人来说很容易被误导。

So, that's why it's probably very misleading for people who don't have extreme symptoms of PCOS.

因为他们认为，如果有月经就意味着在排卵。

Because they think, well, if they're menstruating, then they assume that they're ovulating.

而实际上她们中有20%到30%的人确实在排卵，对吧？

And twenty to thirty percent of them actually ovulate, right?

但她们并不总是排卵。

But they don't always ovulate.

这就是问题所在。

That's the problem.

而在那些排卵的人中，情况会变得更糟。

And of the ones who ovulate, it gets worse.

对于那些下丘脑-垂体-卵巢轴只是部分失调的人来说。

Of the ones who, let's say, this brain pituitary ovary axis is just partially disrupted.

在排卵的女性中，40%的人要么因为卵子质量差导致胚胎无法形成，要么因为子宫环境尚未准备好。

Of the ones who ovulate, forty percent of them, the embryo either doesn't form because the quality of the egg is bad, but also the environment is not ready for it.

所以孕酮水平不足，子宫内膜还没准备好。

So the progesterone, the uterine lining is not ready for it.

这就是这些患者无法怀孕的原因。

That's why these patients don't get pregnant.

是什么被认为会干扰下丘脑GnRH神经元？

What is thought to disrupt the hypothalamic GnRH neurons?

可能是所有因素。

It could be everything.

这涉及到其他所有方面。

It comes to all the other pillars.

可能是因为他们

It could be because they're

但有什么证据呢？我是说，我们不想把所有问题都归咎于心理压力，但随着这些年我对大脑、身体及其相互作用的了解加深，我越发确信心理状态确实会影响激素和大脑功能。

But is there any evidence I mean, we don't want to attribute everything to psychological stress, but the more I learn about the brain and body and their interactions over the years, the more I'm convinced that psychological state does impact hormones and brain function.

任何听到的人都会说，这当然是这样的。

Anyone listening will say, well, of course it does.

但十年前，人们还持有心身疾病的概念。

But ten years ago, there was this notion of psychosomatic illness.

人们会说，哦，他们会说这都是你想出来的。

People would say, oh, they would say it's all in your head.

我们现在知道压力是下丘脑功能的重要调节因素。

We now know stress is powerful modulator of hypothalamic function.

它部分源自下丘脑。

It actually comes from the hypothalamus in part.

那么是否有证据表明这种情况是由压力或创伤等类似因素引发的？

So is there evidence that this is, you know, preceded by stress or trauma, things of that sort?

某种程度上，是的。

It just sort of Yes.

源于

Comes

这是遗传的。

it's genetic.

这就是我想讨论它的原因。

And that's why I want to talk about it.

这只是第一根支柱。

This is just the first pillar.

你看到的第一驱动力就是这条完全紊乱的脑垂体-卵巢通路，70%到80%的患者甚至无法排卵。

You saw like just the first driving force is this brain pituitary ovary pathway that's completely disrupted, that most patients, seventy to eighty percent don't even ovulate.

而在那些排卵的女性中，子宫环境对胚胎并不理想。

And of the ones who ovulate, the environment is not really good for the embryo.

所以这只是第一个方面。

So that's just the first pillar.

但多囊卵巢综合征的核心问题是胰岛素抵抗。

But at its core, PCOS has insulin resistance.

我相信你对胰岛素抵抗很了解，但我想解释一下

And I'm sure you know all about insulin resistance, but I want to explain

请为我们的听众回顾一下。

it Please remind to our audience.

因为有些听众是新加入的，我认为关于胰岛素抵抗的内容怎么听都不为过。

Because we have newcomers to the conversation, and I don't think we could hear enough about insulin Insulin resistance.

作为妇科医生，我来解释胰岛素抵抗。

A gynecologist, I'll explain insulin resistance.

肯定有医生能解释得更好，但我会尽量简化，因为这是导致多囊症状最重要的因素之一。

I'm sure you've had physicians who will probably explain it better, but I'm going to simplify it because it's one of the biggest drivers of PCOS symptom.

而且这种情况非常普遍。

And it's extremely common.

即便是体型偏瘦的多囊卵巢综合征患者也可能存在胰岛素抵抗。

Even lean PCOS patients can have insulin resistance.

那么，什么是胰岛素抵抗呢？

So, what is insulin resistance?

简而言之，当我们摄入碳水化合物时，身体会将其分解为葡萄糖，葡萄糖会刺激胰腺释放一种叫做胰岛素的激素。

The simple way of explaining it is when we eat carbohydrates and our body breaks it down into glucose, glucose stimulates our pancreas to release a hormone called insulin.

胰岛素的作用是作用于肌肉和肝脏中的细胞，打开这些细胞上的通道，将糖分推入细胞内转化为能量。

The job of insulin is it goes to the cells in our muscle, in our liver, and it opens up the channels on these cells and pushes sugar into the cell where it can turn into energy.

所以本质上，胰岛素将血液中的糖分输送到细胞内并转化为能量。

So basically insulin takes the sugar from the blood, pushes into the cell and turns it into energy.

80%的多囊卵巢综合征患者都存在胰岛素抵抗。

PCOS patients, eighty percent of them have insulin resistance.

这并不是她们的错。

It's not their fault.

他们天生如此。

They're born that way.

胰岛素抵抗会有什么影响？

What does insulin resistant do?

当他们摄入碳水化合物，身体将其分解为葡萄糖时，葡萄糖会刺激胰腺释放胰岛素，但他们的细胞会产生抵抗。

When they eat carbohydrate and their body breaks it down into glucose, glucose stimulates their pancreas to release insulin, but their cells are resistant.

我来告诉你原因。

And I'll tell you why.

还记得我之前提到的由于第一支柱从卵巢分泌的雄激素吗？

Remember that androgen that I was talking to you about that gets secreted from their ovaries because of the first pillar?

会使女性更容易产生胰岛素抵抗。

Makes women more insulin resistant.

所以她们的细胞反应不佳。

So their cells don't respond well.

我知道，这就像，让我慢慢解释。

I know, it's like, let me get there.

我本来想问的问题其实是个玩笑性质的。

Question I was going to ask was going be a facetious one.

我本来想说，雄激素有什么好处吗？

I was going to say, Do androgens do anything good?

不，他们当然会。

No, of course they do.

对女性不会。

Not to women.

不，

No,

他们确实会。

they do.

确实需要雄激素，但不需要这么多来自卵泡膜细胞的雄激素。

Well, need androgens, but they don't need this many of androgens coming from the thecal cells.

没错。

Right.

所以当她们的细胞无法吸收这些葡萄糖时，葡萄糖就会在血液中反弹。

So when their cells can't uptake this glucose, glucose bounces in the blood.

嗯，你不能让血液滞留——我是说葡萄糖滞留在血液中，必须清除它。

Well, you can't have blood stay I mean, glucose stay in your blood, you have to clear it.

因此随着葡萄糖水平上升，它会促使我们的胰岛素水平上升。

So as glucose goes up, it pushes our insulin to go up.

胰岛素对多囊卵巢综合征患者有什么影响？

What does insulin do to PCOS patients?

第一，当胰岛素水平上升时，胰岛素会刺激我们的卵巢分泌更多雄激素。

Number one, when insulin goes up, insulin stimulates our ovaries to push more androgens out.

这情况如何？

How about that?

而且它会阻碍排卵。

And it blocks the ovulation.

它让那个卵泡停滞了，对吧？

It freezes that follicle, right?

它还会导致痤疮、脱发、面部毛发增多、体毛增多、月经不调等一系列问题。

And it causes acne, hair loss, facial hair, body hair, irregular periods, all of that.

胰岛素的另一个作用是阻止肝脏分泌性激素结合球蛋白。

The other thing insulin does, it blocks the liver from secreting sex hormone binding globulin.

如果你对多囊卵巢综合征患者进行血液检测，会发现很多人性激素结合球蛋白水平偏低。

If you do a blood test on a PCOS patient, a lot of them, the sex hormone binding globulin is low.

性激素结合球蛋白是血液中的一种蛋白质，它能结合血液中的游离睾酮，对吧？

Sex hormone binding globulin is a protein in the blood that grabs free testosterone from our blood, right?

当由于高胰岛素导致其水平下降时，我们的游离雄激素和睾酮水平就会上升。

When the levels go down because of high insulin, our free androgens and testosterone go up.

于是就会出现更多痤疮、脱发、面部毛发增多、体毛增多等症状。

So more acne, hair loss, facial hair, body hair, all those symptoms.

我明白了。

I see.

高胰岛素还有另一个作用。

High insulin does one more thing.

它基本上是在告诉你的身体，把这些糖分从血液中清除并储存为脂肪。

It basically tells your body, take this sugar, get rid of it from the blood and store it as fat.

它是如何做到这一点的？

How does it do that?

它会促使我们的肝脏将其转化为甘油三酯。

It pushes our liver to turn it into triglyceride.

这些甘油三酯可以：A，以极低密度脂蛋白（VLDL）的形式进入血液并附着在心脏上。

The triglycerides can A, go into our blood as form of VLDL and go and attach themselves to the heart.

这就是为什么多囊卵巢综合征患者必须筛查血脂指标——因为她们的胆固醇问题、心血管疾病风险和糖尿病风险等等。

And that's why PCOS patients, you have to screen them, their lipid panel, because of their cholesterol, risk of cardiovascular disease, risk of diabetes, all of that.

但它的作用是将这些甘油三酯输送到我们的内脏器官。

But what it does, it sends these triglycerides to our visceral organs.

因此这些患者开始出现内脏脂肪堆积。

So these patients start having visceral fat.

内脏脂肪与皮下脂肪是截然不同的。

Visceral fat is very different than the fat that you have under your skin.

内脏脂肪实际上会释放细胞因子和炎症因子，从而加剧炎症反应。

Visceral fat actually releases cytokines, inflammatory factors that increases the inflammation.

炎症会使我们的胰岛素抵抗更加恶化，而炎症（下一个关键因素）会刺激卵巢分泌更多雄激素。

Inflammation makes our insulin resistance worse And inflammation, which is the next pillar, stimulates our ovaries to secrete more androgens.

这是一个恶性循环。我觉得如果我们稍微深入探讨一下内脏脂肪这个话题——我们在这个播客里确实从未真正讨论过它。

It's a And vicious feedback I think maybe if we just double click on visceral fat a little bit, we've never talked about it on this podcast, really.

而且我也不是内脏脂肪专家。

And I'm not a visceral fat expert.

当然，我也没指望你是专家。但我认为值得让大家再听一遍：内脏脂肪不同于皮下脂肪。

Well, nor do I expect you to be, but I think it's worth people just hearing twice that visceral fat is not subcutaneous fat.

这就是为什么有些多囊卵巢综合征患者可能看起来很瘦。

This is why some PCOS patients can be lean.

事实上，很多男性或女性可能看起来很瘦，但内脏脂肪却过多。

Indeed, many people, male or female, can be lean and have too much visceral fat.

这一点很重要。

It's important to Correct.

现在可以通过MRI检测内脏脂肪，我相信核磁共振能做到这一点。

You can now detect visceral fat, I believe MRI will do it.

当然，并非所有人都能获得这种检测机会

Not everyone, of course, has access

或者脂肪肝。

to Or fatty Or fatty liver.

但我想说的是，虽然常被忽视，但由于其引发的炎症反应，这种脂肪其实非常危险。

Know But what I'm it gets dismissed, but it's a very dangerous form of fat because of that inflammation.

我们早就知道有些方法可以改善睡眠质量。

We've known for a long time that there are things that we can do to improve our sleep.

包括服用苏糖酸镁、茶氨酸、洋甘菊提取物和甘氨酸等成分，以及藏红花和缬草根等较为冷门的助眠物质。

And that includes things that we can take things like magnesium threonate, theanine, chamomile extract, and glycine, along with lesser known things like saffron and valerian root.

这些都是经过临床验证的成分，能帮助你更快入睡、保持睡眠状态，并让你醒来时感觉更加神清气爽。

These are all clinically supported ingredients that can help you fall asleep, stay asleep, and wake up feeling more refreshed.

我很高兴地宣布，我们的长期赞助商AG1刚刚推出了一款名为AGZ的新产品，这是一种夜间饮品，旨在帮助你获得更好睡眠，让你醒来时感觉精力充沛。

I'm excited to share that our longtime sponsor AG1 just created a new product called AGZ, a nightly drink designed to help you get better sleep and have you wake up feeling super refreshed.

过去几年里，我一直与AG1团队合作，共同研发这款全新的AGZ配方。

Over the past few years, I've worked with the team at AG1 to help create this new AGZ formula.

它以精准配比将最佳助眠成分融合于一款易于饮用的混合剂中。

It has the best sleep supporting compounds in exactly the right ratios in one easy to drink mix.

这彻底解决了在众多睡眠类补充剂中筛选合适产品、确定正确剂量以及选择适合个人需求的复杂难题。

This removes all the complexity of trying to forge the vast landscape of supplements focused on sleep and figuring out the right dosages and which ones to take for you.

据我所知，AGZ是市面上最全面的睡眠补充剂。

AGZ is to my knowledge, the most comprehensive sleep supplement on the market.

我在睡前30到60分钟服用它。

I take it thirty to sixty minutes before sleep.

顺带一提，它的口感非常棒。

It's delicious by the way.

它显著提升了我睡眠的质量和深度。

And it dramatically increases both the quality and the depth of my sleep.

这一结论既来自我个人对睡眠质量的主观感受，也基于我对睡眠数据的追踪记录。

I know that both from my subjective experience of my sleep and because I track my sleep.

我很期待大家尝试这款新的AGZ配方，享受更好睡眠带来的益处。

I'm excited for everyone to try this new AGZ formulation and to enjoy the benefits of better sleep.

AGZ现有巧克力、薄荷巧克力和混合莓果三种口味可选。

AGZ is available in chocolate, chocolate mint, and mixed berry flavors.

正如我之前提到的，它们都非常美味。

And as I mentioned before, they're all extremely delicious.

这三种口味中我最喜欢的应该是巧克力薄荷味，不过其实我都很喜欢。

My favorite of the three has to be, I think chocolate mint, but I really like them all.

如果你想尝试AGZ，请访问drinkagz.com/huberman获取特别优惠。

If you'd like to try AGZ, go to drinkagz.com/huberman to get a special offer.

再次提醒，网址是drinkagz.com/huberman。

Again, that's drinkagz.com/huberman.

今天的节目也由Juve赞助播出。

Today's episode is also brought to us by Juve.

Juve生产医疗级红光治疗设备。

Juve makes medical grade red light therapy devices.

在本播客中，我始终强调的一点是，光对我们生物学的惊人影响。

Now, if there's one thing that I have consistently emphasized on this podcast, it is the incredible impact that light can have on our biology.

除了阳光外，红光和近红外光源已被证明对改善细胞和器官健康的诸多方面具有积极作用，包括加速肌肉恢复、改善皮肤健康和伤口愈合、缓解痤疮、减轻疼痛和炎症，甚至提升线粒体功能和改善视力本身。

Now, in addition to sunlight, red light and near infrared light sources have been shown to have positive effects on improving numerous aspects of cellular and organ health, including faster muscle recovery, improved skin health and wound healing, improvements in acne, reduced pain and inflammation, even mitochondrial function and improving vision itself.

JuveLights的独特之处在于它采用临床验证的波长，即结合特定波长的红光和近红外光，以触发最佳的细胞适应性变化，这也是我首选它的原因。

What sets JuveLights apart and why they're my preferred red light therapy device is that they use clinically proven wavelengths, meaning specific wavelengths of red light and near infrared light in combination to trigger the optimal cellular adaptations.

我个人每周使用Juve全身面板约三到四次，并在家和旅行时使用Juve手持式光疗设备。

Personally, I use the Juve whole body panel about three to four times a week, and I use the Juve handheld light both at home and when travel.

目前，Juve正在进行年度最大促销活动。

Right now, Juve is having their biggest sale of the year.

从现在到2025年12月1日，您可以在黑色星期五促销期间，为精选Juve设备节省高达1000美元。

From now through 12/01/2025, you can save up to $1,000 on select Juve devices during their Black Friday sale.

只需访问juve.com/huberman。

Just go to juve.com/huberman.

网址是joovv.com/huberman。

That's joovv.com/huberman.

部分适用条款除外。

Some exclusions apply.

所以下一个支柱柱是慢性炎症。

So the next pillar is chronic inflammation.

这就是为什么多囊症患者会抱怨这种慢性炎症。

That's why PCOS patients have this chronic inflammation that they complain about.

而这种慢性炎症基本上会刺激她们的卵巢释放更多的雄激素。

And this chronic inflammation basically stimulates their ovaries to release more androgens.

这种慢性炎症会使她们的胰岛素抵抗变得更糟。

This chronic inflammation makes their insulin resistance worse.

这种慢性炎症会影响她们的肠道。

This chronic inflammation can affect their gut.

这就是为什么多囊症患者会来说，我感觉不舒服。

That's why PCOS patients come and say, I don't feel good.

我对食物过敏。

I have food sensitivities.

我感觉胀气。

I feel bloated.

因为这些荷尔蒙变化和炎症确实会影响我们的肠道。

Because these hormonal shifts and these inflammations do affect our gut.

接下来我们谈谈遗传因素这个支柱。

Then we go to the next pillar, which is genetics.

如果你观察多囊卵巢综合征家庭，会发现有人患有糖尿病、糖尿病前期、妊娠糖尿病或超重。

If you look in PCOS families, there's someone who's either diabetic, pre diabetic, had gestational diabetes, is overweight.

存在某种形式的胰岛素抵抗。

There's some form of insulin resistance.

很多时候你会看到这些患者的父亲患有糖尿病。

A lot of times you see these patients and their dad is diabetic.

所以，你不必只关注母亲这边的家族病史。

So, you don't have to look in your mom's head of the family.

两者都有影响

It's both

很多人只是简单地进行一对一对照，然后假设：如果我母亲没有生育问题，也不超重，没有糖尿病，似乎没有二型糖尿病，那么这就不是问题。

A lot of people just do the direct one to one and they assume, well, if my mother had no fertility issues and she wasn't overweight and wasn't diabetic, didn't seem to have type two diabetes, then it's not an issue.

但确实，父亲的基因同样至关重要。

But yeah, dad's genetics are critical as Huge.

最后一个支柱是表观遗传学，，我知道你经常谈论这个话题。

And then the last pillar is epigenetics, which I know you talk a lot about it.

但关键在于我们的压力。

But it's our stress.

我们的睡眠情况如何？

How much are we sleeping?

我们吃的是哪种食物？

What kind of food are we eating?

对吧？

Right?

有人跟我说过这句话，我非常喜欢这个说法。

Someone said this to me and I love this saying.

他们说，基因装弹，环境扣动扳机。

They said, Your genes load the gun, your environment pulls the trigger.

我很喜欢这个说法，因为即使你携带胰岛素抵抗等基因倾向，你仍能抑制这些症状。

And I love that because even if you're loaded with insulin resistance, all of that, you can suppress these symptoms.

但如果你开始吃不健康的食物，压力过大，睡眠不足，或者缺乏运动，对吧？

But if you start eating unhealthy, if you're stressed out, if you're not sleeping, if you're just not exercising, right?

你就是在扣动那个扳机。

You're pulling that trigger.

这就是为什么安德鲁，所有这些因素都是协同作用的。

And that's why Andrew, all these pillars work together.

这也是为什么这些患者会表现出如此多样的症状，对吧？

And that's why these patients present so many different ways, right?

当你谈到情绪时，为什么有人会感觉糟糕？

And when you were talking about mood, why does someone feel bad?

首先，多囊卵巢综合征患者的雄激素确实会影响并扰乱大脑中的多巴胺和血清素水平。

Why does a PCOS First of all, the androgens do affect, disrupt the dopamine and serotonin in their brain.

这是事实。

That's a fact.

但想象一下一个患有多囊卵巢综合症的年轻女孩，她家里有一位苗条漂亮的母亲或姐姐。

But put yourself in the shoes of a PCOS young girl who lives at home with a thin, beautiful mom or a thin, beautiful older sister.

她超重了。

She's overweight.

她什么都没吃。

She doesn't eat anything.

她每天都在锻炼。

She's exercising every day.

她已经有点焦虑了。

She's already a little anxious.

她长了痤疮。

She has acne.

她妈妈带她去看了医生，给她开了异维A酸。

Her mom takes her and they put her on Accutane.

她不断地做激光脱毛。

She's constantly lasering her hair.

她的月经完全无法预测。

Her periods are completely unpredictable.

她开始出现饮食失调，因为她所做的一切对她都不起作用，对吧？

She's starting to have an eating disorder because nothing she does is working for her, right?

然后你带着这个病人，带着我告诉你的一切，带着所有这些在她体内不起作用的基础问题，带她去看医生，却被医生打发走了。

And then you take this patient with everything I told you, with all these underlying pillars not working in her, you take her to the doctor and she gets dismissed.

这就是我为何在此为她们发声。

That's why I'm here to speak for them.

我感觉过去二十五年来，她们的创伤已成为了我的创伤。

I feel like over the past twenty five years, their trauma has become my trauma.

我现在真的能哭出来。

I literally can cry right now.

很明显你非常关心你的患者，甚至那些并非你患者的人，那些正在遭受这种痛苦的女性们。

It's clear how much you care about your patients and the ones that are not even your patients, just the women out there that are suffering in this way.

或许我们可以探讨另一种可能性，如果我说表型会显得太临床化，但另一种可能只表现出部分症状的人群。说到这里，我突然想到，无论是男性型脱发还是女性型脱发，当雄激素水平过高时都会导致毛囊微型化。

Perhaps, could we explore the possibility of a different, if I say phenotype, it sounds so clinical, but a different person who perhaps is only experiencing a subset of those symptoms And that you just on that note, I'm struck by the fact that what we know from male pattern baldness and female pattern baldness is that when androgens get too high, it miniaturizes the hair follicle.

有趣的是，当卵巢中雄激素过高时，那里的卵泡也会发生微型化。

It's kind of interesting that when androgens get too high in the ovary, they miniaturize the follicle there too.

这似乎说明过量的雄激素对卵泡发育确实有害。

It seems like that basically excessive androgens are bad for follicle development.

惊人发现。

Stunset.

确实。

Yeah.

所以，这是两条完全相同的平行作用机制。

So, two parallel pathways operating in the exact same way.

听起来我们试图把高睾酮作为问题核心，但除非追溯到GnRH神经元过度放电，实际上升高的雄激素更像是整个事件中最尖锐的矛头。

It sounds like we're trying to make high testosterone the issue, but in some sense, unless we think back to the GnRH neurons firing too much, the elevated androgens really seem to be the kind of tip of the spear in this whole thing.

这

Not what initially sets off the cascade, but in terms of tractable things that good medications and good practices might be able to take hold of.

正确。

Correct.

是这样吗？

Is that right?

当然还有胰岛素敏感性。

And certainly insulin sensitivity as well.

所以我在这里想象了许多不同的患者情况。

So I'm imagining a bunch of different patient profiles here.

但我能想象那些20多岁、30多岁的女性，社会告诉她们：'你还具备生育能力'。

But I can imagine women in their 20s, in their 30s, who have been told by society, Okay, you're still fertile.

你没问题。

You're good.

你会好起来的。

You're going to be fine.

这些女性到了30多岁后期和40多岁时来到诊所，问道：'为什么我的卵子数量这么少？'

These are the women that are showing up in clinics in their late 30s and 40s and saying, Why is it that my egg count is so low?

或者为什么我无法受孕？

Or why is it that I can't conceive?

所以多囊卵巢综合症患者的卵泡数量实际上是虚高的，因为这些被冻结在卵巢中从未排卵的小卵泡会分泌抗穆勒氏管激素（AMH）。

So PCOS patients, their egg count is falsely high because of these tiny follicles that are frozen in the ovaries that never got to ovulate, they do secrete AMH.

因此，在2023年，他们修改了第二项诊断标准，将多囊卵巢的特征改为AMH水平升高。

So these patients, that's why in 2023, they changed that second criteria, the PCOS ovaries, to elevated or elevated AMH.

AMH多高才算高？

How high for AMH?

平均值——有时候像标准值...我们

Mean- Sometimes like a norm Let's

说说看，20多岁和30多岁的人典型数值是多少？

say What's typical value for someone in their 20s and 30s?

我认为最高可达6

So I would say up to six

那40多岁的人呢？

is And people in their 40s?

小于一。

Less than one.

零点五。

Point five.

哦，

Oh,

我不想用‘断崖式’这个词，因为可能更渐进

is the I don't want to say cliff because maybe it's more gradual

可能在接近30岁时就开始下降了。

than Probably late 20s, it starts declining.

这就是为什么我总是建议患者，特别是多囊卵巢综合征患者，在28到30岁前冷冻卵子，尽管她们卵子数量很多。

That's why I always tell patients, especially PCOS patients, to freeze by 28 to 30, even though they have tons of eggs.

听着，我接诊过患者，她们来我诊所时会说‘医生，我是新患者’。

Listen, I get patients, they come to my office, they're like, Doctor, new patient.

我去看过我的生育医生。

I went to my fertility doctor.

他根本不知道自己在做什么。

He doesn't know what he's doing.

为什么？

Why?

40、41岁的人。

40, 41 year old.

我取了三十颗卵子，他却连一个胚胎都培养不出来。

I put out thirty eggs and he couldn't make a single embryo.

通过试管婴儿。

Through IVF.

通过试管婴儿。

Through IVF.

40岁本就不该取出三十颗卵子。

Shouldn't put out thirty eggs at age 40.

那是多囊卵巢综合征。

That's PCOS.

这一点对人们来说非常重要，因为我认为卵子数量和足够高的AMH水平经常被吹捧为人们关注的重点。

This is so important for people to hear because I think egg count and elevated or high enough AMH is sort of touted as the thing that people go and look at.

这很合理，对吧？

It makes sense, right?

我是说，他们会做超声波检查，数卵泡数量。

I mean, they'll do an ultrasound, count follicles.

只要你不忽视多囊卵巢综合征就没问题，因为如果是PCOS，胚胎质量就会差，排卵也会不理想，子宫环境也不佳，所有其他问题都需要解决。

It's great as long as you're not missing PCOS, because if it's PCOS, then the quality of the embryo is bad, then the ovulation is suboptimal, the environment is suboptimal, and everything else needs to be fixed.

这或许就是为什么有些人在30多岁时去做试管婴儿之类的事情，实际上他们的卵子数量相对较少。

And this is perhaps why some people go in, in their 30s, they might be doing IVF or something like that, and they actually have relatively low egg count.

他们可能...要定义'少'总是很棘手...比如一侧两三个，另一侧两三个，但试管婴儿却能成功，因为你不需要过度刺激卵巢。

They'll get maybe It's always tricky what low corresponds, but three two, three on one side, two on the other, but then the IVF works because you don't necessarily Far on the crop.

卵子的质量更高。

The quality of the eggs is higher.

没错。

Right.

所以，AMH（抗穆勒氏管激素）最简单的理解方式是每0.1的AMH值平均对应一个卵泡。

So, AMH, anti mullerian hormone, the easiest way to look at it is every 0.1 of AMH averages to one follicle.

这是你心算的简便方法。

That's an easy way to calculate it in your head.

因此，如果你的AMH值为1，你应该有大约10个卵泡。

So, if you have an AMH of one, you should have about 10 follicles.

但如果你40岁时卵巢里有30个卵泡，那就有问题了。

But if you show up at 40 and there's 30 follicles in your ovaries, something's wrong.

那就是多囊卵巢综合征（PCOS）。

That's PCOS.

你必须确认不是PCOS。

You have to make sure it's not PCOS.

你必须确保没有漏诊PCOS，因为这正是这位女性无法怀孕的原因。

You have to make sure that you're not missing PCOS because that's why this woman is not getting pregnant.

安德鲁，你知道吗？有多少患者来到生育诊所时，甚至连他们的生育医生都没有诊断出她们患有PCOS？

And can I tell you, Andrew, how many patients come to a fertility clinic and they're not diagnosed with PCOS, even by their fertility doctor?

嗯，你描述医疗行业标准的方式，既不出人意料又真的——

Well, the way you're describing the sort of standards in the medical profession, it's both not surprising and really-

很可悲。

It's sad.

令人沮丧。

Disheartening.

是的，真的很可悲。

Yeah, it's really sad.

再次说明你今天在这里的原因之一，我认为这种对AMH与卵泡数量关系的重新解读对大家很重要，因为我认识不少做过或正在做试管婴儿的人，AMH和卵泡数量问题就像被奉为圭臬，对吧？

Again, one of the reasons you're here today, I think this reframing of AMH and egg number or follicle number is very important for people to hear because I know a number of different people done IVF, do IVF, and this issue of AMH and follicle number is like kind of held as the thing, right?

如果你有卵泡，天哪。

If you have follicle my goodness.

有人41岁左右还有20个卵泡。

Someone still has 20 follicles at age whatever, 41 or something.

然后他们会经历多轮试管婴儿，结果却...

And then they'll go through rounds of IVF and it's it's

我不是生育专家，但我可以告诉你，在25岁、28岁时，每3个卵子可以形成1个胚胎。

And so I'm not a fertility specialist, but I can tell you if at age 25, 28, every three eggs make one embryo.

到了40岁，你可能需要10到15个卵子才能形成1个胚胎。

At 40, you might need 10 to 15 eggs to make one embryo.

所以如果你40岁时的AMH值是0.5，意味着只有5个卵泡。

So if your AMH at 40 is 0.5, that means five follicles.

因此你可能需要做两到三次卵子冷冻或胚胎冷冻周期，才能获得一个正常的胚胎。

So you might have to do two or three cycles of egg freezing or embryo freezing before you can hit that normal embryo.

这就是为什么保险公司不承保卵子冷冻，明白吗？

So that's why unfortunately insurance companies don't cover egg freezing, right?

我经常说，当女孩们年轻时，她们拥有优质卵子的时候想冷冻，却负担不起高昂的费用。

And I always say this when girls are young and they have beautiful eggs and their eggs are young and healthy and you want to freeze them, they can't afford it because it's very expensive.

而当她们能负担得起时，通常已经30多岁或40岁了，卵子质量下降了。

And then when they can afford it, they're usually in their late 30s or 40s and their quality's down.

这个问题需要解决。

So that needs to be fixed.

我记得我们在湾区讨论过这个话题，很多大公司如谷歌和脸书，实际上会为员工支付冻卵费用。

And we had this conversation, I think, in the Bay Area, a lot of these big companies, Google and Facebook, these companies actually pay for their employees to freeze their eggs.

他们很聪明。

They're smart.

他们不希望员工怀孕。

They don't want their employees to get pregnant.

他们觉得，'我来为你支付冻卵费用'。

They're like, I'll pay for your egg freezing.

继续工作吧。

Keep working.

但大多数女性，大多数女性没有这种机会。

But most women, most women don't have access.

告诉你一个事实，这个国家50%的县连一位妇产科医生都没有。

And let me tell you, 50% of counties in this country don't have an OBGYN.

5050%

5050%

的县。

of counties.

很多女性不得不开车两到四小时去看妇产科医生。

A lot of these women have to drive two to four hours to see their OBGYN.

这太疯狂了。

That's crazy.

这就是为什么这些播客能改变游戏规则——当她们无法获得医疗服务时，人工智能和机器人聊天工具或许有朝一日能在家为患者诊断治疗，省去她们开车四小时看妇产科医生还可能被敷衍的症状。

That's why these podcasts are a game changer because if they don't have access, that's why artificial intelligence, AI, these robotic chatbots that hopefully can someday diagnose these patients and treat them from home without having them have to drive, I don't know, four hours to see an OBGYN, who will then also dismiss their symptoms.

是啊，就像你说的，在某些情况下科技可能比某些医生更靠谱。

Yeah, like you said, in some cases, technology may be better than certain physicians.

这点我完全同意。

I don't disagree with you there.

通过这

By the

期播客结束时，你会相信机器人治疗的

end of this podcast, you'll believe in the robots treating

嗯，我可能会相信机器人和技术在某些情况下能比一些临床医生和科学家做得更好，公平地说。

Well, I'll believe in robots and technologies perhaps doing better than some clinicians, and scientists, to be fair.

但我确实认为，像你这样杰出的临床医生以及其他领域的专家——我认识医学不同领域的人。

But I do think that spectacularly good clinicians like yourself and in other fields I I know people in different fields of medicine.

我很幸运，也很感恩能认识医学不同领域的专家，对他们来说，确实不存在一个机器人甚至15位医生能与之相比的世界，因为真正掌握原理、理解原理背后的原理，并在特定领域长期实践的人有着无可替代的价值。

I'm fortunate enough, blessed, to know people in different fields of medicine for whom you that could truly there's no world where a robot or even 15 doctors can compare, because there's something about knowing the principles of something, knowing the principles below the principles, the principles below and then being a longtime practitioner in a given field.

是的。

Yeah.

我们称之为真正的专业知识、深度专业知识和横向专业知识。

What we call true expertise, deep expertise, and lateral expertise.

不，我正想说，以大多数医学领域为例，比如眼科，对吧？

No, I was going to say, most fields of medicine, let's take ophthalmology, right?

每位眼科医生都了解白内障。

Every single ophthalmologist knows about cataract.

最常见的致盲原因。

Most common form of blindness.

谢谢。

Thank you.

所以，你去找眼科医生看白内障却得不到诊断的情况很罕见，对吧？

So, it would be rare for you to go to an ophthalmologist with cataract and not get diagnosed, correct?

没错。

Correct.

那么为什么地球上导致不孕的主要原因，90%的女性却得不到诊断？

So why is it that the leading cause of infertility on this planet, ninety percent of women are not diagnosed?

女性健康与其他医学领域截然不同。

Women's health is very different than other fields of medicine.

这是个完全不同的难题。

It's a different monster.

就像那个白内障患者看了20个眼科医生，她不停地说'我看不见'。

It's that cataract patient that goes to 20 ophthalmologists and she keeps saying, I can't see.

而眼科医生却说'你疯了'。

And the ophthalmologist says, You're crazy.

你没什么问题。

There's nothing wrong with you.

这个比喻非常精妙，不仅因为涉及视觉——这是我的专业领域，更因为我认为人类极度依赖视觉。

That's an excellent analogy, not just because it's vision, that's my home area of science, but because I think humans are so dependent on vision.

对于有视力的人来说，失去视觉的想法本身就极具挑战性。

And just the idea of losing vision for people who are sighted is so challenging.

我的意思是， 整个系统运作起来就像一场优美的交响乐，其中精妙的反馈循环机制表明，这些环节中微小的扰动都可能引发深远的连锁反应。

Oh, I mean, the number of incredibly elegant feedback loops and the way the whole thing works like a beautiful symphony when it works, also indicates that like small disruptions in these things can cause really downstream consequences.

我很好奇，为什么多囊卵巢综合症如此普遍？

I'm curious, why so much more PCOS?

还是说像许多医学领域一样，可能这种病症长期存在，只是我们过去没有意识到？

Or is it like so many areas of medicine where it probably was around a long time, but we just weren't aware?

我可以指出胰岛素抵抗的问题。

And I can point to the insulin resistance.

也许是人们的饮食习惯问题，以及血管内脂肪导致的慢性炎症反应。

Maybe it's how people are eating and the downstream chronic inflammation from the intravascular fat.

可能是我体内的神经科学家在作祟。

Maybe it's the neuroscientists in me.

一直在思考大脑中那些突然开始放电的GnRH神经元，对这种现象我有一大堆个人理论，当然，我没有任何数据支持。

Keep thinking of these GnRH neurons in the brain that are suddenly start I firing have all sorts of pet theories as to why that could be the case, but of course, I don't have any data.

压力肯定会影响它。

Stress affects it, for sure.

睡眠-觉醒周期紊乱。

Disrupted sleep wake cycles.

某种程度上会默认倾向于

Would sort Yes, of default then to

你会看到这些在充满爱的美好家庭中长大的年轻女孩。

you see these young girls who grow up in amazing, loving families.

她们从未经历过任何压力。

They've never had any stress.

也没有任何创伤。

Didn't have any trauma.