Episode 7: PCOS

Transcript

Speakers:

Host - Olivia

Guest – Dr. Bassel Wattar

00:00:04 Olivia Moir 

Hello everyone and welcome back to it all starts here. This is a podcast focusing on the communication of topics in reproductive science and Women's Health. I am your host, Olivia Moir, and we are here at the Institute for Women's Health at UCL here in London. And we are back. I'm so excited. After a bit of a summer holiday and by summer holiday, I really just mean writing up my 20,000 word dissertation, which is almost done. But I'm so excited to be back here today. And we are going to be talking about PCOS, which is also known as polycystic ovary syndrome. And to do this I have with me Dr. Bassel Wattar, who is a consultant obstetrician and gynecologist based in London. He has advanced expertise in various areas, including fertility assisted conception, endocrine, gynecology and of course, importantly for today, PCOS.  

So very interestingly, he is the co-leader of a research group dedicated for evidence synthesis at UCL, which is something that we've talked a lot about on this pod. And really the importance of having evidence based research. So it is such a pleasure to have you here with me today.  

I always love to start off a little bit of back story so maybe you can give us maybe a quick run through of how you got here today and really why you're so keen to study PCOS and briefly a little bit on your evidence based research group, EVIE. 

00:01:42 Dr. Bassel Wattar 

Lovely. Thank you for the kind introduction and thank you for having me here today and covering an important topic like for PCOS. Back stories. Oh gosh, I'm not sure how far to go back, but I'm originally Belgian Syrian and I came to the UK immediately after my Med school to do my advanced training in obstetrics and gynecology. A lot of people ask me why OBGYN and to me it's like the most satisfactory and discipline because you're helping you know, creating families and helping, you know, mothers stay healthy. And that's the key, in my opinion, to a healthy family in a healthy society.  

So it gives a lot of satisfaction and I'm you know, I'm glad I I went in this very long venture. And endocrine and fertility. So I guess a key exposure when I was in my first year of training, I got a sort of opportunity to do some early research on a intravaginal probe that was detecting changes in temperature to detect ovulation and that sort of sent me on a rabbit hole of when ovulation happens and how a cycle is regulated and what the hormones are - and I still to this day finding this ever fascinating.  

And because it just has so many sort of question Marks and we have a lot to understand and sort of PCOS is the pinnacle of so many question marks still to unravel and there is more and more research and we do know quite a bit about how to manage it and and and deal with its consequences. Till this day, we don't really know the main cause of PCOS like where does it start? 

00:03:19 Dr. Bassel Wattar 

It’s sort of the chicken and the egg story, because people who are gynecologists like me tend to think it starts in the ovaries, while endocrinologists tend to think it starts in the brain and the hypothalamus and where the hormones are secreted. And this imbalance between the hypothalamus and the ovaries is all dealing with all the posing this imbalance in hormones and leading to these different symptoms that women with this condition tend to suffer from. 

So yeah, extremely interesting and still finding interesting and enjoy research in it and most importantly, enjoy looking after women with this condition in the NHS. 

00:03:55 Olivia Moir 

I love that. I love hearing about where it kind of starts and I agree it's so it's so important and I think so interesting to start off with studying things relating to the beginning of life. You know, where we all come from and what goes into that? So in terms of bringing together the evidence based research, you started this or you're co-leading a group on this kind of research. What is that you focus on different topics? 

00:04:23 Dr. Bassel Wattar 

Yeah. So the groups called Evie Evidence synthesis methodology in Women's Health and we are dedicated to Women's Health. And the idea came about that if you look across London, there's so many different, you know, leading universities that are really top class in medical research. But actually there is not even one single research group that is doing evidence synthesis in Women's Health and evidence synthesis is, for our audiences is the in very simple terms, the process of translating research and putting it back into clinical practice. And it goes from doing systematic reviews, meta analysis, clinical practice guidelines and so on and so forth, assessing the evidence, putting down the findings from different studies so that we can have more confidence, more precise results, and then that could help guide clinicians in the practice of evidence based medicine, because that's what we would like to offer our patients is that we're offering them the best quality clinical advice that is underpinned in top quality research and and that is what EVIE really wants to achieve.  

So we are a vibrant group of both clinicians, methodologists systematic reviewers, statistician, health economist and which is a sort of a combination of different talent across UCL and we look into so currently we're looking into a big project looking into treatments for heavy menstrual bleeding, which is funded by the NHR. We do a lot of research on PCOS, on menopause and PMS, and obviously fertility and assisted conception and technology. In terms of assessing what treatments are good in IVF, how can you maximize the success rate at IVF and obviously is more and more reliance on assisted conception. So that's really the the, the, the story behind why EVIE came through is just to fill a gap and the need for better evidence to inform clinical practice in, in the domain of women's healthcare. 

00:06:17 Olivia Moir 

That's fantastic and it's honestly just mind blowing that it's the only group amongst all of these universities that are focusing on that evidence based kind of research, we really need more of that, especially with Women's Health. 

00:06:30 Dr. Bassel Wattar 

And we need more researchers there is there is a steady decline in the number of researchers in Women's Health across the UK. I'm talking specifically and for a variety of factors and and you know if if if we can achieve something from today is to inspire more and more young sort of doctors to come into Women's Health research. 

00:06:50 Olivia Moir 

I love it. Yeah, absolutely. So we sort of began to talk about PCOS. You know, you said that there's different causes. We don't really know. Could be hormonal. Could be something to do with the ovaries, we're not really exactly sure where it starts, but if you were going to just broadly cover for everyone listening, who maybe doesn't know as much about what this condition is, what would you say are the main kind of characteristics or things to know? Like, what is PCOS really? 

00:07:16 Dr. Bassel Wattar 

So it's important to call it a condition, not a disease. It's not a disease. It's by far the most common chronic disorder affecting women. And people underappreciate how prevalent it is technically in the UK, we estimate between 10% to 15% of women to be affected by PCOS, so a really common condition. And it starts from the early adolescent years and goes all the way to menopause. So it evolves, it changes how it manifests. And most importantly, as it's a syndrome, it has a collection or a group of symptoms that manifest, but it manifests differently in different women. So not everyone will have the same symptoms and these symptoms will vary in severity from one domain or the other. 

00:08:04 Dr. Bassel Wattar 

So that what makes it a little bit challenging to diagnose it and managing it cause it's not like a a disease where you give one tablet, that's it, you're cured, carry on the tablet. It doesn't work that way. So the main diagnosis of PCOS is based on something called the Rotterdam criteria, which is established about 20 odd years now and you need to have two to three symptoms or signs. One being irregular or absent periods. When we say absence more than six month, no period. Excessive hair or growth or acne on the on the hair on the face, chest, arms. You know, wear a woman would not normally have excessive. And plus, minus and appearance of multiple cyst on the ovaries on ultrasound scan. Now they're called cyst. They're not really pathological cysts. They're basically follicles that are arresting. They're not developing to ovulate, and thus they they stay in the ovaries and they give that sort of very distinct appearance of multiple follicles in the ovaries that are between 2mm to 9mm. Their need to be more than 20 as per the new sort of guidance from the international PCOS guideline and and basically if you have two of the of these three symptoms, you're diagnosed with PCOS. 

00:09:26 Dr. Bassel Wattar 

The key feature is that these women often don't have any periods which you know have a lot of health problems. They do not overlay it, and as such they can't get pregnant without any help. Again, I emphasize not everyone has the same symptoms. They have excessive hair, which is you can have really severe body image and self esteem sort of implications and there's high prevalence of anxiety and depression in this sub-cohort and they also have insulin insensitivity, meaning there's high insulin resistance in their body tissue and therefore they're having to secrete higher levels of insulin. And yet the body processes sugar in a less efficient way compared to someone who does not have PCOS. As such about 50% are either overweight or obese because their body can fetch sugar so quickly to to fat, and it's so much harder for them to lose weight. So it's a sort of a vicious cycle where this imbalance of hormones keep feeding into more and more adverse symptoms. 

00:10:23 Dr. Bassel Wattar 

Now, long term PCOS also have long term implications and that these women, as you probably have guessed, are at higher risk of type 2 diabetes. So they need to be watching watchful of it and primarily with lifestyle intervention, but also with other treatments we'll we can cover them later.  

There is also because they're not having periods, they're uterine endometrial thickness Is increased and they're more at risk of having something called endometrial hyperplasia, which is a precaution for endometrial cancer. So it's important for them to at least have one period every three months. 

00:10:56 Olivia Moir 

Right. 

00:10:57 Dr. Bassel Wattar 

And again is the mental health challenges that I that I managed are unfortunately often brushed off and not covered very well in, in, in healthcare services and for many, many, many reasons. So that's also a summary of what what are the common symptoms that women with PCOS would suffer from. 

00:11:15 Olivia Moir 

Yeah, that was. That was great. That was, I feel like I understand it so much better, myself. So OK, so then thinking about treatment. So obviously as you said, there are different symptoms depending on the person and severities, I'm sure of the PCOS affecting whoever has it. But if you were going to say just in general how you manage PCOS, what is the normal kind of standard protocol with that? 

00:11:42 Dr. Bassel Wattar 

So as I mentioned, the key message is to have individualized management plan, so it's not one-size-fits-all and piece where specifically on in medicine in general, but specifically in piecewise, cause each women will have different symptoms. 

The other key message is early adoption of intervention. So often a lot of these women will would experience delayed diagnosis because a lot of health professionals are the unconfident or they don't know enough about the condition. Talking specifically, GPS in the community. So they're afraid of calling it PCOS so they delay having all the different investigations and therefore the diagnosis is delayed. 

00:12:20 Olivia Moir 

Right.  

00:12:21 Dr. Bassel Wattar  

So a large proportion will actually be labeled PCOS when they come to see a fertility specialist like me, and we do investigations. Why you're not getting pregnant. And we thought, ohh, when you have PCOS, you're not ovulating, which is what? Late 20s, early 30s. While in reality, they probably could have been diagnosed in the year early 20s, late adolescent years and they could have started sort of lifestyle interventions or other treatments that could help them reduce the impact of PCOS. 

00:12:44 Olivia Moir 

Right. OK.  

00:12:50 Dr. Bassel Wattar 

So the first line, if there is now, luckily we have an international PCOS guidelines and it's led by Monash University in Australia. But it has international sort of input and a few of us in the UK has contributed to it.  

So the first step in the guideline is lifestyle intervention. And I don't want to sound like I'm lecturing, saying it's diet, diet, diet. It's not, it's lifestyle intervention. As in, look into the patient's lifestyle and see how you can optimize it. So can they increase exercise? Exercise doesn't need to be. Go on a CrossFit. It could be just, you know, having a brisk regular risk walk. It could be taking your dog for a walk regularly for example. It could be having yoga or or some or Pilates. It doesn't need to be strenuous exercise.  

Smoking, secession and most importantly, dietary intervention. 

00:13:40 Dr. Bassel Wattar 

And so if you extrapolate on what we discussed about the insulin resistance, you can pretty much guess that these women cannot take a lot of high glycemic index diet. They cannot enjoy chips or ice cream or so on all their guilty pleasures in life, unfortunately. So. And it's important that we support them to understand them. Now unfortunately, I think in the health service, we're very good in dismissing it and simplifying it and say, oh, go eat 5 feet piece of fruit today like this is not going to resolve the problem. You need to help them to a understand their trigger foods. So when you're someone is being emotional, often you grab a piece of chocolate and and while it sounds like a 2, two seconds thing, it actually has a lot of impact if you have PCOS. 

And also about like following a distinct sort of dietary regime. So I recommend to my patients the mediterranean diet to maintain weight. They're not going to lose weight on it or an intermittent fasting or get a diet to have to do a short burst of aiming to lose weight. And then you do it only for a few weeks. Try to lose some weight and then you go back to a maintenance. 

Because I'm sure you and myself and everyone listening have tried to go on a diet, you can't do it for more than a month or so. You'll just refer it back to your normal lifestyle. It's just the nature of it. So you know, it's important when we are counselling women to ensure it doesn’t sound like you just need to lose weight and oversimplify. And it's really hard and we need to understand it and support with a lot of information and teaching and education for the patient to enable it. 

So that's the very first line intervention.  

00:15:22 Dr. Bassel Wattar 

And then if we sort of reverse engineer from the symptoms we discussed.  

You need to give them a period at least once every three months so that either go on the contraceptive pill to have regular periods, or sometimes have a withdrawal bleed with the prestone only pill that they take every through, every every 4-5 to six days every three months to have another period. 

Some will prefer to have a intrauterine Mirena coil, which releases progesterone internally, which is more effective, but again, you have to tailor it to the patient in you know age group, someone who's 20 years old will probably not want to have a coil, right, for someone whose late 30s and had her children, probably she wouldn't mind it, and she'll find it advantageous. So it's important to consider that the thing sort of individualized characteristics and treatment of hair, citizen and acne. So that could be either with antiandrogenic agents within the pill. So some of the some contraceptive pills have this sort of hormone, or you could just use an anti-androgen like spironolactone or finasteride for example. They're becoming more and more prevalent and actually there's been a very recent RCT in the BMJ and probably a couple months ago which showed significant improvement for symptoms like any acne, and so there's more sort of uptake of these treatments to help women with these symptoms deal with it. 

00:16:47 Dr. Bassel Wattar 

Some don't want to take pills, so they resolve to laser treatment or hair removal. Unfortunately, they're not available in the NHS everywhere, and so they could be quite expensive to access to everyone.  

And then you know beyond that we can talk about the fertility treatment, which is a completely like, you know, separate topic.  

And surveillance? So that's a very important thing. As we discussed, there are at high risk of diabetes. I would recommend at least a yearly test for their blood sugar to check that there is they're not edging towards diabetes cause you can always do an intervention to bring yourself back to safety. 

00:17:24 Olivia Moir 

Right. 

00:17:25 Dr. Bassel Wattar 

And as we said, if they're not having periods, they are high risk of hyperplasia. So it's important to continue with that.  

And lastly, the mental health elements and this doesn't always need to be in healthcare sort of services professional healthcare services sometimes just engaging with the peer support group could be could go a long way and offering support. And I always tell my patients look look at the very PCOS charity which is the UK charity for it. They have wonderful resources and support groups for women that would really help them deal with the symptoms and you know, cope with everything that they have to go through. 

00:18:01 Olivia Moir 

Yeah, it sounds like, I mean, obviously it just sounds a lot like the sort of empowerment around this topic is maybe lacking and and giving women sort of that feeling that they're not just kind of making it up or that these things are valid things and you know, as you said, don't put all the emphasis on diet, but feeling like those little bits can make a difference, I think, cause as you said, you know or alluded to is just that maybe sometimes, you know, all of the little things in combination might make a big difference overall, or at least helping to manage the symptoms that you're going through. 

00:18:38 Dr. Bassel Wattar 

100% and as you rightly mentioned is that sometimes a lady would come and say look, my main problem is that I'm not able to get pregnant and get diagnosed with this. 

Yes, but we are guilty of of as health professionals as that we don't probe for the rest of the symptoms unless you ask someone. Look you. So they have higher tendencies of sleep apnea and snoring at night. If you're not going to ask for it, they'll think. Ohh just me because I am overweight. I just snore and it's like no, it's a consequence of PCOS. And you need help with it because it can increase the risk of cardiovascular disease in the future and saying if you say look, do you have, you know, anxiety, depression, how do you, you know, see your body image if you don't probe for them, if you don't believe and and help them to explore it they will not even know how to start to seek help. So it's important to keep a comprehensive perspective about it and you know be open minded and helpful about exploring the different symptoms. 

00:19:37 Olivia Moir 

I love it. I love how much you care, and it's such a I feel thorough, kind of like analysis that you have about the whole topic, and it's just so lovely.  

So then in terms of you sort of touched upon the fertility kind of aspect of this. So what I got from part of the management was that, you know, just the act of a period. So the shedding of the endometrial lining, you need to sort of have that you know, in order to not have a build up, I guess over a few months so. 

00:20:01 Dr. Bassel Wattar 

Yes, yes. 

00:20:03 Olivia Moir 

In terms of fertility, like, are those kind of connected? I mean, you're not ovulating. So how how is that all kind of being managed when you have PCOS? How can that affect your fertility long term, and what can you do to help? 

00:20:20 Dr. Bassel Wattar 

In theory, and again, I don't want to sound like I'm lecturing and oversimplifying it. If you adopt early lifestyle measures and helpful measures, so I forgot to mention insulin sensitizers or anti diabetic drugs like metformin that we also can can use and they can help to attenuate the symptoms of PCOS. So if you adopt such measures early on you might avoid having the consequences of issues. Not necessarily, but they would reduce it. But let's say you did not know and you're in early 30s and you're ready to start your family trying for two years and you can't get pregnant, so you'd come technically to the fertility specialist and I don't know why we waste a lot of time asking for what could be the reason it it takes only an ultrasound scan and just asking do you have regular periods? No PCOS. You could get diagnosis, so it's really should be quick. Unfortunately, that's not the what happens on the on the ground. So the key thing is to restore ovulation and the way we restore ovulation as traditionally is by, you know, invoking a withdrawal date. If someone doesn't have any period. And then starting them on a pharmacological ovulation induction agents such as clomiphene or letrozole. They work slightly differently, one as an aromatase inhibitor, one as an anti estrogen receptor. So currently the evidence is in favor of using letrozole as a first line pharmacological ovulation induction agent and that is because we've done quite a few trials and we've found that because women with PCOS have several follicles, if you give them the agent without monitoring, they might have more than one egg ovulatin, increasing risk of twins. So it it needs to be monitored. 

Because the key information is that women with PCOS have higher association with miscarriage, their association with preterm birth and higher risk of complications in pregnancy and all these risk dimensioned are also increased in twins. So the key thing is to avoid having twins and piecewise. 

00:22:27 Olivia Moir 

Right. 

00:22:28 Dr. Bassel Wattar 

It's not that it's a disaster and I want to make it like or avoid it at all costs. But look, you want a healthy pregnancy, so just have a singleton pregnancy. That is the objective of it should be the objective of fertility treatment. 

And so a lot of patient comes to me and say, oh, I'm busy as I'm I will never have children. Like, no, the treatment is really simple. You just have a pill for five days of the beginning of the period you ovulate and you just get pregnant as anyone else. So and it's very successful. So the restoring ovulation with just the pills of about 80% success chance. And with the presence of ovulation without any other reason for security, there is about 20% chance of clinical pregnancy per cycle. 

So you know, it's not a very complex treatment. 

Unfortunately, not everyone responds the same, and unfortunately there is less understanding of it and of this management specifically among fertility specialists, and thus where a lot of patients get exposed to IVF unnecessarily. 

00:23:32 Olivia Moir 

Right. 

00:23:33 Dr. Bassel Wattar 

So when they fail ovulation induction or they don't get treatment pregnant after three cycles, a lot of patients get told, oh, you need IVF and and, you know, I think everyone listening will agree that IVF is more expensive, more invasive and more emotionally draining. So unless you really need it, just don't, you know, expose the patient to it. And so pros and cons like, you know, it's just about tailoring the treatment and individualizing it as we discussed. 

So IVF does have a success, so can increase the success rate in those patients who are not responding to ovulation induction. But I would still maintain and we recently published an article in reproductive biomedicine online arguing that ovulation induction is the first line treatment. It should stay there versus others were arguing that, you know, delete ovulation induction altogether out of the treatment cycle and just go for IVF, right away, it's like absolutely makes no sense and not even ethical because the first rule of medicine is do no harm. So why? Why would I expose my patient to unnecessary harm if they can get pregnant with just a simple tablet they can they can take for five days of the month. 

00:24:43 Olivia Moir 

Right. I think it's interesting because in different sort of conditions or complications with health, Women's Health that I've talked about on this podcast and learned about in my courses this year, it's not always the case or most of the time it's not the case that the clinician doesn't know or the researcher doesn't know about what the condition is. It's that the patient you know doesn't have a background in science or doesn't know much about Women's Health themselves. Unfortunately, they weren't taught in school, but it feels like, particularly with PCOS, there seems to be some sort of block in terms of what a clinician knows, and I don't really understand because surely it's not a new condition like surely this has been happening for many years. 

00:25:25 Dr. Bassel Wattar 

You're very right in your conclusion, and if you extrapolate a little bit further, we did a recent survey of women in the UK and asked them what is your health priority? Why is the thing that upsets you the most in accessing healthcare for PCOS, and unanimously #1 is lack of awareness from health professional. 

00:25:47 Dr. Bassel Wattar 

And specifically they struggle with GPS and I'm not, you know. You know. Yeah, yeah. I respect everything GP's do in the Community and they they do face a huge challenge. I mean, I cannot look after a patient in 10 minutes. It's just I I cannot do it. So with all the respect, it's just that I think it's not covered in the medical curriculum enough and there is not enough exposure to dealing with it in the community and what needs to be dealt in the community and what needs to be dealt with in the secondary or tertiary care and then also the nature of PCOS because it has so many varied symptoms. So the traditional pathway you find someone pathways going to see the fertility specialist. Get pregnant. Going to see the dermatologist for the hair going to see the endocrinologist for the risk of diabetes. Going to see the GP for the mental health disorders. But then these specialists are not talking among themselves. So instead of one trip that you'd go to a specialist PCOS clinic, this patient will have to be to make 3-4 trips to three different, four different specialists who might, you know, not be talking to each other, and that further sort of make the patients frustrated because they feel like no one is listening to them. They have these symptoms and each specialist is telling them something different. So it's just about the model of care and the access to healthcare sort of that is needed to change. It is evolving gradually. So we're seeing more and more specialized PCOS and guiding endocrine clinics and it's a slow process, but I think I see some some, you know, some winning in it. 

00:27:20 Olivia Moir 

Yeah, I think, yeah, I I hope you know, going forwards it will be, you know better addressed by people that maybe even aren't specialized like as you said, going to your GP if you know it, it would be great if you that could involve an ultrasound every time just going to your GP, you could get an ultrasound and bam, there's your diagnosis because as you said, it can be just do you have regular periods and you know, looking on the ultrasound. So I kind of hope going forward maybe that could be implemented, but in terms of you know, giving a piece of advice for people that are listening that are maybe going through this syndrome or they don't know or they're going through something and they maybe don't have a diagnosis yet of PCOS do you have? You know, let's first focus on the patient. Do you have advice for someone going through this? Like what they can do in terms of advocating for themselves or how to bring awareness to this? Like, what are some steps that you think would be helpful for the patient to acknowledge with that? 

00:28:21 Dr. Bassel Wattar 

As we previously discussed it all starts with education and then I think if you have the condition you need to start educating yourself about what resources out there. I'm very aware that a lot of it is dull, dry medical sort of language that is could be very hard to to comprehend. And I struggle with it sometimes, but I would say just sort of visits the websites that are available from charity. So I mentioned the PCOS variety charity in the UK. There's quite a few sort of international charities that are more and more offering advice and support for for PCOS. 

I mentioned the international guideline. It is available online for free. You don't need to read the technical documents about 300 pages, it's quite. It's quite long, but they interestingly and sort of a shout out for the researchers who produced the guideline. They did work collaboratively with lay patient representatives and they did produce sort of lay summaries of the guideline and very simple infographs that if you just read them and take them to your GP and say, look, this is what the international guideline is saying, can I please receive that? Can I please tailor that to my specific condition?And I think you will be at a very, very good start.  

And after that is this really trying to find a health professionals that understands you so often I get I get questions or my GP is refusing to do this to me or to do that to me. And I just say look, I'm sorry there's nothing you can do except changing your GP. That that's what it comes down to it. And there is a human element Into it, 98% of GP's are extremely helpful and they want to help. There is a minority that would just not want to understand this condition. They might not be, they might not feel comfortable dealing with it. If you ask me something in Pediatrics, I'd say I'm so uncomfortable to deal with it. So it is it. There is a human element into it. So just you know, look, you be proactive and look for the health care professionals that will help you and finally join the support group is very important and yesterday we did a webinar with variety PCOS charity about support groups at the workplace and how can you tailor your workplaces to support you if you have PCOS. And so I think this idea is, is is emerging and it doesn't need to be a face to face. It could be online and and it's just a a peer of of people who you know share you’re your symptoms and share your condition and what you're going through that could really go a long way to help to support. 

00:30:55 Olivia Moir 

Yeah, absolutely. I love that. I think that's great advice and great practical advice. 

00:31:01 Olivia Moir 

OK, so I normally end the episode with sort of what are your hopes for this field? And you know what can you think of that might be better implemented in this kind of area? But I feel like we've already covered that and I have an idea I think of what you know, especially based off of EVIE and the evidence synthesis of conditions like PCOS, but, I mean, if you were to say that there are things that you hope for going forwards? 

00:31:27 Dr. Bassel Wattar 

Yeah. So three things.  

Number one is better education for health professionals in general and we are working on this and we're about to start an online course specific for for health professionals in the community. It will be free to attend and it's in collaboration with the charity. So watch the space. But this needs to have better adoption from, say, like the Royal Colleges and other sort of stakeholders like policymakers. 

00:31:56 Dr. Bassel Wattar 

Number two is better data curation, so thanks to COVID, we've become so much better in capturing data, large scale data, sort of perspectively in healthcare system, but not many people are doing it in PCOS. I'm hoping that we'll we'll have better resources, infrastructure, and methodology to capture large scale data and produce research at scale to inform clinical. 

00:32:22 Dr. Bassel Wattar 

And Nnumber three is have stronger collaboration with the patient representatives and at Evie, we're very mindful of that and we try to have input from the patient directly into the research we do because at the end of the day, we are doing this research to help the patients to help them improve their life. It's not for me and so it's important to have their input into it and we're always striving for better sort of partnership with them. 

00:32:48 Olivia Moir 

Yeah, that's awesome. I hope for that as well, but honestly this has just been such a great and informative episode and honestly so grateful for having you here speaking with me about it today. 

00:33:00 Dr. Bassel Wattar 

Always a pleasure and thank you for organizing this and great, great effort to put into organizing this podcast, so really respectful. Thank you.