AMA ASK ME ANYTHING · 25 years as an OBGYN EDITION

On PCOS, perimenopause, what medicine keeps getting wrong, and why I built a company. And am starting a podcast!

Apr 30, 2026

I’ve been an OB/GYN for 25 years. Now I have a podcast. Ask me anything.

Dr. Herm Weiss · hweissmd · The Metabolic Fix

Let me be honest about why I’m doing this.

I spent 25 years in clinical OB/GYN watching the same patterns repeat themselves. Women coming in with PCOS who’d been told to “just lose weight.” Perimenopausal women being handed antidepressants when what they actually had was a hormone story nobody had taken the time to read. Patients who were doing everything right and still not getting better, because the system was optimized for throughput, not answers.

I started writing. Then I started talking. The Metabolic Fix is the result — a place where I can say the things I didn’t always have time to say in a 15-minute appointment. And this AMA is a chance for you to push back on me, stump me, or just ask what you’ve always wanted to ask your gynecologist but felt like you couldn’t.

So. Let’s go.

ON PCOS — WHAT MEDICINE GETS WRONG

Why does it take so long to get a PCOS diagnosis? It happened to me at 31 after a decade of being told I was “just irregular.”

Because the diagnostic criteria are genuinely contested among endocrinologists, and because gynecologists — myself included — were trained in an era when PCOS was still primarily understood as an ovarian problem rather than a metabolic one. We were looking for the wrong things, in the wrong order, with the wrong urgency.

The Rotterdam criteria — which most of us still use — require only two of three features: irregular cycles, elevated androgens, or polycystic ovary morphology on ultrasound. The metabolic component, the insulin resistance that is present in 70–80% of cases, is not in the diagnostic criteria at all. So we diagnosed the surface and missed the engine.

Ten years is not unusual. I’ve heard worse. And I say that with genuine regret, not as a deflection.

My doctor told me metformin is the gold standard for PCOS insulin resistance. Is that still true?

Metformin is a useful drug and I’ve prescribed a lot of it. But “gold standard” is doing a lot of work there.

The evidence for myo-inositol — particularly at the 40:1 ratio with D-chiro-inositol — is now comparable to metformin for insulin sensitization in PCOS, with a significantly better tolerability profile. More than 30 randomized controlled trials. First published in the New England Journal of Medicine in 1999. And yet I still encounter patients whose physicians have never mentioned it.

Berberine is another one. AMPK activation, comparable glycemic outcomes to metformin in multiple trials, studied specifically in PCOS. Not a supplement fad — a mechanism.

Metformin has its place. It is not the only place.

Everyone online is telling me a different diet for PCOS — keto, low GI, Mediterranean, carnivore. Who’s right?

They’re all partly right and all partly missing the point.

What the research actually shows is that reducing insulin burden matters more than the specific dietary label you adopt. Keto does it by eliminating carbohydrates. Low GI does it by slowing glucose absorption. Mediterranean does it through fiber and fat quality. Carnivore does it by removing processed food entirely. The mechanism is the same. The packaging is different.

The question I ask patients is simpler: what can you sustain when you’re tired, traveling, or at someone’s birthday party? Because that’s when it has to work. A perfect protocol you abandon in month two is outperformed by an imperfect one you keep doing in month twelve.

My honest framework: eat real food, prioritize protein at every meal, make fiber non-negotiable, and stop eating in a way that requires a spreadsheet. The rest is details.

“We diagnosed the surface and missed the engine. The insulin resistance that drives 80% of PCOS wasn’t even in the diagnostic criteria.”

ON PERIMENOPAUSE — THE CONVERSATION NOBODY IS HAVING

I’m 44, my cycles are fine, but I feel like a different person — anxious, brain fog, not sleeping. My doctor ran labs and said everything is “normal.” What is going on?

Welcome to perimenopause. It starts, on average, in the mid-40s — sometimes earlier — and it starts before your labs show anything obviously abnormal. Because the first hormonal shift is not a drop in estrogen. It’s a drop in progesterone. And progesterone is the hormone that calms the nervous system, supports sleep architecture, and keeps anxiety from taking the wheel.

A standard FSH and estradiol panel, drawn on a random cycle day, will often look completely normal at this stage. Which is technically accurate and clinically useless. The biology is transitioning. The labs haven’t caught up.

When a 44-year-old woman tells me she’s anxious in a way she’s never been before, not sleeping through the night, and feels like her brain is running on half its usual capacity — I am not ordering more labs. I am having a conversation about perimenopause. Because that is what she is describing.

Should I be on hormone therapy? I’m scared of the breast cancer risk.

I understand why you’re scared. The 2002 Women’s Health Initiative study generated headlines that scared an entire generation of women off hormone therapy — and scared an entire generation of physicians off prescribing it. That fear persists even though the WHI findings have been substantially reanalyzed, recontextualized, and in many respects walked back in the literature.

The current data, particularly for women who initiate hormone therapy before age 60 or within ten years of menopause onset, shows a risk profile that is far more nuanced — and for many women, far more favorable — than the original headlines suggested. The risks are real. They are also individualized, time-sensitive, and need to be weighed against the documented risks of untreated menopause: cardiovascular disease, bone loss, cognitive decline, and a measurably lower quality of life.

This is a conversation, not a protocol. Any physician who tells you HRT is categorically safe or categorically dangerous without knowing your individual history isn’t giving you medicine. They’re giving you a policy.

I have PCOS and I’m now in perimenopause. It feels like my body is fighting itself on two fronts. Am I right?

You’re right that it feels that way. You’re partly wrong about what’s actually happening — and I mean that in the most encouraging way I can.

PCOS and perimenopause share an underlying biology: insulin resistance, chronic low-grade inflammation, and hormonal dysregulation. They’re not two separate battles. They’re the same terrain, shifting. And the metabolic work you’ve done over years of managing PCOS — understanding insulin, understanding inflammation, paying attention to what you eat and how you sleep — is not wasted. It is a head start.

Here’s something that surprises most patients: the androgen excess that defined your PCOS experience often mellows in perimenopause, because estrogen decline changes the hormonal ratio. Acne can improve. Hirsutism can ease. The picture shifts. Not always, and not cleanly — but it shifts.

The women who navigate this transition hardest are the ones who’ve never had to pay attention to their metabolism before. You have been paying attention for years. That is worth something.

Why did you start a company? Isn’t that a strange move for an OB/GYN?

It looked strange from the outside. From the inside it felt like the only logical next step.

Clinical medicine at its best is an extraordinary privilege. You are present for some of the most significant moments in a person’s life. But the system it operates in has become increasingly hostile to the kind of care I wanted to deliver — time, depth, the space to actually explain the mechanism behind what I was prescribing. A 15-minute appointment slot is not sufficient for a woman with PCOS who has spent a decade being dismissed. It is not sufficient for a perimenopausal woman who needs to understand what is happening to her body and why.

ProvationLife is my attempt to build the infrastructure that medicine didn’t give me. Education at scale. Evidence-based tools. Products formulated by someone who has read the actual literature and spent 25 years watching patients respond — or not — to what’s available. I’m not anti-medicine. I’m frustrated by its limitations in the spaces where women need it most.

I still see many patients and am actually trying to live a double life.

What’s The Metabolic Fix actually going to cover? Why a podcast?

The podcast covers what I wish every woman with a hormonal or metabolic condition had been told from the beginning: the mechanisms, not just the symptoms. Why insulin resistance drives androgen excess in PCOS. Why estrogen’s departure in perimenopause is also the departure of its anti-inflammatory function. Why the gut microbiome is not a wellness concept but a peer-reviewed regulatory system with direct effects on hormones.

Why a podcast? Because the fifteen-minute appointment isn’t enough, and a Substack post — including this one — has a ceiling. Audio lets me think out loud. It lets me be a physician and a person simultaneously, which is harder to do in writing than you’d think. And it reaches women who are driving, or walking, or lying awake at 3am wondering why their body has stopped making sense. That’s my audience. That’s who I’m talking to.

That’s the pre-loaded version. Now it’s your turn.

Leave your questions in the comments — on PCOS, perimenopause, supplements, hormones, the podcast, the company, or whatever else you’ve been carrying around that nobody has given you a straight answer on. I’ll be working through them over the next week, and the best ones will become future episodes of The Metabolic Fix.

No question is too basic. No question is too clinical. The whole point is that you should have been told this already.

— Herm

Dr. Herman Weiss

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