Rheumatologic Disease and Infertility: A World of Possibility with Dr. Brittany Panico

Have you ever been told that your rheumatologic disease precluded you from trying to conceive? Or that the medications you needed were unsafe in pregnancy and that would dictate your trajectory? Or that nothing could be done for your diminished ovarian reserve in the context of a rheumatologic diagnosis? 

Please join us today as we challenge previously held assumptions about the following:

• The crossover between infertility and rheumatologic disease, and the "why" of it all 
• Diagnosis
• Treatment
• Medication combinations and possibilities
• Fertility preservation
• Patient advocacy

Dr. Panico takes a patient-centered, whole health approach to her patients. May you borrow her wisdom and take with you pearls which might help you along your own journey, whether you have a rheumatologic diagnosis or not.

As always, please keep in mind that this is my perspective and nothing in this podcast is medical advice.

If you found this conversation valuable, book a consult call with me using this link:

www.loveandsciencefertility.com/contact

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Please don’t let infertility have the final word. We are here to take the burden from you so that you can achieve your goal of building your family with confidence and compassion. I’m rooting for you always.

In Gratitude,

Dr. Erica Bove

Transcript

Hello, my loves and welcome to the Love and Science podcast.

I am so honored to have an amazing guest today.

Her name is Dr. Brittany Panico.

She is a friend, she is a colleague, she is a rheumatologist.

She's a fantastic person and I'm so excited because there's so much we don't understand about rheumatology and infertility and recurrent loss and the overlap.

And today, hopefully we're going to shed some light on those topics.

So just be by way of introduction, Dr. Brittany Panico is a board certified rheumatologist.

She is the chief of rheumatology at Summit Rheumatology, where she has offices in Arizona, Colorado, and Oklahoma.

You all know I travel between two states and to travel between three states.

I do not know how she does it, but she does with grace and she always looks fabulous.

And she's a gout specialist too.

So I remember like two seconds in med school learning about gout.

And I didn't quite realize or appreciate how much it affects people's quality of life and really is present, not just for men, but women too.

And so I'd love to talk about that today as well, just to kind of remind us that this exists.

And if that is you, that Dr. Panico is here to help.

So welcome, Dr. Panico, so lovely to have you.

Thank you.

I'm so excited to be here.

Yeah, absolutely.

So I'd love to start by talking a little bit about sort of what you see in your practice in terms of people who've come to you with infertility who also have rheumatological disease.

Like what is your approach to that sort of a patient?

That's a great question.

And I think it really depends on what the big picture of what's going on is.

So one of the first things that we think about in phytoplogy is identifying if you have something that is in the heart of your diagnosis.

So a lot of times people think that rheumatologist will treat Hashimoto's.

And I think that's kind of a whole other story for a different day.

But we're not the endocrine specialists.

So we are the immune system specialists when your immune system is essentially reacting against your body.

And I'll let you can say that about Hashimoto's.

We're not that kind of specialist.

But we identify things like lupus, rheumatoid arthritis, psoriatic arthritis.

There's a lot of different other phytoplogy diagnoses thrown in there.

And one of the more, I guess, more pressing ones that we look for when we think about women who have either recurrent loss or are struggling to actually conceive is something called the anti-phospholipid-antibati syndrome.

And that's a syndrome where your immune system actually makes it more possible for you to develop blood clotting.

And you can have bleeding and blood clotting happening simultaneously together.

And so it can result in essentially decreased blood flow to the developing placenta.

And so we can kind of go into details of that.

But we do testing and really take a very detailed history about things that may be part of your family history, things that you may be subtle symptoms that you might not necessarily relate to the fertility process, but actually mean quite a bit in terms of developing a diagnosis or understanding why it may be difficult to go through that process.

Yeah.

And I'm still glad you brought up APLS.

I have diagnosed so many people with it in my career.

And it's amazing.

People come with so many losses.

And it's like, why?

Or maybe they've had a live birth and then they just keep miscarrying over and over again.

And it's like, this was so, quote unquote, easy the first time and now it's happening.

And that is one of the things that we can actually act on.

We can prescribe anticoagulation, baby aspirin, levonox, and really get somebody through a pregnancy.

I find sometimes it's because I think the diagnosis of APLS is so stringent.

You need two sets of labs over 12 weeks and so many of my patients and clients don't want to wait that three months to kind of find out we're often in this gray zone of like, and what if the antibodies are intermediate? What if you don't get the slam dunk diagnosis, but you think somebody's on the spectrum?

I think every situation needs to be handled as an individual situation in the context of somebody's life.

Have I treated somebody before 12 weeks when they just felt so anxious about moving forward?

I have.

I think it's really, really important also to realize that we now believe, and we have data to show that recurrent implantation failure, which is a phenomenon of IVF where people are just having embryo after embryo transferred and they're not implanting, that can also be related to APLS too.

So I was always taught like, oh, it's after the pregnancy has been established and people are having these often later losses and you have to think about it.

But now as the science evolves, we now know that even at the point of getting the uterine lining to a place where it's a fertile ground for an embryo, even APLS can affect that too.

So I think it's really important to have that high end of differential and to do the testing when appropriate.

Yeah, exactly.

Yeah.

Yeah.

And then different factors, right?

Like you mentioned the inability to implant, anytime you're asking blood vessels to grow, right?

You need the right things to happen in the body.

And you also, we kind of think about it as like, well, my body should know how to do this, right?

Right, right, right.

To a certain extent, if your immune system is prohibiting or blocking that process from happening, then your body is not getting the right signals for that process to move forward.

And so we, you mentioned, you know, science and data, and there's a lot of science that we don't understand during the pregnancy phase or pre-pregnancy phase for women with autoimmune conditions, because part of it is we don't have that population to actually study from.

It's very difficult to perform, you know, scientific studies.

And the question is, you know, we have a handful of medications that are safe.

And so there's not really new drugs being developed showing benefit in pregnant females.

I think one of my biggest sort of areas of ACE in rheumatology is we have a very limited number of medications that are studied to be safe.

And we have data from mother to baby, and there's a database that shows us, you know, where we can pull that information from.

But the new drugs that are coming on the market and being approved are not showing safety during pregnancy.

And so it's sort of this sort of like area of frustration where it's like, we know there's a growing need for safety information during, you know, trying to conceive being safe during pregnancy, safe after pregnancy.

And it's just kind of one of those things where, you know, we need the science to be there.

I'm glad you brought that up.

>> Yeah, no, absolutely.

I think just there's so many unanswered questions in the field.

And if you are somebody who's struggling and really has, you know, a tough rheumatological disease, I think it can be really hard to know.

It's like, what's the best of the bad choices?

You know, sometimes it's like, you know, what do you do?

One thing I wanted to ask you about, and I, you know, I have a rheumatologist colleague who's also gone through infertility who obviously she has kind of a special interest in this area.

And she says that like lupus in and of itself has just been, you know, she's noticed a lot of infertility in people with lupus.

And I have to, but I don't have a patient population that's like entirely people with lupus.

And, you know, I always always thought, oh, is this sickle phosphamide?

And they're, you know, sort of given such gonadotoxic therapies to control the lupus.

We do inpatient consults all the time on people with a new diagnosis, even children, right?

With pediatric lupus about fertility preservation.

But, you know, there also seems to be something about people with lupus that before they even get, you know, an agent that their anti-mularian hormone is lower than you would expect your age.

And, you know, we also see this with other rheumatological conditions.

And so, you know, is this, is there some something sort of like, you know, inflammatory that's going on in the system?

Are there anti ovarian antibodies as well?

Because there's this sort of autoimmune phenomenon and we know that autoimmune diseases tend to run together.

Like, what do you think is going on for these people who, you know, have rheumatological diseases?

Maybe they even haven't gotten agents yet that we know are harmful, but we're already seeing it.

We know AMH is not a fertility test per se, but there's something going on with their egg reserve that may affect, you know, future outcomes.

Yeah, I love that question.

And I wish I had, you know, bulletproof answer about that.

But I do, I do see, and this is, this is really in all stages of autoimmunity, is that, and the way I describe it to my patients is your immune system is like a factory.

It's designed to make and, and differentiate types of white blood cells to essentially fight infection in our body.

But during the autoimmune process, what happens is that factory setting, right, that's set at a threshold and then elevates when you have an infection is set at a threshold that's higher, creating a lot of energy or needing a lot of energy to produce these cells.

And that energy then is turned around and focused inside your body.

So instead of outwardly trying to fight infection, you're essentially using your own energy reserves to target your own body.

And so that caloric, essentially intake or the need for that drive to happen, overrides basic bodily things.

Meaning we see a lot of hair loss in people who have autoimmunity syndromes because you turn off signals to allow your hair to grow when you're using that energy.

We see weight changes either up or down because you change, you know, your metabolism changes.

And so there's all these things that are using energy in your body to essentially target itself.

And so that energy that would otherwise be devoted to other things, right, is put aside or told it's not as important.

So oftentimes menstrual cycles will change and be really off if you're somebody who's been very regular.

A lot of things can change in terms of like how much bleeding you have during those cycles, your energy, you know, fatigue and those kind of things, the way that your mental functioning, you know, we talk a lot about brain fog and fatigue.

And so I really do think that there's this reserve that is otherwise devoted towards our reproductive cycle, that when there's inflammation inside of your body, your body says that's not important to me right now.

That's not something that I'm going to focus on.

And therefore it sort of puts it in the closet a little bit or puts it somewhere where it's not as at the forefront, even though mentally, right, we have our one agenda for our lives.

We want other things to happen.

And so, you know, we're trying to override those signals.

And a lot of it has to do with, you know, again, when we talk about medication, are we using something that is not intended necessarily to, I guess, harness those energy reserves?

So we can use things like I'm just going to use prednisone as my basic example, because prednisone we use a lot of times to calm inflammation down.

But prednisone doesn't necessarily change the course of the disorder that's going on underneath the surface.

So it just sort of puts a blanket on top of the inflammation.

So it's not really solving any issue underneath the surface.

And so a lot of times we think about using steroids for inflammation and controlling it and then people start to feel better.

And then there's not a next phase.

So in rheumatology, our next step is always to find, okay, what can we do that acts a little bit like prednisone, but actually does more to treat the underlying issue.

And so if we just give sort of surface level medications of like, this is going to work for now, and we're not actually treating that underlying inflammatory signaling, we're essentially putting again, putting cloud over things and ignoring those signals that are really driving the force to happen.

So I'm not necessarily saying that a lot of people are under treated, but I do think there's a phase of autoimmunity, especially in the beginning, or especially when women say to their physician team or their medical team, you know, I would like to start trying to conceive is we do what we feel like is safe and kind of what we know has been safe in the past.

And so a lot of patients get converted to some version of steroid for a little while.

And without us really understanding that's not doing anyone any favors, even though it's quote unquote safe.

So I think there's sort of this misunderstanding about if we're not actually controlling the driving force of why that inflammation is happening, then we're not allowing your body to recognize the signals, it's okay that I devote energy towards these other things.

It's okay now that I can, you know, move forward with, again, making sure my uterus is a habitable place, making sure the mucus is in it, you know, all those things that have to be exactly in line for, you know, for fertility.

And so we, I think, you know, the best that we can in rheumatology, we try to work with, again, what's safe.

But at the underside of that, we also have to recognize if the disease is still going on, right?

Process may not happen in alignment with, again, with mentally what we're looking for.

That's so fascinating, really, really fascinating.

And you know, I've actually never heard anybody describe it quite like that.

You know, we think about that in terms of like hypothalamic amenorrhea, that the body is just shunting energy towards like the necessary organs, but I had never thought about kind of how that sort of disease process is sort of taking the energy.

Sure, I thought about it in like cancer, but not rheumatological disease.

And that makes so much sense for what we see.

And also, you know, I talk about luteal face defect like this as well, like, sure, I can give you a progesterone, but that's like a band-aid on the problem.

Like let's correct the problem at the source so that you could actually have a good ovulation.

And then, you know, we're going to move on forward.

And so it just makes so much sense.

And thank you for such a clear explanation because I think it's going to resonate with a lot of people.

And now I have so many thoughts, but like one thought I want to say is what if someone comes to see me in my clinic with infertility and they actually have a rheumatological, you know, like I always take a full review of systems.

Like what if they tell me they have like joint aches and joint pains and, you know, and they've never really made, you know, so many people don't even have a PCP.

Like, you know, at what point do you start to think about saying, huh, I wonder if, you know, there was some sort of chronic disease element going on here, right?

Because we have so much unexplained infertility.

A third of patients have unexplained infertility, which I just think is like undiagnosed, right?

So undiagnosed infertility.

Exactly.

Yeah.

So I think the first place to start is, I mean, the easiest things to look at is sedimentation, right?

You can call it ESR and C-reactive protein.

So if those are elevated, right, there's some inflammatory process happening.

However, on the other side of that, patients with psoriatic arthritis or like psoriasis, for example, may not have elevated effolation levels.

So it gets a little bit tricky to rely on those specifically for, to help with the diagnosis.

But I do think there's a component of, you know, establishing to, if you're complaining of a lot of joint symptoms or you have rashes or you have something that just, you know, these symptoms that you can't explain, to see a rheumatologist and specifically, and I don't, I don't mean this in, you know, a biased way, but I do think there's something about women helping women where we have a little bit of a different perspective of the urgency or the fertility/infertility arena, right?

And so I do find in rheumatology, there's sort of this, I guess, traditional approach of women being heard or being told that they can't try to conceive and fix their underlying issue at the same time.

And that's just not true.

Right.

We have medications that are safe.

We have medications that have been proven to not lead to, you know, increased risk of birth defects and things like that.

And so working with, you know, a team of people who are comfortable with using those medications is really recommended.

And there's, you know, we can do, again, nothing happens overnight, right?

But we can do things that sort of speed up the process.

And even something like hydroxychloroquine.

I know it's in the news a lot.

I know, you know, COVID, people think, oh, well, that's just the thing, you know, that was popular during COVID.

There's a lot of role for that during sort of the fertility workup because it's an anti-inflammatory in a way that modifies underlying disease.

So we call that disease modifying agent.

And it's very simple.

It's, you know, there's very few side effects.

It's not, it may not be something that somebody takes long term.

I have plenty of patients who say, you know, I'm going through this process working with, you know, their female healthcare team.

And we opt to use it just for a short period of time, just to see if the body, you know, the inflammation responds or calms down.

So I think sometimes there's this idea of like, I have to be on as minimal things as possible, which I completely agree.

But when we can't answer the question, when we know there's some inflammatory thing happening, and maybe our labs don't show that, or maybe we just can't put a name to it with a blood test.

I do think though, you know, as long as somebody has the time, maybe say one to three months of just seeing if that helps, because again, it's a safe medication, our lupus patients, you know, will lie on it.

And so if we can calm that inflammatory process down, there may again, there may be something to it that we just haven't found yet to put into words or put a name to that sort of again, takes that inflammation, all of that metabolic energy, triggering inflammation and, and calms that down in a way that prednisone can't.

So again, it's not to say well, here's, because I think that's kind of been our approach is like, here's a little bit of prednisone.

We know you can kind of get by with this, but that may get you to step A or B, but it might not carry you through CD and down the line.

Yeah.

Yeah.

And that makes so much sense.

There are actually some per limb data I used to actually give not so much anymore.

And I guess I changed practices and sort of stopped.

I need to revisit that, but I used to give plaque, one L or hydroxychloroquine to patients with a current loss.

And some of the preliminary data actually was encouraging in that population.

So it was just interesting to think about.

Yeah.

Thank you for sharing that.

Another question I had as you were talking about sort of this, these rheumatological processes and maybe stealing energy from fertility, these are chronic diseases, right?

There's different phases, but there's something that you don't really undiagnosed somebody with these things.

And one question I have is now we have the possibility for fertility preservation, right?

And, you know, yes, certainly for girls who are about to get, you know, toxic agents and such, but also even for like, you know, young adults, right, who are they've had, they've gotten through puberty, right?

But maybe their egg reserve is lower than we might think under different circumstances.

If they didn't have these diseases, it would be higher.

We just don't know.

So one thought that I have is like maybe thinking about sort of opening up the communication a little bit better between fertility specialists and rheumatologists about, okay, you know, it only takes two weeks to do a cycle of egg freezing or embryo freezing.

And you know, if we know that these things can be progressive, like, you know, it could there be a role for more fertility preservation, obviously with shared decision making, but a fertility is a priority for people and we know it gets worse with time.

Maybe that's something to sort of open up the conversation a little bit more.

Yeah, I love that.

And I think really this just about opening the conversation, right?

It's joining together to say, you know, I do these kind of things and I can offer these kind of services if you have anybody who, you know, fits this description, you know, let's work together.

And I do think as you know, as we're talking about this, it like sparked so many ideas that I have because you're right.

We see people of all age spectrum, right, who may not even be thinking about it.

And we typically ask in the mythology, you know, I make a point to ask, are you trying to conceive or is your goal to have, you know, to try to conceive within the next, I usually say six to 12 months, because that gives me an idea, okay, if this doesn't work today, what's going to be my next step and what am I thinking about?

And I do think having that at least, you know, coordinating relationship where we can say, I've worked with, you know, somebody in town who does this, would you like a consultation, at least to understand what your options are?

Because you're right. Sometimes we get, you know, we get to a point in our life where it's like, you know, I wish I would have thought about that.

Nobody explains to me what my options were.

Right.

And sometimes it can be so heartbreaking, especially and I'm here a lot of times, you know, women will come with a diagnosis and they'll say, well, I can't try to conceive.

And it's like, but explain to me why.

Well, I was told through this journey, right, that these medications may make it so that I can't.

And aside from cyclophosphamide and repetitive doses of it.

So typically one cycle we think, you know, doesn't significantly limit your ovarian reserve.

But again, we don't know because we're not always testing every single person prior to using it, but not necessarily, you know, there's not a ginormous population of patients that require that medication.

Right.

So, so I do think just having that is a, you know, would you like to explore what your options are with somebody who understands that conversation?

Absolutely.

We've done a lot better in the oncology world, I think, you know, and, you know, people are already getting blood work.

Right.

So I think in both directions, right?

Like when I see a patient, I'm like, Oh, maybe they have rheumatological disease.

I can head on a set of, right?

Because we're already getting five vials of blood.

Right.

Like same thing with rheumatologists, like an antinolarian hormone, you know, it's very controversial in our field because a lot of people say it is not a screening test for fertility.

You can conceive with an undetectable image.

Absolutely.

And I think that sometimes trending it over time, you know, once the image is undetectable, there's data that menopause happens in like five to six years.

And if you're 22 with an undetectable image, then that, you know, you might want to know about that.

So I think that just, you know, some rheumatologists might say, Oh, I don't know how to interpret it.

Like if it's less than one, not so great.

If it's above one, you know, better, but also kind of looking at it sort of age, age related, like if you're 22 and have an image of one that's very different than if you're 39 and have an image of one too, because that would be expected at 39, but not at 22.

So, you know, maybe there's even more like, Oh, your image is 0.6 and you're 25.

You already asked the question, which I think is amazing.

But then pairing that to say, huh, you know, that's how I counsel people when they come to see me, there may be more, you know, I put urgency in air quotes, but you know, sort of a little bit more motivation to consider fertility preservation when we see a low value and to have a baseline is really helpful because then you can see if they have to go on one of these agents, like how much has it affected things?

Sure there's a natural decline over time, but like to have two data points is always better than just, you know, sort of that question mark.

What was it before we started?

Right.

So it's just an idea that I had.

That's fascinating.

What other thoughts are coming to your mind as we're talking, you know, just so many options for collaborations.

Yeah.

I think, I mean, for me, the biggest thing is just never stop asking questions.

If you really are curious, I mean, there, there may be people who may be in a situation where we say, I don't know, I'm not really sure about the answer to that question, but it sparks interest.

You know, if patients are asking, it does pull the level of accountability of like, hmm, I should probably look into this and find this out for somebody else who asks that question.

So I think it's never, you know, it's never wrong to ask.

And I also think when, if you come into a situation or come across a situation where you're told, you know, this medication will change your ability to conceive, always clarify that.

Because we often will use medications in rheumatology where we're advising patients not to try to conceive during, when you're on that medication, for example, because it may lead to increased risk of birth defects.

Methotrexate is the biggest one that comes to mind.

It's really, it's a very common medication and we do not want you trying to actually know, no, no, no.

But just because you're on Methotrexate doesn't mean you can't stop it and be transitioned to something that is safe during that phase of your life and then manage, you know, your condition in a safe way.

So I think there is sort of this idea of, well, I'm on this and my doctor hasn't offered to switch me on to something else.

Therefore, I don't want to rock the boat or they're telling me this is what they think I need.

But we oftentimes don't understand or don't ask or don't know what people's goals are.

And so we oftentimes we rely on the patient to say, you know, I am actually thinking about trying to conceive or I'm meeting with a fertility specialist in the next amount of time.

How might my treatment change if we go down that road?

And often, you know, now I really encourage patients to use chat GPT.

If you're nervous about asking your doctor a question or your health care team a question, put that in chat GPT and you can actually bring something with you to say, you know, I don't really know how to ask this question, but this is what I'm thinking about.

This is what I found on the internet because then we were forced to answer to that.

Right.

So I think if people get upset or get annoyed that people are asking questions, they're not the right health care team for you.

We want to align with your goals as a patient.

And it really is about what you want for your body.

And I think we don't take that into account as much probably as we should in health care.

And especially with autoimmunity, you know, because there's such a wide range of medications, really making sure that your goals align with what your health care team is, you know, expressing is quote unquote necessary or recommended.

Right.

Because we can always change treatment.

We can always do something else.

I've had patients who, you know, say they're trying to conceive for years and we keep them on medications that are safe and we make it work.

I have patients that go, you know, from pregnancy, breastfeeding to, you know, trying to conceive again right away.

And we just have to have that conversation of, okay, what's happening inside your body?

What are the changes happening?

And what was what?

How is your autoimmune condition?

You know, what do we think it's very active?

Do we think it's controlled?

Especially with lupus, you know, we brought up lupus trying to conceive during a phase where your lupus is very active is going to be significantly challenging because again, your body is using a lot of energy to create that inflammation.

And so we want to set things up for the best possible results, but that may require a little bit of time to get your diagnosis under, you know, under better control.

Yeah.

And that makes so much sense.

I think maybe some doctors don't ask, some patients don't say, I also wanted to bring up, I think there's a lot of women, especially in their thirties who are like, maybe I want a family, maybe I don't, I'm not really sure.

You know, sort of, I think with like the advent of birth control, you know, and everything, I think there's just a lot more ambivalence that I see about family building.

And so I might even extend that.

So if you're in that gray zone of like not being sure, I would still bring it up and just say, Hey, I've been thinking about this and I heard this podcaster, you know, and I, you know, I think I might want to conceive if I were to shift gears and that was my reality, how could, how might my treatment be different?

Right?

And it is its own sort of a, it's not like I've been trying for six months or 12 months and it's not working.

It's like, you know, what could the landscape look like, which I just think opens up so much possibility for decision making.

Yeah.

Especially if you're somebody, you know, with your rheumatology team or you're on three months cycle or six months cycle, right?

With your medication, we want to, we want to be able to make those adjustments with you.

And so it is really important to break that up of, you know, even if you're thinking about it, so to consider.

And that's also a great population of people who might benefit from fertility preservation too.

Maybe now it's not the time, but I mean, gosh, like, I mean, we saw this with COVID five years go by and you go from being 32 to 37 and things aren't as easy and people kick themselves.

I see so much regret.

I have podcasts about regret.

And so, you know, if there's even that like sort of glimmer, that sort of inkling in your mind, just sort of just, just lean into it and think about it because it's always easier sort of on the front end than on the back end, I would say from my experience.

Yeah.

And if things, you know, if you change medication and your body doesn't feel as good, it's not a defeat like, okay, this is never going to work again.

It just may not be the right time.

And that's a conversation of, okay, well, what are some of the other things that we can do to maybe help us be more open.

I think sometimes we have to get, you know, open our minds to adding medications that may, we may not pair together all the time automatically.

But again, in the, in the situation where somebody's, you know, wanting to conceive, we have to think about that.

And so you may go from being on one medication to now maybe needing two, but those two are much safer for you if you make that decision and that's okay.

It doesn't mean that things are worse.

It doesn't mean that you failed.

It doesn't mean that your body, you know, is failing you.

It just means that we have to be.

I use the term kind of creative in a sense of we have to open our minds to what might work for an individual, even though something else was working before.

And that's okay to revisit, you know, multiple times if needed.

That's so beautiful.

What I'm, my coach brain is like, this is possibility thinking at its finest, right?

Like being creative thinking outside the box.

Dr. Pinnico, you were a gout specialist and I about in the last year, so my first patient with infertility and gout.

And so that was really interesting for me because I kind of had forgotten that those two can coexist.

Can you share maybe a minute or two, just about, you know, what's new in the gout space?

What if you have infertility or you're trying to conceive and you do have gout, like what, what's going on there?

Cause I can't think of anybody who has their finger on the pulse.

Is that the right expression?

Yes.

Kind of knowing what's up with gout right now.

That's a great question.

You're putting me on the spot about medications and we're talking about that.

So yes, it's certainly possible.

Women of any age can have gout, especially if you have a family history.

It's a metabolic disorder.

So it does not mean that you're eating bad foods.

It doesn't mean you're making, you know, bad lifestyle changes choices.

It really has to do with your body's ability to filter out your acid through your kidneys.

And let's say maybe you're a transplant patient, right?

You've had a transplant and you develop gout because of the medications, you know, the effects on your body.

And so I'd have to go back and double check, you know, medications, but I definitely, you know, it's certainly possible to treat you through that process and, you know, working through fertility and also understanding that, you know, that it's certainly possible.

I do think there's sort of this idea and I'm working so hard to bust the myth that women, especially premenopausal women can have gout.

I have patients who are in their 30s, you know, and have had gout before.

And so it certainly is possible.

And also, you know, it goes back to that inflammation, right?

If there's inflammation going on in your body, that's not the ideal post to try to, you know, hurt to have a pregnancy.

And so we want to make sure we get that inflammation that gout can trigger under better control so that your body does have the energy reserves and, you know, can sustain a pregnancy to term.

And so I think there's, you know, there's ways to find gout specialists in your area.

Google is a great resource.

Again, ChatGPT is a great resource.

But I think certainly, you know, young women can have gout and I'm so glad you brought it up because it's definitely out there and I think, you know, misunderstood and misdiagnosed.

And you know, a lot of patients are treated as rheumatoid arthritis or seronegative arthritis, right?

And they actually have gout.

So if your medication isn't working, then consider gout is a diagnosis even.

Yeah.

All I remember is that there was a medication she was on and there was a way through.

And so again, possibility thinking, I think we just have to like think about it more broadly and know that there are ways that there are ways through.

So that's a great segue.

I wanted to just sort of have you have a platform to share where can people find you?

I think your approach to rheumatology is very novel.

I think you are so, your fund of knowledge is so deep and your experience is, you know, obviously spans many years.

And as we've heard today, your perspective being very holistic and goal oriented and patient centered, I think we need more of this in this space.

And so I'm sure people are like, where can I find her?

So share, please share, where can people find you?

Yeah.

So I'm at some of rheumatology.

I'm a wonderful team.

And so my practice, my name location is in Arizona, but I have practices in Colorado, Omaha.

And then I'm at Dr. Brittany Pnico on Facebook and Instagram as well.

So Dr. and my name Brittany.

Yes.

Follow her, please.

And thank you so much for sharing your wisdom.

I know so many are going to benefit and until the next time.

Yeah.

Thank you for having me.

Absolutely.