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I wish I had a best friend like Brienne of Tarth. First of all, her name is totally badass. Just say it
over and over –it’s super fun. Tarth. Tarth. Ok, I’ll stop. One more time. Tarth. Just rolls off
the tongue.
But I digress. In George R.R. Martin’s description of Brienne when we first meet her he says,
“Brienne is unfeminine in appearance and is considered unattractive by Westerosi standards. She
is tall, muscular, flat-chested, and ungainly, with long, shoulder-length brittle straw-colored hair
and broad, coarse features that are covered in freckles. She has large, beautiful blue eyes.”

Thanks for that, George.

If I had to guess today, she’d have some polycystic ovarian syndrome—or PCOS. Most women
that come to see me with PCOS complain about “manly” symptoms—such as increased hair
growth in typically masculine areas, acne, infrequent or absent periods. (and for the record, I
have some PCOS patients who look like Arya Stark, too, although it’s more rare.)

A lot of my patients with PCOS feel ashamed because they have trouble losing weight or feel
like they “look like a dude” but that’s the hormones –you PCOS ladies are BEAUTIFUL!!!! If
Brienne of Tarth can be the biggest (meant that figuratively) badass woman on TV—you can be
too!

PCOS is a hormonal disorder common among women of reproductive age. Women with PCOS
may have infrequent or prolonged menstrual periods or excess male hormone (androgen) levels.
The ovaries may develop numerous small collections of fluid (follicles) and fail to regularly
release eggs.

We don’t know what the exact cause of PCOS is. Factors that might play a role include:

 Excess insulin. Insulin is the hormone produced in the pancreas that allows cells to use
sugar, your body's primary energy supply. If your cells become resistant to the action of
insulin, then your blood sugar levels can rise and your body might produce more insulin.
Excess insulin might increase androgen production, causing difficulty with ovulation.

 Heredity. Research suggests that certain genes might be linked to PCOS.
Brienne’s mom and sisters died when she was very young, so although we know she’s a
descendant of an equally badass knight (one of Westeros’ legends), we know little about
her maternal genetics.

 Excess androgen. The ovaries produce abnormally high levels of androgen, resulting in
hirsutism and acne. Since a MAN wrote the novels and since MEN wrote and directed the
series, I can only presume these symptoms are what they are talking about when they
discuss her “ill looks”. Give the woman a freakin’ break!

Complications of PCOS can include:
 Infertility
 Gestational diabetes or pregnancy-induced high blood pressure
 Liver inflammation caused by fat accumulation in the liver
 Metabolic syndrome — a cluster of conditions including high blood pressure, high blood
sugar, and abnormal cholesterol or triglyceride levels that significantly increase your risk of
cardiovascular disease
 Type 2 diabetes or prediabetes
 Sleep apnea
 Depression, anxiety and eating disorders
 Abnormal uterine bleeding

Obesity is associated with PCOS and can worsen complications of the disorder. A diagnosis of
PCOS is made when you experience at least two of these signs:

 Irregular periods. Infrequent, irregular or prolonged menstrual cycles are the most
common sign of PCOS. For example, you might have fewer than nine periods a year, more
than 35 days between periods and abnormally heavy periods. Martin doesn’t give us ANY
insight into the menstrual cycles of ladies of Westeros, so we’ll have to surmise.
 Excess androgen. Elevated levels of male hormone may result in physical signs, such as
excess facial and body hair (hirsutism), and occasionally severe acne and male-pattern
baldness. Saw Palmetto is an OTC herb that can help reduce androgen levels.
 Polycystic ovaries. Your ovaries might be enlarged and contain follicles that surround the
eggs. As a result, the ovaries might fail to function regularly.

I have no idea what they eat in Westeros –I don’t think I ever see them eating—except for that
weird Walter Frey cake made out of his sons…but I’m pretty sure it’s like the diet at Medieval
Times. So aside from a ton of ale, I don’t think Brienne’s diet is an issue. And jeez she works
out like 15 hours a day!

Weight loss for PCOS ladies can be challenging because insulin resistance makes it harder to
lose weight. I try to recommend a low-carb eating plan for my PCOS gals. And don’t kill
yourself at the gym or at knight training. PCOS is a SYNDROME—not a terminal disease– so
even a modest reduction in your weight — for example, losing 5 percent of your body weight —
might improve your symptoms.

Medications
To regulate your menstrual cycle, the Grand Maesters-Flash might recommend:
 Combination birth control pills. Pills that contain estrogen and progestin decrease
androgen production and regulate estrogen. Regulating your hormones can lower your risk
of endometrial cancer and correct abnormal bleeding, excess hair growth and acne.
 Progesterone therapy. Taking progesterone for 14 days every months can regulate your
periods and protect against endometrial cancer. Progestin therapy doesn't improve
androgen levels and won't prevent pregnancy. The progestin-only mini-pill or progestin-
containing intrauterine device is a better choice if you also wish to avoid pregnancy. Wild
yam cream also is a natural version of this and is available online or in natural food stores.
To reduce excessive hair growth:
 Birth control pills. These pills decrease androgen production that can cause excessive hair
growth.
 Spironolactone (Aldactone). This medication blocks the effects of androgen on the skin.
Spironolactone can cause birth defect, so effective contraception is required while taking
this medication. It isn't recommended if you're pregnant or planning to become pregnant.
 Eflornithine (Vaniqa). This cream can slow facial hair growth in women.
 Electrolysis/Laser.  Ouch, but effective.

I hope she gets some help soon because infertility can be an issue with PCOS—and I want to see
some Tormund/Tarth offspring when this is all over!

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