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Is your menstrual flow abnormal?

Last week I wrote about irregular menstrual cycle patterns, and what they might mean from a stress physiology perspective. Tracking will help you identify what is happening with your menstrual cycle, but interpretation of those patterns requires an understanding of what is considered normal vs abnormal.

This post is part of a series covering frequently asked questions about your menstrual cycle, with an emphasis on abnormal presentation. What a normal period should look and feel like was discussed in a previous post. In this post we will cover abnormal menstrual flow patterns which should be distinguished from non-menstrual flow patterns. The term abnormal uterine bleeding encompasses both.

Menstrual bleeding: heavy periods, light periods, prolonged bleeding, menstrual clots

Non-menstrual bleeding: mid-cycle bleeding, premenstrual bleeding, bleeding after sex

I want to emphasize that this post is not meant to replace medical advice from a doctor or other healthcare provider. There are certainly times when it is strongly advised to see your doctor. For example:

  1. No periods
  2. Cycles that are shorter than 21 days or longer than 35 days
  3. Bleeding for more than seven days
  4. Losing more than 80 mL of menstrual fluid in one period
  5. Period pain so bad that you cannot do your normal activities
  6. Pain between periods, especially if it is severe
  7. Bad-smelling vaginal discharge
  8. Bleeding between periods that is not ovulation spotting

Excerpt From: Briden, Lara. Period Repair Manual: Natural Treatment for Better Hormones and Better Periods.

Let’s start with a definition. Abnormal uterine bleeding (AUB) is bleeding that is abnormal in duration, volume, frequency, or regularity; and has been present for the majority of the previous 6 months (McCance KL & Huether SE, 2019). Outdated definitions remain commonly used and include terms like: menometrorrhagia, menorrhagia, menorrhea, polymenorrhea, metrorrhagia, and hypermenorrhea. In some cases, I will refer to these terms. Current terminology describes AUB as chronic, acute, inter-menstrual and heavy. Studies show that ten to thirty percent of women will experience AUB in their lifetime (McCance KL & Huether SE, 2019).

2. Menstrual flow

Do you have heavy periods?

The outdated medical term for heavy periods is menorrhagia. According to Medscape, “Menorrhagia is defined as menstruation at regular cycle intervals but with excessive flow and duration and is one of the most common gynecologic complaints in contemporary gynecology”(Julia A Shaw et al., 2018).

Two important pieces of information in that definition: 1. excessive flow AND duration; and 2. regular cycle intervals.

1. Excessive flow AND duration. Normal menstruation length is 3-7 days. Normal blood loss is 25-80 ml. To visualize this, one soaked normal-sized tampon or pad holds a teaspoon (5 ml) of blood. Depending on the model, a menstrual cup holds about 2 tbsp (30 ml) of blood. What type of tampon or pad (liner vs overnight) was used and if it was soaked may add some insight, since quantity is a very subjective issue.

Taken together, this means that heavy bleeding is flow that lasts longer than 7 days and blood loss greater than 80ml.

2. Regular cycle intervals. Menorrhagia is defined as heavy menstruation at regular cycle intervals. Heavy menstrual bleeding should be distinguished from other bleeding patterns because of the lengthy list of possible causes. The workup will be different for other diagnoses, so it’s important that you know your cycle length. If you don’t already do so, please start tracking your cycle. For example, menometrorrhagia is the medical term used to describe frequent and excessive flow. It is a combination of heavy menstrual bleeding and irregular bleeding; therefore, factors contributing to both must be considered.

This leads me to the next point. The workup.

Heavy bleeding requires a thorough patient history, physical examination (including pelvic exam), imaging studies (if indicated) and appropriate lab studies. Pregnancy is the most common cause of irregular bleeding in women of reproductive age and the first diagnosis that should be excluded before further testing or treatment. Depending on your signs and symptoms, your doctor will want to rule out underlying medical conditions, including bleeding disorders. This is strongly considered when someone has any of the following:

  1. Menorrhagia since menarche
  2. Family history of bleeding disorders
  3. Personal history of 1 or more of the following: (1) Notable bruising without known injury, (2) bleeding of the oral cavity or gastrointestinal tract without an obvious lesion, or (3) bleeding from the nose of more than 10 minutes’ duration, possibly requiring packing or cautery (Julia A Shaw et al., 2018).

Causes are numerous and often unknown. Factors contributing to heavy bleeding can be sorted into four categories: organic (eg bleeding disorders), endocrinologic (eg PCOS), anatomic (eg fibroids), and iatrogenic (eg IUDs) – medical term that means it was caused by medical examination or treatment (Julia A Shaw et al., 2018). If the workup does not provide any clues to the cause, a diagnosis of dysfunctional uterine bleeding (DUB) is given. Most cases of DUB are secondary to anovulation. I wrote extensively about anovulatory cycles in this post. In DUB, cycles are usually irregular.

Once this workup is complete, treatment should be tailored to the underlying cause, your health history, your health needs, and desired health outcomes. Treatment must also address the specific part of the menstrual cycle perceived to be abnormal, (ie, cycle length, quantity of bleeding, presence of clots and their size).

After a proper workup, if the cause is still unknown or if medical therapy fails to alleviate symptoms, iron-deficiency anemia as a result of blood loss must be considered and addressed. Iron studies will help with this assessment. Breathlessness, easy bruising, palpitations and fatigue may be experienced.

People who do not respond to medical therapy may be offered surgical intervention to control the menorrhagia. For some people this may be the right option. However, it is at this point (before surgery) that a naturopathic doctor may recommend functional lab testing, like a month-long salivary or dried urinary hormone test. This type of cycle mapping provides the full picture of a woman’s hormonal pattern throughout her menstrual cycle. The two main hormones that are said to impact menstruation are estrogen and progesterone. These hormones regulate the cycle. Unopposed estrogen (due to lower than optimal progesterone levels or estrogen excess) can result in heavy bleeding because estrogen allows the endometrium to proliferate and thicken. Progesterone keeps that growth in check. But why would this imbalance occur? A number of factors contribute to hormonal imbalance. The problem with standard serum lab testing is that it only tests reproductive hormones on a single day or two days (day 3 and/or day 21) of your cycle. But what if everything appears normal at that specific point in time? This is where functional medicine testing can help. Once the hormonal pattern is fully elucidated, symptoms can be correlated with hormone levels.

Here is a DUTCH cycle mapping sample report from Precision Analytical.

Source: https://dutchtest.com/resource/dutch-cycle-mapping-sample-report/

A complete picture of your cycle in graph format (fun, I know) will allow for a more accurate and comprehensive treatment program specific to your situation and needs. This is what individualized medicine is all about. In my practice, I do not charge a mark-up on these tests. I charge what the lab charges me. In many cases, I need this information. I will never order unnecessary testing for financial gain. This is something that I feel very strongly about, so I want to be transparent with my approach here. If I order functional lab testing, it is because I need it. Not because I want to make an extra buck or two.

Recap: So are your periods heavy? Ask yourself:

  • Do you pass clots?
  • Do you have to change menstrual products overnight?
  • Do you experience “flooding” where the blood seems to pour out?
  • Does the bleeding interfere with your normal activities? Consider your physical, emotional, and social quality of life.
  • Has the heavy bleeding made you anemic or low in iron and red blood cells?

These are some of the questions I ask my patients as part of a menstrual history when heavy bleeding is suspected or reported. Common and concerning symptoms around menstruation should be openly discussed with your healthcare provider. There is a lot of information that can be obtained from a thorough health history.

Do you have menstrual clots?

One feature of heavy bleeding is passing clots (lumps of blood) during menstruation. When menstrual flow is heavy, your body’s clotting system is activated. The clotting or coagulation system is a group of plasma proteins that, when activated sequentially, forms a blood clot. However, if this system doesn’t have time to keep up with the flow (because of heavy bleeding), you will see menstrual clots. A few clots are fine, but if you regularly see clots larger than a quarter, then please see your doctor.

Are your periods light?

If normal menstrual fluid loss is 25-80 ml, it stands to reason that light menstruation is less than 25 ml. Again, quantity is a very subjective issue so be sure to track your menstrual product use.

If you have determined that your periods are light, then the next important step is determining if you’re ovulating. If you’re not ovulating, then it’s not a true period. It’s an anovulatory bleed. You must restore ovulation. Menstruation is part of a cycle. Remove any part of that cycle, and you can’t progress from one step to the next. The fertility awareness method (FAM) is a way to track your physical signs of ovulation. Read more about it here and here.

It’s normal for this to occur occasionally. If it’s happening regularly, then you should talk to your doctor about PCOS. If that’s been ruled out, stress could be the cause. Stress disrupts the communication between your hypothalamus and anterior pituitary. The consequence of this disrupted communication is a mistiming of the release of pituitary hormones, and a subsequent lack of ovulation and/or estrogen and progesterone production by the ovaries.

If you are ovulating and your periods are still light, this could be normal for you. However, this could also be a sign of low estrogen levels due to smoking, under eating (a type of stressor) or too much soy or phytoestrogens in the diet.

I’ve kept this part of the discussion relatively brief because I covered anovulatory cycles thoroughly in this post.

Do you have prolonged bleeding?

Normal menstruation length is 3-7 days. If your flow lasts longer than seven days, you likely had an anovulatory cycle. That can occur with PCOS or perimenopause.

Polycystic ovary syndrome (PCOS)

The main symptom of PCOS is irregular periods – late periods or too many days of bleeding. Irregular periods are typically due to anovulatory cycles. In fact, PCOS is the most common cause of anovulation and ovulatory dysfunction in women (McCance KL & Huether SE, 2019).

The mechanisms of PCOS are better understood than the causes. According to medscape, the exact cause of this condition is unclear. “PCOS can result from abnormal function of the hypothalamic-pituitary-ovarian (HPO) axis. A key characteristic of PCOS is inappropriate gonadotropin secretion, which is more likely a result of, rather than a cause of, ovarian dysfunction” (Richard Scott Lucidi et al., 2019).

Key point: result of, rather than a cause of, ovarian dysfunction. But why is there ovarian dysfunction in PCOS?

PCOS is associated with elevated insulin levels (called hyperinsulinemia), which may have gonadotropin-augmenting effects on ovarian function. The main gonadotropins are follicle stimulating hormone (FSH) and luteinizing hormone (LH). These hormones are made and secreted by the anterior pituitary. They act upon the ovaries, where they regulate the production of steroid hormones. In PCOS, there is increased circulating LH and decreased FSH. This imbalanced LH:FSH ratio leads to excessive production of androgens:

“Under the increased stimulatory effect of luteinizing hormone (LH) secreted by the anterior pituitary, stimulation of the ovarian theca cells is increased. These cells, in turn, increase the production of androgens (eg, testosterone, androstenedione)” (Richard Scott Lucidi et al., 2019). This is why we see high androgens on a blood test or physical signs of androgen excess in people with PCOS.

High androgen levels in the ovary inhibit FSH; hence, they also inhibit development and maturation of the follicles. Ovarian follicles are sacs within your ovaries that contain the eggs. In a normal menstrual cycle, ovulation occurs when one dominant follicle (rarely two) finally ruptures and releases an egg. After ovulation, the emptied follicle restructures itself into a progesterone-secreting gland called the corpus luteum. Since there isn’t total suppression of FSH in PCOS, follicular growth continues. But not to the point of maturation, which is needed for ovulation. Increased androgen secretion by the ovaries contributes to premature follicular failure (known as atresia) and persistent anovulation. A vicious cycle ensues when the chronic absence of progesterone (due to anovulation) contributes to the high levels of LH and low levels of FSH. Over time, persistent anovulation causes enlarged polycystic ovaries characterized by a smooth, pearly white capsule.

The classic polycystic ovary that results from a state of chronic anovulation can be seen in the picture below:

Ultrasound of polycystic ovary

Source: McCance, K. L., & Huether, S. E. (2018). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). St. Louis, Missouri. Elsevier Health Sciences. 1720 pages.

It’s much more complicated than this, with many other hormones and signalling pathways involved, but this provides a basic understanding of the hormonal mechanisms that lead to anovulation.

Diagnostic criteria for PCOS can get very confusing. Since PCOS is a syndrome (a group of symptoms) and not a disease per se, there is a broad set of criteria used to determine if a woman has PCOS. Different societies have different criteria. In my practice, I look at ovarian dysfunction (irregular periods) and signs of androgen excess (high androgens on a blood test or symptoms of high androgens such as hirsutism, acne, and androgenic alopecia).

This is similar to the criteria set forth by the Society of Obstetricians and Gynaecologists of Canada (SOGC). They indicate that a diagnosis of polycystic ovarian syndrome (PCOS) is made in the presence of at least 2 of the following 3 criteria, when other reasons for high androgens have been ruled out (eg. congenital adrenal hyperplasia, androgen-secreting tumors, or Cushing syndrome):

  1. Oligo-ovulation or anovulation*
  2. Clinical/biochemical evidence of hyperandrogenism
  3. Polycystic ovaries on ultrasonograms (Richard Scott Lucidi et al., 2019)

*Oligo-ovulation and anovulation manifested as infrequent or irregular periods and absence of periods, respectively.

Women with PCOS experience abnormal menstruation patterns due to infrequent, irregular or chronic anovulation. In general, the majority of abnormal uterine bleeding is due to lack of ovulation. Remember that ovulation is needed for progesterone, and progesterone keeps estrogen in check. Estrogen encourages endometrial growth, whereas progesterone limits growth. Without ovulation, menstrual flow may become irregular, excessive, or both, resulting from the large quantity of tissue available for bleeding (McCance KL & Huether SE, 2019). Treatment goals for women who experience irregularities in their menstrual bleeding due to lack of regular ovulation should focus on inducing regular menstrual cycles.

Conclusion

The first step in assessing abnormal bleeding is to determine the cause of bleeding. If no cause can be found, it is usually assumed that the bleeding is caused by lack of regular ovulation.

Abnormal uterine bleeding encompasses several patterns. In this post we covered the patterns that are observed during menstruation and what they might mean. In another post, I’ll cover the non-menstrual patterns of abnormal uterine bleeding, like mid-cycle bleeding, premenstrual bleeding, and bleeding after sex.

McCance, K. L., & Huether, S. E. (2018). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). St. Louis, Missouri. Elsevier Health Sciences. 1720 pages.

Irregular menstrual cycle

Irregular menstrual cycle patterns – stress perspective

Photo by JESHOOTS.COM on Unsplash

Last week I wrote about what a normal period should look and feel like.

This post is all about irregular menstrual cycle patterns, and what they might mean from a stress physiology perspective.

Tracking will help you identify what is happening with your menstrual cycle, but interpretation of those patterns requires an understanding of what is considered normal vs abnormal.

In this post we will cover irregular periods. Both long cycles and short cycles are types of irregular periods. Lack of periods, known as amenorrhea, will also be discussed. There are many reasons for an irregular cycle. Stress being a common one, especially for women 45 years of age or younger. However, certain medical conditions, like thyroid disease, celiac disease, PCOS, and others should be ruled out first. When no medical diagnosis can be found, stress may be the cause. But how exactly does stress lead to irregular periods?

Recap – Menstrual cycle irregularity: no periods; late periods and early periods (includes long cycles and short cycles, respectively)

I want to emphasize that this post is not meant to replace medical advice from a doctor or other healthcare provider. There are certainly times when it is strongly advised to see your doctor. For example:

  1. No periods
  2. Cycles that are shorter than 21 days or longer than 35 days
  3. Bleeding for more than seven days
  4. Losing more than 80 mL of menstrual fluid in one period
  5. Period pain so bad that you cannot do your normal activities
  6. Pain between periods, especially if it is severe
  7. Bad-smelling vaginal discharge
  8. Bleeding between periods that is not ovulation spotting

Excerpt From: Briden, Lara. “Period Repair Manual: Natural Treatment for Better Hormones and Better Periods.”

No periods at all?

First off, if you are aged 16 or older and have never had a period, then please see your doctor. That is known as primary amenorrhea (absence of periods). If you used to have them but now they’ve stopped, then that’s called secondary amenorrhea. That’s what we’ll be focusing on here.

Causes may include: pregnancy, perimenopause, stress, and other medical conditions.

PREGNANCY

This might seem obvious, but you could be pregnant. Don’t rule this possibility out until you’ve done a pregnancy test, even if it’s been several months since your last period. Light bleeding (as in, strangely light period) is common in early pregnancy as well, just FYI. If in doubt, test test test.

PERIMENOPAUSE

The beginning of menopause is a transition period, so things are changing. It could be the reason for your lack of periods; however, it’s unlikely if you are 40 years old or younger. Premature menopause is possible though, and sometimes looking at family history can help. Ask your mother, aunts, older sisters, etc, when their periods stopped. Your doctor can also easily check by running a blood test called FSH, which tests levels of follicle stimulating hormone.

STRESSED OR SICK?

Stress comes in many forms – physical, emotional, under eating, exams, trauma, surgery, a really bad cold, you name it. Your reactions to stress are controlled by a complex set of feedback interactions among the hypothalamus, the pituitary gland, and the adrenals (known as the HPA axis). External stressors are translated into messages which influence the feedback loops of the HPA axis. Meaning, if your brain perceives a particular stressor to be threatening, then it’s not a good time to make a baby. This executive decision is made by your hypothalamus, the part of your brain that acts like a command centre for your hormones. It’s not very discerning. Basically, stress is stress. At a certain threshold (and everyone is different), repeating or chronic stress can stop your period. But this is usually temporarily, until the situation improves.

Take under eating as an example. If you aren’t consuming enough food for yourself then you probably don’t have the resources to support another life inside of you. From your body’s perspective, health is synonymous with reproduction. Even if you don’t want a baby, this stressor will trigger a “starvation” response by the hypothalamus to suppress reproduction. Interestingly, this can happen with low carbohydrate diets too, even if you are consuming enough calories. Everyone is different, so saying “low carb” isn’t that helpful, but too few carbs for you can trigger the starvation response in your hypothalamus. Some women need a lot of carbohydrate to ovulate, while others need less. Definitely something to consider if you’ve made some drastic dietary changes recently.

If this situation becomes chronic (6 months or longer), it is called hypothalamic amenorrhea (HA). Other causes must be ruled out first before this diagnosis is given. Again, this is just your hypothalamus telling you that it’s not a good time to make a baby. Maybe you don’t have the resources or it’s too dangerous to do so (remember that the hypothalamus can not discern between life threatening stressors and other types of stressors).

MEDICAL CONDITIONS

Lack of periods can also be caused by certain medical conditions, like thyroid disease, celiac disease, PCOS, and others. Your doctor should rule out these other causes. When no medical diagnosis can be found, lack of a menstrual period for more than six months is diagnosed as hypothalamic amenorrhea (HA).

Irregular periods

Are your periods late? If your periods come later than every 35 days then that’s considered a long cycle, which is a type of irregular period. Either you didn’t ovulate or your follicular phase (the first half of your cycle) is very long. One of the most common causes is PCOS. For people older than 45 years, it is important to rule out thyroid disease, PCOS or perimenopause.

Causes may include: anovulatory cycles, long follicular phase

External stressors like illness or under eating could be the cause for both anovulatory cycles and a long follicular phase.

1. ANOVULATORY CYCLES

This is a cycle where you do not ovulate. It’s normal for this to occur occasionally. If it’s happening regularly, then you should talk to your doctor about PCOS. If that’s been ruled out, stress could be the cause. Stress disrupts the communication between your hypothalamus and anterior pituitary, which affects the release of hormones that stimulate the ovaries to produce estrogen and progesterone. “A disruption in the messages between the hypothalamus (which produces gonadotropin- releasing hormones) and the anterior pituitary (which releases FSH and LH, follicle-stimulating and luteinizing hormones) brings about a mistiming of the release of these hormones and a subsequent lack of ovulation and/or estrogen and progesterone production by the ovaries. The timing of the release of these pituitary hormones, as well as of estrogen and progesterone, is what determines a normal, regular menstrual cycle. This timing can be adversely affected by stress, and by the same token, the timing can be improved by stress reduction” (Women’s Encyclopedia of Natural Medicine, Tori Hudson, 2008).

The timing of the release of pituitary hormones (LH and FSH), as well as ovarian hormones (estradiol and progesterone), is what determines a normal, regular menstrual cycle.

Figure explanation: The communication between the brain and ovaries is known as the hypothalamic–pituitary–gonadal axis (HPG axis). Two glands are involved, the hypothalamus and the pituitary. GnRH is a hormone from the hypothalamus. It tells the pituitary to release two hormones, LH and FSH, which speak to the ovaries to produce progesterone and estradiol. The hypothalamic-pituitary-adrenal (HPA) and the hypothalamic-pituitary-gonadal (HPG) axes work together. Activation of one affects the function of the other and vice versa.

Source: McCance, K. L., & Huether, S. E. (2018). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). St. Louis, Missouri. Elsevier Health Sciences. 1720 pages.

But how exactly does stress intercept the communication between the brain and the ovaries? Three words: gonadotropin-releasing hormone (GnRH). In the hypothalamus, the release of GnRH stimulates the gonadotropin production of FSH and LH. The constant and pulsatile release of GnRH is critical to the timing of the menstrual cycle.“…activation of the stress axis, especially activation that is repeating or chronic, has an inhibitory effect upon gonadal hormone secretion. For example, stress and stress hormones inhibit the release of gonadotropin releasing hormone from the hypothalamus, and glucocorticoids inhibit the release of luteinizing hormone from the pituitary and E2 and progesterone secretion by the ovary…” (Toufexis, D., Rivarola, M. A., Lara, H., & Viau, V. (2014). Stress and the reproductive axis. Journal of neuroendocrinology, 26(9), 573–586. doi:10.1111/jne.12179).

Basically, stress inhibits hormone secretion, which has a profound effect on human reproductive health and emotional well-being. Going back to stress as a cause of anovulatory cycles, it makes sense that a hormonally mediated event (ovulation) is suppressed when its hormonal trigger (LH surge) is inhibited.

If your doctor has ruled out all potential medical causes for an irregular cycle, then you should not be disappointed. A full workup and thorough assessment is not wasted effort. If everything comes back “normal”, then that is a great outcome.

Please be aware that you can’t test for HPA or HPG axis dysfunction, per se. At this stage, there is no reliable way to assess it; however, your signs and symptoms are a good place to start. Sometimes certain tests can help, such as salivary cortisol levels or serum DHEAs levels. Your naturopathic doctor may run these, along with others. But these tests should be evaluated in the context of your symptoms.

2. LONG FOLLICULAR PHASE

The menstrual cycle consists of two phases: the follicular/proliferative phase (postmenstrual) followed by the luteal/secretory phase (premenstrual).

Source: Hall, J.E. 2019. Yen and Jaffe’s Reproductive Endocrinology, Eighth Edition. Physiology, Pathophysiology, and Clinical Management; Chapter 7 – Neuroendocrine Control of the Menstrual Cycle, Pages 149-166.e5. Available online 22 February 2018.

The follicular phase is the period of recruitment of multiple follicles (sacs within your ovaries that contain the eggs) and emergence and growth of one dominant follicle. Around day 7, all of the follicles stop growing and begin to degenerate except for one. During this phase, rising levels of estradiol are associated with thickening (that’s why it is also called the proliferative phase) of the endometrium (the lining of the uterus). Those follicles are secreting estradiol into the blood, telling the anterior pituitary to secrete LH. Eventually, the one dominant follicle secretes a large amount of estrogen into the blood stream, which tells the pituitary gland to release a huge surge of LH into the blood stream. In a 28-day menstrual cycle, this is occurring around day 12. LH spikes in the middle of the cycle (between the follicular and luteal phase). That occurs right before ovulation. This is all normal physiology.

Now imagine what happens with chronic stress: your HPA axis has been activated, stress hormones inhibit the release of gonadotropin releasing hormone from the hypothalamus, and the release of luteinizing hormone from the pituitary and estradiol and progesterone secretion by the ovary. Hormones are inhibited at three levels: hypothalamus, pituitary and ovaries.

From our discussion of normal menstrual physiology we know that a surge in both FSH and LH levels is required for final follicular growth and ovulation. With all that hormonal inhibition going on, the hormonal surges aren’t happening. Follicle growth is slowed, therefore, hormones aren’t reaching peak levels, and the follicular phase drags on. Ovulation likely won’t happen (anovulatory cycle), but eventually your endometrium will start to degenerate (menstruation begins). You can see why this whole process in the follicular phase would take longer without the appropriate hormonal signals. If you’re younger than 45, a long follicular phase could be stress or PCOS. If you’re older than 45, a long follicular phase could be thyroid disease, PCOS, or the final transition to menopause.

Are your periods early? Like long cycles, short cycles are a type of irregular period. As an adult, a healthy menstrual cycle is anywhere between 21 to 35 days, with 28 days being the average. Your period should come no sooner than 21 days. A healthy menstrual cycle between 21 to 45 days is considered normal for a teenager. Teenagers have longer cycles because it can take up to 12 twelve years to develop a mature menstrual cycle.

Causes may include: an anovulatory cycle, a short follicular phase, or a short luteal phase

1. SHORT FOLLICULAR PHASE

So far, we’ve covered how stress induced hormonal changes can cause a variety of menstrual cycle disturbances, like anovulatory cycles, irregular periods, and even amenorrhea. Our discussion will continue to focus on stress as a cause, especially for a short luteal phase; however, a short follicular phase is different. It is most common during perimenopause. This is beyond the scope of this post, but since you are pretty much hormonal experts by now, I’ll say this. During perimenopause your pituitary starts making more follicle stimulating hormone (FSH). As you get older, your ovaries become less response to FSH, so your brain makes more to compensate for this lack of response. Higher FSH speeds up all of the hormonal surges that eventually trigger ovulation, which effectively ends your follicular face. Voila, short follicular phase.

2. SHORT LUTEAL PHASE

A short luteal/secretory (premenstrual) phase can be caused by many of the same things that cause lack of periods, stress being the most common.

The luteal phase, which begins on the day after the LH surge, is characterized by the formation of the corpus luteum (yellow circle with bursting purple follicle in image above). The corpus luteum is a hormone secreting structure. It secretes progesterone to prime the uterus for implantation (secretory phase). In the absence of pregnancy, the corpus luteum declines (yellow fluffy clouds in image), therefore hormone secretion declines, resulting in the endometrium losing its blood supply. It is then shed, which is the beginning of menstruation.

The luteal phase, which begins on the day after the LH surge, is characterized by the formation of the corpus luteum (yellow circle with bursting purple follicle). The corpus luteum is a hormone secreting structure. It secretes progesterone to prime the uterus for implantation (secretory phase). In the absence of pregnancy, the corpus luteum declines (yellow fluffy clouds in image), therefore hormone secretion declines, resulting in the endometrium losing its blood supply. It is then shed, which is the beginning of menstruation.

With a healthy corpus luteum, you can expect 11-16 days between ovulation and the first day of your period. Unless you are pregnant, your luteal phase can never be more than 16 days. That’s because your corpus luteum can survive only 10 to 16 days, which is what defines your luteal phase. But if it’s fewer than 11 days, then you’ve had a short luteal phase.

The biggest issue with a short luteal phase is that it results in low progesterone production. A healthy period depends on having optimal progesterone levels. By healthy period I mean it arrives on time, with no PMS symptoms in the luteal phase, no premenstrual bleeding or spotting, and your uterine lining is in good shape (well-formed and not too thick or inflamed, and fairly easy to shed).

You’re probably wondering how stress can shorten the luteal phase. Not surprisingly, it’s all about hormone balance – again. When hormones are balanced, all four phases of the menstrual cycle are normal: menstruation, the follicular phase, ovulation and the luteal phase. In the hypothalamus, the release of GnRH stimulates the gonadotropin production of FSH and LH. The constant and pulsatile release of GnRH is critical to the timing of the menstrual cycle. You can see this illustrated in the image above (green bar with black arrows). The black arrows indicate the pulse frequency of GnRH.

Gonadotropin- releasing hormone is produced by the hypothalamus, aka the command centre for your hormones. Stress disrupts the pulsatile release of GnRH (due to stress hormone inhibition), which causes a downstream inhibitory effect on hormones released from the anterior pituitary and the ovaries. The consequence is a mistiming of the release of FSH, LH, a lack of ovulation, and/or a lack of estradiol and progesterone production.

A number of factors increase the chance of irregular menstrual cycle patterns. This post focused on stress-induced hormonal changes. The two main hormones that are said to impact menstruation are estrogen and progesterone. These hormones regulate the cycle. Now you understand why and how they do that.

The underlying cause for their imbalance is upstream, at the brain level. That is where stress is perceived and where stress triggers a cascade of hormonal responses via the HPA axis and its interaction with the HPG axis.

McCance, K. L., & Huether, S. E. (2018). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). St. Louis, Missouri. Elsevier Health Sciences. 1720 pages.

leighann-renee-opGKCk9GImU-unsplash

What should a normal period look and feel like?

Last week I wrote about period tracking – what to track and why it is important.

This post is all about normal menstrual cycle patterns. Tracking will help you identify what is happening with your menstrual cycle, but interpretation of those patterns requires an understanding of what is considered normal. In this post we will cover the following components of your menstrual cycle, with an emphasis on normal presentation.

  1. Menstruation length, blood loss, and period pain
  2. Flow assessment
  3. Bleeding between periods
  4. Day 1 of your period
  5. Menstrual cycle length and regularity in an adult vs a teen
  6. Consistency and colour of menstrual fluid
  7. Hormonal balance
  8. Why ovulating is crucial for your menstrual cycle
  9. How to track your physical signs of ovulation: fertility awareness method
  10. Premenstrual syndrome

I wrote briefly about normal menstruation length, blood loss, and period pain in an earlier post, 5 things you should know about your cycle. Here’s a recap.

Normal menstruation length is 3-7 days (4-5 days is average). Normal blood loss is 25-60 ml (50 ml is average). To visualize this, one soaked normal-sized tampon or pad holds a teaspoon (5 ml) of blood. Depending on the model, a menstrual cup holds about 2 tbsp (30 ml) of blood.

Menstruation should occur virtually symptom free. Most women feel bloating or a heavy sensation. A little bit of cramping on day one is considered normal. Normal period pain should improve with NSAIDs and analgesics, and it should not interfere with your daily activities.

Flow assessment

Flow can be assessed roughly by the number of pads or tampons used daily, but that’s not always accurate since women differ in their definitions of heavy, moderate, or light flow. Do you usually soak a pad or tampon, or spot it lightly? Adjust your count accordingly. The same can be said for a menstrual cup. If not filled, adjust the count. Also, do you use a pad and tampon at the same time? You should not have to change your pad or tampon more than once every two hours during the day. And at night your flow should slow so that you don’t have to get up to change your pad.

Bleeding between periodsIn terms of bleeding between periods, have you noticed mid-cycle bleeding, premenstrual bleeding or bleeding after intercourse? In some cases, these bleeding patterns can be normal and harmless; however, in other cases, bleeding between periods can be a sign of a more serious gynaecological condition such as uterine fibroids, endometriosis, pelvic infection, or uterine polyps. If you are unsure as to the cause of your bleeding, please see your doctor.

Day 1 of your period

When I ask a patient about her menstrual cycle, I start with the date of her last menstrual bleed, or put differently, when was day 1 of her last period. Day 1 of your period is the first day of heavy bleeding, not spotting. For many women, this day is often the most painful. As her flow slows, cramping and pain usually decrease.

Menstrual cycle length and regularity

The next important piece of information is the length of her menstrual cycles (from “day 1” to the next “day 1”). Period tracking apps are especially helpful for recording this type of information. It is hard for anyone to recall when their last period was, let alone the last 3 or 6 periods. Just enter your first day of heavy bleeding as “day 1” of your period in your tracking app. After a few months you will see if there is variation in your cycle length. As an adult, a healthy menstrual cycle is anywhere between 21 to 35 days, with 28 days being the average. The key here is that every woman is different. What is your normal? A regular cycle should not vary, meaning day 1 of your period arrives every “x” number of days, on average. If it’s 21 days one cycle, then 32 days the following cycle, then 25 days and so on, then that’s considered an irregular cycle. It is important to note that teenagers have longer cycles. It can take up to 12 twelve years to develop a mature menstrual cycle. A healthy menstrual cycle between 21 to 45 days is considered normal for a teenager. Longer cycles for a teen is considered normal because it can take up to 12 years to develop a mature menstrual cycle, regular ovulation and an optimal level of progesterone (according to Dr. Jerilynn C. Prior, a Canadian endocrinologist with expertise in reproductive hormones). This is an important consideration for girls who take hormonal birth control to regulate their cycles.

Just FYI, missed, early, or late periods are also considered signs of an irregular cycle.

Consistency and colour of menstrual fluid

Your menstrual fluid should be a reddish-brown colour because blood turns darker when it is exposed to air. And unlike normal dark reddish-brown menstrual discharge, excessive flow tends to be bright red and may include clots.”Your menstrual fluid should be mostly liquid, with no large clots. As your uterine lining breaks away and sheds, your body releases natural anticoagulants to thin it and help it to flow more easily. If you flow heavily, then you may form a few clots because the anticoagulants do not have time to do their job. Menstrual clots are normal, but they should be few and fairly small: about the size of a dime (1.8 cm).” – Briden, Lara. “Period Repair Manual: Natural Treatment for Better Hormones and Better Periods.” iBooks.

Hormonal balance

Overall, your uterine lining should be fairly easy to shed. But that depends on having adequate progesterone levels, which depends on the health of the corpus luteum.

The corpus luteum is the final stage of your follicle’s 100-day journey to ovulation. Ovarian follicles are sacs within your ovaries that contain the eggs. As they develop, these follicles produce estrogen, progesterone, and testosterone. These hormones determine how you progress through all the menstrual cycle phases to your menstrual flow or period.

It takes approximately 100 days for ovarian follicles to mature from a dormant state all the way to ovulation. Ovulation occurs when one dominant follicle (rarely two) finally ruptures and releases an egg. After ovulation, the emptied follicle restructures itself into a progesterone-secreting gland called the corpus luteum. Healthy follicles => production of estrogen, progesterone, and testosterone => ovulation => healthy corpus luteum => more progesterone => hold and nourish a pregnancy OR healthy period

By healthy period I mean it arrives on time, with no PMS symptoms in the luteal phase, no premenstrual bleeding or spotting, and your uterine lining is in good shape (well-formed and not too thick or inflamed, and fairly easy to shed).

Therefore a healthy period depends on having optimal progesterone levels.

With enough progesterone, your period will arrive smoothly, with no premenstrual symptoms, spotting or pain. Progesterone counterbalances estrogen. It thins your uterine lining, whereas estradiol stimulates your uterine lining to grow and thicken. The more estradiol you have, the thicker your uterine lining, and the heavier your period will eventually be. That is why unopposed estrogen due to low progesterone or estrogen excess will result in symptoms like heavy bleeding. That is true whether you have a relative excess (ie too much estradiol because progesterone levels are low) or a true excess of estradiol levels (usually due to impaired estrogen metabolism or detoxification). We need both hormones in balance because they both have specific and, usually opposite, roles in regulating the menstrual cycle.

The importance of ovulation. Do you ovulate? When it comes down to it, a healthy cycle is all about ovulation. Ovulation matters because it’s how you make progesterone. Progesterone is important for keeping estrogen in check. It’s also beneficial for mood, metabolism, and bone health.

But how do you know if you’ve ovulated? Just because you get a period every month doesn’t mean that you ovulate every month. These are known as anovulatory bleeds. Anovulatory cycles are common with PCOS and peri-menopause, but they can occur occasionally at any time or during stressful times, like over exercising and under eating (calories or carbohydrates). Implant and injection methods of hormonal birth control also suppress ovulation. Pill bleeds are drug withdrawal bleeds from synthetic estrogen and progestin. If you take the pill then you do not ovulate.

Going back to our question about ovulation, the fertility awareness method (FAM) is a way to track your physical signs of ovulation. It requires observation and tracking of three fertility signs: basal body temperature, cervical mucus, and cervical position changes. This is different from the rhythm method which solely relies on dates on the calendar. FAM helps you learn about your cycle, your body and how it changes throughout your cycle. But how do you do FAM and is it right for you? Talk to a healthcare professional about your options and make sure you are using fertility awareness correctly. You can also check out the 2015 American College of Obstetricians and Gynecologist (ACOG) statement about fertility awareness method here.

Here are a few points to get you familiar with the concept of FAM

  • Basal body temperature (BBT) tracking: Oral temperature is taken upon waking and before getting out of bed. For consistency, take your temperature at the same time each day (weekends too!) Your temperature should increase with increasing progesterone levels during the luteal phase of your cycle (see image below). With a healthy corpus luteum, you will see 11 to 16 “high-temperature” days between ovulation and the first day of your period. I say “high temperature” in quotations because they’re not “high” per se. Do not expect huge temperature shifts with this. The temperature shifts are subtle, but when graphed reveal a distinct pattern. BBT tracking can tell you a lot about your cycle, but it is NOT a good predictor of ovulation since the temperature shifts after ovulation. But it can tell you if ovulation is occurring. Downloadable charts for tracking can be found here.

Source: Hall, J.E. 2019. Yen and Jaffe’s Reproductive Endocrinology, 8th Edition. Physiology, Pathophysiology, and Clinical Management; Chapter 7 – Neuroendocrine Control of the Menstrual Cycle, Pages 149-166.e5. Available online 22 February 2018.

  • Cervical mucus changes throughout a cycle are normal and healthy. It can be used to track ovulation and fertility for a woman who wants to track her cycle. For example, fertile mucus is like egg whites; rich in water, inorganic salts, and mucin, which forms a gel that keeps the cervical canal open. Itlasts approximately 3-5 days (can be 1 day), is stretchy like egg whites, discharged in copious amounts (women will report feeling wet), and forms a symmetrical circular spot on underwear. Infertile mucus on the other hand can be dry, watery, milky, sticky, or crumbly.
  • Cervical position: If you are comfortable checking the texture and position of your cervix, then you will notice that in the days just before ovulation it will be higher and softer. Otherwise, it sits low (about one finger length inside your vagina) and it feels hard like the tip of your nose.

Once you know when and if you’ve ovulated, you can expect your period 10 to 16 days later. Unless you are pregnant, your luteal phase can never be more than 16 days. That’s because your corpus luteum can survive only 10 to 16 days, which is what defines your luteal phase. If your period comes earlier, it is irregular. A short luteal phase is a type of irregular cycle that results in low progesterone. In some women, this could be the cause of prolonged or heavy menstrual bleeding, bleeding between periods, and premenstrual syndrome.

Premenstrual syndrome

In the week or two leading up to your period you may experience a wide variety of symptoms, known as premenstrual syndrome (PMS). PMS is characterized by a number of significant mental, physical, and behavioural changes. These changes recur in the luteal phase of a woman’s cycle, and cease soon after menstruation starts. If these changes are severe enough to disrupt quality of life and affect your normal activities of daily living, then a diagnosis of premenstrual dysphoric disorder (PMDD) is considered.

I mention PMS here because it is common, not because it is normal. This post was all about normal menstrual cycle patterns, so please be aware that PMS symptoms are not considered normal. Given their recurrent nature in the luteal phase, PMS symptoms may be caused by a hormonal imbalance of high estrogen, low progesterone, and inflammation.

When hormones are balanced, all four phases of the menstrual cycle are normal: menstruation, the follicular phase, ovulation and the luteal phase. A number of factors increase the chance of abnormal menstrual cycle patterns. Most relate to hormone production. The two main hormones that impact menstruation are estrogen and progesterone. These are the main hormones that regulate the cycle.

Next post, I’ll cover common abnormal menstrual cycle patterns or “period clues”, and what they might mean.

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Wondering what your periods say about your health?

The average woman has approximately 456 total periods over 38 years. If her period lasts about 5 days, that’s 2,280 days of menstrual bleeding or 6.25 years of her life. 

Your periods matter! 

And your period problems are no longer something to be endured, hidden or managed with the oral contraceptive pill only. There are better solutions and alternative options. Women everywhere are catching on, asking questions, educating themselves, and taking their health into their own hands ???????? I’m excited to be part of this movement as both a woman and a healthcare provider. People need access to information to make informed choices. That’s where I come in.

Today’s post is all about period tracking – what to track and why it’s important.

Most people use period apps to track data about their monthly cycle. Good old fashioned pen and paper will do the trick too, but period apps are easy and fun to use. Tracking your cycle’s signs and symptoms is the best way to get to know your body. Your period problems are essentially clues, telling you that something is off. You may not know this, but evaluation of menstrual patterns is like a vital sign, such as blood pressure. When blood pressure is too high or too low, that is a sign of a potential health concern. In a similar way, you can view your menstrual cycle patterns as a sign of your underlying health. But what is it telling you? Information about menstruation patterns helps me assess overall health status.

As a period detective, your first job is to collect information. Identifying your menstrual patterns may require a few months of tracking; however, you probably have a good sense of your most concerning period problem(s). Then, by understanding what is normal vs abnormal, you can interpret your period clues in the context of your health.

In summary, how to interpret your period clues:

  1. Collect information – tracking your cycle
  2. Understand how your period should be (what is normal)
  3. Understand the things that can go wrong (what is not normal)
  4. Reasons why. You may need to ask your doctor for help at this stage*
  5. Treatment. By this stage you’ll feel empowered to have a very open and productive conversation with your healthcare provider about treatment options

* You know your body better than anyone else, but we are all susceptible to personal biases. It is best to have a professional healthcare provider (HCP) evaluate your health concerns in the context of your overall health status. This blog post is an educational resource. It is meant to highlight potential root causes for common period periods for the purpose of self-awareness. It is not meant to replace diagnosis by a qualified HCP.

Collect information – tracking your cycle

If you’re not using a period app (and even if you are), this is almost everything that you could track.

  1. First day of your heaviest day of bleeding is day 1 of your cycle
  2. Number of days between “day 1” and your next “day 1” is the length of your cycle
  3. Number of days of bleeding
  4. Bleeding between periods (spotting)
  5. Amount of menstrual fluid lost – determined by use of diva cup, pads, tampons
  6. Consistency and colour of flow, including number and size of menstrual clots
  7. Cervical fluid (read this post)
  8. Pain: quality, intensity, location, characteristic and duration
  9. Genitourinary and gastrointestinal issues, like urinary tract infections, nausea, abdominal pain etc.
  10. Life events: what is the impact of your symptoms on daily life, work, socializing and sex?
  11. Waking temperatures or BBT tracking (read this post)
  12. Duration of luteal phase, or the second phase of your cycle
  13. Premenstrual symptoms such as irritability, headaches, acne, or food cravings
  14. Unusual stress or illness
  15. Mood, emotions, affects: depression, mental fogginess, social isolation, stress, trauma, anger, guilt, and irritability
  16. Fatigue, sleep, sickness: severe fatigue and its relation to your period, fever and cold before period, interrupted sleep cycles
  17. Diet, exercise, and weight changes
  18. Treatments: medications, hormonal medications, herbs, supplements, vitamins, alternative treatments like acupuncture.

This is a lot of information to track. But having all of this information will put you and your HCP in the best possible position to understand your menstrual cycle patterns. Period apps make this easier, but they aren’t perfect. Track what you can with whatever method you prefer. If this seems overwhelming or cumbersome, you won’t do it at all. If that’s how you feel at this point, then I suggest starting with the basics. The basics of period tracking: day 1 of your cycle, cycle length, number of days of bleeding, amount of menstrual fluid lost (light, moderate, heavy), and the characteristics of your most concerning period problem.

Track these period signs and symptoms for at least 3 cycles. It takes approximately 100 days for ovarian follicles (sacs within your ovaries that contain the eggs) to mature from a dormant state all the way to ovulation. A healthy period starts with healthy follicles because as they develop, they produce estrogen, progesterone, and testosterone. “Your ovarian follicles need to be healthy for all of their hundred-day journey to ovulation. If they’re unhealthy for part of their journey, the result will be low progesterone months later.” Briden, Lara. “Period Repair Manual: Natural Treatment for Better Hormones and Better Periods.” iBooks.

Hormones interact and function as a team in one interconnected super system. Your health today will be reflected in your period months from now. Therefore, the right treatment for your health and your periods will be based on the factors affecting the health of your ovaries, like stress, under eating, nutrient deficiencies, sleep deprivation, circadian disruption (jet lag or staying up late), illness, and certain medical conditions.

Next week, we’ll look at some common menstrual cycle patterns or “period clues”, and what they might mean.

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Does your doctor treat you or your labs?

There’s a good chance you’ve found this page because you are suffering. Pre-cycle and menstrual cycle symptoms, like pelvic pain, are a sign that something is off. Hormones are susceptible to many influences so it is important to identify and address the principle causes of your symptoms. ​

Although many of your symptoms may be common, that does not mean they are normal. For example, period pain is experienced by around 80% of women at some stage in their lifetime. But in 5% to 10% of women the pain is severe enough to disrupt their life. There is nothing “normal” about pain that disrupts a women’s life. In medicine, the term “normal” is used to describe a pelvis that looks healthy at laparoscopy (an operation to look inside the abdomen). Meaning, there is no pathology or disease seen that can explain the pain. The problem is that the term “normal” is being used inappropriately to describe a common symptom – pain. 

Many women feel alone and misunderstood when it comes to their pelvic health concerns (symptoms of the bladder, bowel, and sexual/reproductive systems). If that’s you, then I want you to know that you are not alone. 

If you feel that your symptoms have been ignored, brushed off as normal, or inadequately managed, then consider a different approach. Naturopathic medicine offers a holistic approach, meaning “treat the whole person” instead of their symptoms. Hormones interact and function as a team in one interconnected super system. You can’t address hormonal issues without addressing the whole person. Your symptoms, laboratory results, and imaging studies are all considered in the context of your detailed health history, which is usually your first appointment. ​

How to get started:

1. Book here if you have not scheduled your initial appointment yet. 

2. Read my FAQ page here.

3. Manual download for Zoom desktop client (Windows or Mac) here.

Why are appointments with naturopathic doctors (NDs) so long?

Each of you is unique and will respond differently to my treatment recommendations, often due to different underlying hormone irregularities, environmental influences, needs, and adaptive mechanisms. To provide you with the best care and guidance, I need to complete a thorough history. This appointment is absolutely critical for gathering the information that I need to best serve you. The second appointment gives me the opportunity to research, request more information from you, order and analyze labs, and then put all the pieces together.

Addressing the underlying causes of your symptoms is going to take time. Many hormone-related concerns require a minimum 3 month commitment to see changes. You may see results sooner, but I want to strongly emphasize this point because it’s important to manage expectations realistically and to be informed. I typically recommend monthly follow-up appointments until symptoms resolve or until you can manage your own care. In my personal experience, this frequency guarantee’s the best results. I truly want all of my patients to feel more competent in managing their symptoms so that they can have greater autonomy and control over their lives.

I truly want all of my patients to feel more competent in managing their symptoms so that they can have greater autonomy and control over their lives. To achieve that, most people need consistency, support and accountability. This is especially true in the beginning, before new habits are solidified.

Is naturopathic medicine the right fit?

Time for patient interaction iswhere we shine. NDs are in a unique position to offer this kind of care because we typically spend more time with patients. I will take the time needed to document and fully understand the constellation of symptoms you experience and explicitly discuss it in the context of your disease, along with your needs and treatment goals.

If you want a better understanding of the philosophy and approach behind naturopathic medicine, check out this quiz: “Is it time to see a naturopathic doctor?

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mHealth Apps Focused in Endometriosis and Chronic Pelvic Pain

Mobile health (mHealth): defined as the delivery of health care and health-related services via communications devices.

As a healthcare provider, I believe that smartphone and tablet technologies in the health care context can improve my patient’s quality of life. By nature of their design, consumers who download these apps are choosing to be more engaged with their own health. This is particularly important for individuals with endometriosis, an enigmatic disease with a wide range of symptoms. Due to the severity and impact of symptoms on quality of life, people with endometriosis experience strong negative emotions. On top of that, their symptoms have historically been stigmatized and ignored by medical and research communities.

People with endometriosis feel unheard. Their pain is real, yet they feel alone and isolated when it comes to understanding and managing their condition. This is likely a strong incentive for the use of mHealth apps, especially self-tracking apps. Self-tracking apps can help users make sense of endometriosis, in the context of their needs and goals. Similar to the medical body, individuals with endometriosis often have a limited understanding of their own condition.

People with endometriosis are faced with a complex set of decisions and environmental triggers to navigate. Self-tracking of one’s health and disease patterns to produce personally meaningful data, provides an exciting new way to engage people in disease self-management and self-discovery.

However, I must acknowledge that there are risks involved, since the credibility of these apps is likely unknown to most users. Consumers often choose to download based on apps’ reviews or the information that developers provide.

This can be risky for women using these apps, since sometimes this can be their only approach and understanding of the disease.

According to one study, twelve out of 26 (46%) mHealth apps specifically relating to endometriosis and chronic pelvic pain, had documented evidence base (EB) practice. Eleven (42%) had Medical Professional Involvement (MPI) in their development.

Nine apps (34.6%) are clinical guidelines providing information about the diagnosis, the clinical management and the treatment. However, not all of them had documented EB practice or MPI in their development.

A lack of EB or MPI in the development of such apps may result in the wrong approach of endometriosis, its symptoms and its management. The majority of apps reviewed in this study (61.5%) are focused on the symptoms and how to avoid them or improve everyday quality of life.

The majority of apps reviewed in this study (61.5%) are focused on the symptoms and how to avoid them or improve everyday quality of life. By learning about trends in your health, you are in a better position to manage your symptoms, your life, and improve communication with your healthcare provider.

Take home point: If you are using an app targeted at endometriosis, then it is important to understand why you are using it. What’s your intention behind its use?

Functionalities range from: educational reference tools and glossaries to more complex functions such as self assessment, appointment management and reminders, and social networking tools.

Once you have that clarity, this review may help you choose the right app for your needs and goals. 

References:

Gkrozou F, Waters N. (2019) A Preliminary Review of the mHealth Apps Focused in Endometriosis and Chronic Pelvic Pain. Health Sci J Vol. 13.No.3:656.

McKillop M, Voigt N, Schnall R, Elhadad N. Exploring self-tracking as a participatory research activity among women with endometriosis. J Participat Med. 2016 Dec 29; 8:e17.

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How to beat your period cramps, according to doctors

Take a pain reliever to calm inflammation.

This is a common recommendation, with good reason! It often works.

But what if ibuprofen- or naproxen-based meds, including Aleve, Motrin, or Advil are not an option?

These options are not a solution for every women because of personal preference, adverse side effects, or inadequate relief.NSAIDs work by blocking the production of chemicals called prostaglandins (hormone-like substances that trigger uterine contractions) that cause discomfort and inflammation.

The root of Zingiber officinale (ginger) has previously demonstrated anti-inflammatory activity through the same mechanisms as pharmaceutical NSAIDs.

This has been shown with both oral and topical applications. However, oral ginger (like any medication) is not free of side effects. In some cases, side effects are desirable. For example, ginger is also used for its antiemetic (anti-nausea) properties. This is great news if you experience nausea during your periods too, which is very common.

When taking NSAIDS the key is to be proactive. NSAIDs are most effective if they are started before menstrual symptoms begin (before the production of prostaglandins), and then taken on a regular schedule for two to three days. This is a great reason to track your cycle.

Talk to your Medical doctor or Naturopathic doctor before starting any new medication. Be informed, stay open to new options, and seek professional help for period related dysfunction.

Period pain is common, but that does not mean it should be dismissed.

Nine out of ten women suffer from period pain. Sharing this post may help someone you know who is suffering.

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The only sugar-free cookie that actually tastes good

Banana Oatmeal Cookies

I’ve made these every week since I discovered the recipe from Blue Zones. However, as usual, I made a few tweaks. No disrespect to Centenarians in Loma Linda, but I think I improved the recipe. I’ll let you decide…

INGREDIENTS

2 cups old fashioned oats (small oat flakes*)

1 teaspoon baking soda

1 teaspoon cinnamon

1 tablespoon unsweetened cocoa powder

¼ teaspoon ground ginger**

3 medium sized ripe bananas

1/4 cup nut butter (your choice)

1/4 cup almond flour

Optional add-ins: ⅓ cup chopped nuts or 1/4 cup dried fruit. I find that these add-ins make the cookies too dry and too wet, respectively.

DIRECTIONS

1. Preheat oven to 350˚F or 175°C. Line a baking sheet with parchment paper.

2. Use a high power blender or food processor to process oats to the consistency of flour.

*If you like the texture of oatmeal cookies, process only one cup of oats into oat flour. Leave the other cup as whole oats. This is why I recommend small oat flakes.

3. Pour into mixing bowl and add baking soda, spices, and almond flour.

4. Blend bananas until completely smooth. Add nut butter and blend again.

5. Add to oatmeal mixture along with the nuts (or other dried fruit) and mix until combined.

6. Drop 2 tablespoon balls of dough onto cookies sheet, spacing well.

FYI: Dough is sticky!

7. Use lightly moistened fingers to flatten each cookie. Bake for 15 minutes.

8. Cool cookies on wire rack and store in an airtight container.

Makes 15-16 cookies

Soft or crispy cookies?

Most people fall into one of these two cookie camps. I prefer soft cookies. If you slightly overcook these, the outside will become golden and crispy, but the inside will remain soft and oatie.

Did you know…

**Ginger for period cramps: The root of Zingiber officinale (ginger) has demonstrated anti-inflammatory activity through the same mechanisms as pharmaceutical NSAIDs. If you find relief from using ibuprofen- or naproxen-based meds, including Aleve, Motrin, or Advil for period cramps, then ginger might work for you too! Read more here.

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How to eat for PCOS: 15 guidelines

PCOS is the most common hormone dysfunction of women, affecting 10-20% of women (some sources say up to 25%)!

The features of PCOS have enormous mental and physical consequences for women, including acne, menstrual disorders, excessive male distribution pattern body hair, obesity, high blood pressure, diabetes, fertility challenges, low libido, and polycystic ovaries. These features are part of a syndrome, meaning that not all women with PCOS present the same. If you struggle with your appearance, fertility, weight, sex drive, menstrual cycle, and overall well-being, then I am happy to tell you that you have the capacity to heal yourself.

I’m not going to lie. The changes that you need to make take dedication and hard work. But it’s not complicated. And the results will be worth the time and effort.

Conventional and naturopathic medicine both recommend lifestyle modifications as first-line treatment for adolescent girls and women with polycystic ovarian syndrome (PCOS). You guessed it, friend. Diet, exercise, and weight loss. *I can almost hear the eyes rolling*

But, HOW does diet treat such a complex issue? In one word, inflammation.

Enter, the microbiome (oooohhhh, ahhhhh). Unhealthy changes in the microbiome, gut inflammation, leaky gut, dysbiosis (whatever you want to call it), all lead to systemic (aka whole body) inflammation, which leads to insulin resistance, weight gain, hyperandrogenemia (fancy word for high androgens), and ovulatory dysfunction (making it hard to get pregnant). Sounds like the features of PCOS. Basically, inflammation mucks up all the signals that are being sent between the different systems in your body, starting in your gut.

And that’s because those little bacteria communicate with every aspect of our biological systems: digestive, metabolic, nervous, reproductive, mental, immune.

So YES, it’s true. A healthy microbiome is essential for hormone balance in women with PCOS (and other hormonal disorders)! Diet, or more specifically, diversity in the diet, is a major influencer on the microbiome. There are others, but let’s focus on this one for now.

The good news is that you can restore a healthy gut microbiome through dietary choices. And the best part is that eating the right foods will have a cascade effect on the rest of your health, including your weight.

Let’s get started.

  1. Eat 2-3 meals a day and no snacks
  2. Periodic fasting
  3. Local and home grown
  4. Home cooked
  5. Avoid refined oils/trans fats/alcohol
  6. Avoid food allergens and sensitivities – consider elimination diet
  7. Include phytoestrogens: organic, whole soy, flax seeds (talk to your doctor first if you have a personal or family history of hormone related Cancer)
  8. Strive for 100% organic
  9. Sugar free, artificial sweetener free
  10. GF/DF: Gluten free and Dairy free/reduced
  11. High fiber/resistant starch
  12. Non-GMO (based on data on Roundup and Glyphosate)
  13. Real foods in natural state
  14. Variety of colourful fruits and vegetables
  15. Limited processing

As a naturopathic doctor, I tell my patients that food is information, it’s medicine, and it’s nourishment for our gut microbiota. But I completely understand that it’s also social and fun. Do what you can, and do your best. Stress also affects the microbiome. So don’t stress about doing all of these things at once. Pick a couple to start with (or one!), and then add another item when you’re ready for a new challenge.

Here’s a checklist that you can stick on your fridge as a reminder.

If you are interested in balancing your hormones and supporting your overall endocrine system with diet, then following the guidelines above will help you achieve that. That’s because your microbiome is involved in hormone production, metabolism, and signalling. But it will take time. Re-evaluate your symptoms on a monthly basis, but that sweet spot is about 3 cycles. It could take longer depending on the state of your gut, underlying gut infections, stress, sleep issues, medications, exposure to endocrine disruptors, etc. There are lots of things that affect the microbiome. Don’t be discouraged by set backs. More importantly, don’t let set backs further derail you.

I know that you are here because you are trying to fix the underlying cause. In many cases, that underlying cause is gut inflammation. Or at the very least, it is part of the problem. Deep down your gut feeling (pun intended) is that diet is playing a role. Many women will see drastic improvements in their overall health by making these changes. But that’s not to say that you won’t see enhanced benefit from other therapeutic interventions, like botanical medicine and supplements. In some cases, it may be worth considering an appointment with a doctor for a full assessment. As I mentioned before, gut infections might be playing a role. Those should to be resolved before dietary changes are implemented.

If hormonal dysfunction is at play, and your diet is less than veggieful (can I make up words?) then this is a good place to start.

Subscribe to my email list at the bottom of this page (in the footer section) and I’ll send you a notification when I write the next post.

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PMS-depression VS PMDD

Premenstrual Syndrome (PMS) is characterized by a number of significant mental, physical, and behavioural changes that recur in the luteal (second half/post ovulation) phase of a women’s cycle, and that cease soon after menstruation starts.

If these changes are severe enough to disrupt quality of life and affect one’s normal activities of daily living, then a diagnosis of premenstrual dysphoric disorder (PMDD) is considered. PMDD is a particularly severe form of premenstrual syndrome with an emphasis on the affective (psycho-emotional) symptoms. There are specific diagnostic criteria used to determine if it’s PMS or PMDD. This quiz is a helpful tool, but please don’t use it as a diagnostic tool. (1) PMDD Quiz: Do you Have Premenstrual Dysphoric Disorder?

“Because PMDD differs from PMS in severity but not type of symptoms, there is considerable debate as to whether PMDD is a subset of PMS or constitutes a distinct entity”. (2)

This is an interesting point because it suggests that two women can have the same PMS symptoms, yet the degree to which they are affected by them is different. For this reason, it is difficult to differentiate between PMS and PMDD.

The following symptoms are part of the DSM-IV Criteria for Premenstrual Dysphoric Disorder. (2) If you think that you may be suffering from PMDD, I encourage you to seek diagnosis and treatment from a healthcare provider and/or a mental health professional.

  1. Markedly depressed mood; hopelessness; self- deprecating thoughts
  2. Marked anxiety, tension, feeling ‘‘keyed up’’ or ‘‘on edge’’
  3. Marked affective lability (feeling suddenly sad or tearful; increased sensitivity to rejection)
  4. Persistent and marked anger, irritability, or increased interpersonal conflicts
  5. Decreased interest in usual activities
  6. Difficulty concentrating
  7. Lethargy, easy fatiguability, or marked lack of energy
  8. Marked change in appetite, overeating or specific food cravings
  9. Hypersomnia or insomnia
  10. Sense of being overwhelmed or out of control
  11. Physical symptoms such as breast tenderness or swelling, headaches, joint or muscle pain, bloating, weight gain

I want to emphasize that these symptoms (or the severity of these symptoms) are not in your head! There is a reason that you feel this way.

Overview of PMS-depression symptoms (3)

  • Depression
  • Angry feelings for no reason
  • Feelings that are easily upset
  • Poor concentration or memory
  • Feelings of low self-worth
  • Violent feelings

From my experience and training, I would add tearfulness, appetite changes, fatigue, insomnia, apathy (lack of interest), feelings of hopelessness, and low libido to that list.

“Some 150 symptoms have been ascribed to PMS—most commonly feelings of anxiousness (premenstrual tension was the first name given to this syndrome), irritability, and anger or moods vacillating unpredictably among the three. Some women feel predominantly sad or self-deprecating, others simply fatigued and lethargic. Physical changes include bloating, breast tenderness, food cravings, headache, and gastric upset. No particular assortment of symptoms is diagnostic; it is the regular recurrence of symptoms on a monthly basis, just before the menstrual period, that matters” (4).​

Pain points of PMS-D

Does this sound like you?

  • My mood is all over the place. One second I’m sad, the next I’m angry.
  • If my partner just looks at me, I’m irritated.
  • I feel tense and on edge for no reason.
  • Why am I so tired? I had a good night’s sleep, I think.
  • I just looked at a snail and cried. It was so tiny and vulnerable.
  • Why don’t I want to do anything except veg, watch Netflix, and eat peanut butter out of the jar?
  • I feel like my hunger is never satisfied (she says as she scarfs down her 5th “healthy” post-workout brownie. She didn’t even work out).
  • I’m sick of looking so bloated that people ask me if I’m pregnant!
  • I can go on, but I think you get the point.

Most of the pain points (or problems you are experiencing because of PMS-D) are similar to the ones I discussed in my post about PMS-A. There is certainly overlap between all of the PMS types, but what makes this problem bad enough that you’re here trying to solve it? The answer is different for everyone. Here are a few common themes.

1. Frustration. This is a major one because depression limits you from enjoying your life or taking part in your typical activities of daily living due to lack of interest (that is what apathy is). What are you unable to do, enjoy, experience because of PMS-D?

It can be incredibly frustrating to feel this way for 1-2 weeks every month. When you consider a women’s lifetime menstruating, that isa lot of time not feeling your best. If you do the math, right now, how much of your life is spent experiencing PMS-D? Do you experience symptoms of PMS-D for days or weeks? Did it start with your first menses? How many more periods are ahead of you, if we say that menopause usually occurs between 45 and 55 years of age? For some women, this could be half of their reproductive years.

2. Decreased self identity/feeling lost. When faced with a complex and frustrating condition like PMS-depression, it is common to feel lost. You don’t feel like yourself. And what’s worse is that you feel bad for feeling bad, and suddenly you’re caught in a self perpetuating thought cycle of self deprecation. When does it end?

3. Lack of understanding. Given the cyclical nature of PMS symptoms, we often brush them off as normal, or wait for things to get better. And they usually do, for awhile. But when you’re feeling your worst, you probably catch yourself asking “is this normal”? Let me be clear that PMS symptoms are common, but they are not “normal”. Given the complexity of this syndrome, I advise you to seek diagnosis and treatment from a healthcare provider.Trying to understand, treat, and manage this syndrome on your own often leads to suboptimal outcomes. And it can seem overwhelming. But with the appropriate guidance and care, you can become more capable of maintaining your own health. One of the significant benefits of treating PMS naturally is that it serves as a motivator to make lifestyle changes that have a positive cascade effect on overall health.

Benefits of solving these problems

We often make changes only when the consequences of not doing so becomes too painful. Women are tough! But please don’t wear this as a badge of honour. I know you’re tough. Other women know it too. That resilience and mental toughness does not mean that you have to tolerate feeling less than. Even if you could tolerate feeling overwhelmed, sad, angry, irritated, bloated, tearful, tired, lethargic, etc. why would you? These feelings (yes, bloated is a feeling too) feed into a self perpetuating thought cycle that leads to more negative emotions. No thank you! I wanna feel awesome every day, or at the very least, remove the obstacles to feeling awesome every day.

Even when presented with options or solutions, one may catch yourself saying that you don’t want to put in the work for potentially little to no return. Why follow a plan for no reason? Let’s talk about those reasons, or better stated, the benefits of solving these problems.

Let’s use our pain points from earlier as a thought experiment. Imagine your life without these symptoms. What does that look like to you? How does that change your daily activities, social interactions, work-life balance, self-identity? My mood is all over the place. One second I’m sad, the next I’m angry.

Your mood is stable. Sure you still feel sad and angry sometimes, but those mood swings don’t confuse your loved ones anymore. Heck, you’re less confused too! Bonus: you’ll probably notice that all your friends and family who are usually “busy” at this time of the month are suddenly free and excited to hang out! If my partner just looks at me, I’m irritated.

Improved relationship with your partner. Even if it’s just PMS induced, how many arguments could have been avoided if your mood was less volatile? How many times have you apologized to your partner for “starting a fight” due to raging hormones? I think it goes without saying that it’s probably better for your relationship if PMS-induced arguments were minimized. I feel tense and on edge for no reason.

Feelings of unexplained tension are decreased or gone. There are plenty of real things to be stressed and anxious about. No need to add nothing to the list, am I right? I’m being cheeky, but really, I don’t want to waste my energy feeling edgy for no reason. I need to save said energy for more resourceful and productive activities, like baking more “workout” brownies. Did I say baking, I meant work. Yes, more energy for work purposes of course. Why am I so tired? I had a good night’s sleep, I think.

Sustained energy levels throughout the day. And I’m not talking about espresso energy. No jitters or crashes please. Ain’t nobody got time to stand in line at Starbucks 4 times a day. This is true energy, a clear head, a rested body, harnessed from good ol’ balanced hormones. ‘Nuff said.

Point being, by knowing what solving your problems will allow you to do, you can imagine what’s on the other side of seeking treatment. ​

Alternatively, we can think about the risks of not solving this problem. Here is another thought experiment to help you visualize this. Think about the number of days you spend every single month not feeling like the best version of yourself. Remember that math we did? Even if it’s just 5 days a month that you experience these symptoms, how many days over your lifetime is that? If you do not solve this problem now, how many more days do you risk feeling sad, hopeless, lost, and [insert your symptoms here]. Then, make a list of all the things you usually pass up when you experience PMS-D symptoms. Look at both of these metrics. How many opportunities are you potentially missing out on, both personally and professionally? ​

How can naturopathic medicine help you solve these problems? Or more specifically, what does a private naturopathic consult contain that will help you?

Hormones are susceptible to many influences. To ensure that we get to the root of the problem, we must identify and address the principle causes of your hormonal disruption.

No cause has been established as the clear dominant cause of PMS, and no cause explains every case. It is likely multifactorial… But influences may include:

  • Hormonal imbalance, specifically a low progesterone level during the luteal phase of the cycle
  • Abnormal neurotransmitter response to ovarian signalling
  • Abnormal HPA (hypothalamic-pituitary-adrenal) hormone secretion
  • Nutritional deficiency including magnesium, certain B vitamins
  • Carbohydrate intolerance
  • Environmental factors, including stress

Based on this list, I can tell you that PMS-depression (just like PMS-A) is highly influenced by diet, sleep, blood sugar, inflammation, hormones, fatigue, mental states, stress, and exercise. As your doctor, I need to identify the factors that are most likely driving your symptoms and address them to achieve reliable and sustainable improvements. A thorough history will help me identify and address those factors. What works for one person may not work for another. We are truly individuals with our own unique physiology, stressors, and psychological makeup. There is no clear dominant cause of PMS, but it is likely multi-factorial. That means that this is going to take time.

From your initial 90-minute online (private and secure via ZOOM) Naturopathic consult you will:

  • Have a new framework for understanding and treating your PMS symptoms
  • Receive clear explanations of the principle causes of hormonal disruption to ensure you get to the underlying cause of the problem
  • Learn about the most appropriate lifestyle changes for PMS problems and how to implement them
  • Receive recommendations for acute treatment options, as well as a clear long term management plan
  • Have access to handouts, resources, ZOOM recordings, and my private online dispensary

Please refer here for more specific information about the initial and follow-up appointments.

This might be obvious, but at the risk of sounding repetitive, I want to re-iterate that the content I write and the care that I provide is based on four principles: listen, validate, inform, involve.

Listen, Validate, Inform, Involve

Listen. The foundation of naturopathic diagnosis is an extensive patient history – aka, your story. Each one of you has a unique story to tell. By assessing the physical, environmental, lifestyle, attitudinal, and emotional aspects of your life, I am in the best position to provide individualized and wholistic care for your health concerns and overall well-being.

Validate. Your symptoms are real, and it is not all in your head. I can’t emphasize this enough.

Inform. Your health status is likely a product of your environment and your reaction to environmental stimuli. For this reason, lifestyle and behavioural interventions are often key components of treatment strategies. Understanding the factors that affect your health provides a new perspective and awareness.

Involve. You are an active participant in your health. My patients are involved in their treatment program and learn to make effective, educated, self-care decisions that can prevent future health problems. Optimal wellness and improved quality of life is within your capacity.

Naturopathic medicine is perfect for those who are

  • Seeking complimentary and/or alternative treatment options to manage the symptoms of PMS
  • Committed to a minimum 3 month timeline
  • Motivated and ready to make long term changes

FYI (if you are ready to book): The best evaluation and determination of PMS is a symptom diary relating symptoms to the menstrual cycle. Here is an example of one. Please use it as a template to track your PMS symptoms leading up to your initial appointment.

Source: Romm, A. Botanical Medicine for Women’s Health (2009, Churchill Livingstone)

Finally, I want to discuss objections: time, money, and the uncertainty of success

This is an investment of both your time and money – two things we all hold dear. There is no getting around the time required to address hormonal problems. A three-month minimum time commitment is what I recommend, since our bodies need time to adapt and respond to the changes you are implementing. This leads to the next objection: the uncertainty of success. My mission is to provide patients with the information and tools that they need to take care of their own health. The health industry is full of many ways to change your body, your nutrition and your psychological well being. I believe in treating all patients as individuals. Not a one size fits all. I hope you appreciate this approach. Having said all that, consistency is everything. If you consistently work at improving the factors that influence your hormones (which I will teach you), then you will see improvements.

In terms of money, the value of this service is likely going to be based on your results, which depends on your level of commitment and consistency over the next 3 months. That makes this hard to determine right now. Values are extremely personal. If you are thinking of investing in this, then you likely value the perceived benefits to your health or you value avoiding the pain and inconvenience of symptoms associated with your problem. Some people are positively motivated, while others are negatively motivated. There is no right or wrong motivator. In either case, if money is a serious objection, then perhaps you are not in the right head space to make the commitment right now. That is okay. I wish you health and success no matter what you decide to do.

For everyone else, this is the start to a new hormonal symphony. Book now.

References:

Cover Photo by Volkan Olmez on Unsplash

(1) Remedy Health Media & PsyCom

(2) Romm, A. Botanical Medicine for Women’s Health (2009, Churchill Livingstone)

(3) Premenstrual Syndrome Clinical Presentation: History, Physical Examination https://emedicine.medscape.com/article/953696-clinical?src=soc_tw_share via @medscape

(4) Hudson, T. Women’s Encyclopedia of Natural Medicine (2008, McGraw-Hill)