If someone's menstrual cycle is

irregular, should they be concerned?

>> Yes.

>> Yes. Yes. Yes. Your body is meant to

work like clockwork.

>> And our monthly cycle is so much more

than getting ready to have a baby,

especially when we're looking at

exercise. And it's important to say if

you don't have a period, it's very

harmful to long-term health, brain

health, mental health, low energy, mood,

and libido. And I don't want the younger

generations to have to go through the

stuff that we've gone through. So, it's

an important discussion that we need to

have. We are joined by four leading

female health experts from very

different fields

>> to have a crucial conversation about

women's health. With over 80 years

combined experience, they're sharing the

truth about what every woman and every

man needs to hear.

>> We asked a thousand women to submit

their questions ahead of this

conversation. And I got so many

questions around fertility,

understanding hormones, PCOS, birth

control pill, miscarriage.

>> And I'll say this, Stephen, it's because

we haven't had these discussions

publicly. When we look at funding in

women's health, it's horrible. like less

than 1% is spent on women over 40.

>> Women are living 20% more of our lives

with chronic disease or mental health

disorders. I mean 50% of patients with

unexplained infertility have

indometriosis. But yet it takes women 7

to 10 years to get a diagnosis after

symptoms start. But also there are

things that we do that will inherently

harm our fertility because we're not

taught this and it predisposes you to

many medical problems later in life.

>> And patients will say but I have a

really high pain tolerance like it's a

badge. And so they gaslight themselves.

And that's what we're all trying to

fight here. But there are a lot of

things we can do to deal with this.

>> And then I want to talk about menopause.

>> So in medical school, menopause just

gets shoved into a tiny box. This is a

scary statistic. So Oh my god,

>> it's crazy.

>> I just think it's insane. This is why we

need to create change.

This might be one of the most important

conversations we ever have on the diio

because women's health has long been a

total mystery to so many people and so

many people are struggling with all of

the issues that we're going to talk

about today with their menstrual cycles,

PCOS, endometriosis, with diet, with

understanding how to exercise as a

woman. It's probably never going to be

the case again that these four

individuals that at the very top of

women's health in their fields will be

in the same place at the same time

having this conversation. We structured

this conversation into two parts. They

cover completely different subjects, but

they're fundamentally interlin. For me,

the understanding that I got from this

conversation at this table with these

four women has fundamentally changed my

life. It's going to change how I deal

with my romantic partner, my sister, my

team members that I work with every

single day. And funnily enough, because

it's a conversation I wouldn't have

clicked as a man, it turned out to be

the conversation that I needed the most.

And I don't think I've ever said this

before, but if there was ever an episode

to share with a loved one, then this is

that episode. Please share this episode

with as many women as you can, but also

with as many men as you can.

[Music]

Ladies, we should start with some

introductions. Could you give me a brief

introduction, Stacy, as it relates to

your perspective and your experience and

what your sort of bias is as it comes to

this debate? When I say bias, I mean

your your your experience and your your

research that you're lending to this

conversation today.

>> I come from the exercise fizz and sports

med background. Um, so I'm always

looking through the lens of activity and

nutrition and how that has a impact on

our stress and our stress outcomes and

how we can adapt to specific applied

stressors especially when we're looking

at improving health span, improving

mood, improving body composition, all of

those things. I've worked with and still

work with uh the subset of active women.

Um, I come from an endurance and a

high-profile high performance sport

background. So, that's where I've gotten

my chops and then brought it over into

the general recreational female athlete

kind of perspective. Natalie,

>> I'm a fertility doctor and every day I

help patients with IVF get pregnant

because I have an IVF clinic. But my big

passion has always been natural

fertility after I experienced my own

pregnancy losses. trying to understand

how we interact with the world and how

that changes our hormones and help women

understand what their hormones are, what

natural fertility is, what happens as we

age to our bodies, our eggs and our

hormones, and let them be better

stewards of their own fertility and

their own health decisions.

>> Mary,

>> I have a background in general OBGYn, so

I'm considered to be a women's health

specialist. And it wasn't until I kind

of went through my own menopause that I

realized that there was significant gap

in my training. You know, hearing

watching Dr. Sims on um I think your

podcast talking about how women are not

little men really struck such a chord

with me and made me realize I was

siloing women's health to the

reproductive organs, the breast, the

uterus, the ovaries, the vagina and that

if I really wanted to make a difference

in a woman's whole health life, this

last 30 years, 30, 40 years of her life,

I needed to refocus

what we were thinking about women's

health for the long term. So I come from

a background in academics. I was a

professor for 20 years. I was a

residency program director. Stepped away

from that so I could focus on the lack

of my own education and knowledge in

menopause care. And now I want to step

back into the academic world to bring

everything I've learned and change the

way we educate our providers. Vonda

>> I am a orthopedic sports surgeon by

training and I sit at the unique

juxtaposition of orthopedics and

performance having taken care of elite

athletes most of my life aging and

longevity most of my academic research I

too as an academic is on subjects of

muscularkeeletal aging but many years

ago added a third circle of the whole

health of a woman and so sitting in this

place it fits directly into the mantra

of my career which has always been I am

going to change the way we age in this

country and the world because the tool

that I bring to the table is the fact

that if I save your mobility I'm going

to save you from the ravages of chronic

disease and so the work that I do is not

only educational it's uh research and

it's now education of the world about

these subjects

>> explain this to me like I'm an idiot

ladies why do we need to have a

conversation about women's health and

not just health broadly.

>> I think the statistic that people don't

realize on a day-to-day basis is that

women are 51% of the population. We're

actually not a minority. We're the

majority and yet often our health, our

healthc care access, the research treats

us as if we're a niche product,

>> but we are the majority product.

We have to have this conversation

because data show that

of the $450 billion dollars spent on

research in this country alone, less

than 1% is spent on women over 40.

>> And yet we are nearly 90 million people.

And we make 80% of all the health care

decisions in this country for ourselves

and everyone we touch. And so even

though when you look at the the

long-term data, women are winning the

longevity race here. We're living an

average of 6 years longer than men. But

as all of us talk about all the time,

women suffer longer.

>> Yeah.

>> We're living 20% more of our lives

versus our male counterparts in poor

health with chronic disease or mental

health disorders. And so McKenzie looked

at the data and it was for the Gates

Foundation and what they found was yes,

we live longer. We've all known that.

However, we have, you know, twice as

high of mental health disorders. We're

two times as more likely to end up in a

nursing home. We are much more likely to

lose our long-term independence from

frailty or dementia, much more than our

age matched male counterparts. And

that's I think what we're all trying to

fight here. And diseases that impact

women specifically and only things like

PCOS, endometriosis are extensively

underfunded and not researched. It takes

women 7 to 10 years to get a diagnosis

of endometriosis after symptoms start.

And we know this is a disease that

impacts your entire body in addition to

your fertility. But women are dismissed.

They're not taken seriously. and there's

not research guiding what we can do in a

lot of these situations to try to help

them the best.

>> Why isn't the research there? Why why

don't they research if women are the

majority of the population? Why is all

the funding going to researching men?

>> You have to think about who was in the

room when medicine and science first

started. So if you think about back when

the industrial revolution and the

modernization of what we know is

medicine, women were pushed out because

they were believed to have smaller

brains. thanks to Darwin and not thought

to have a seat at the table. So when

you're thinking about designing studies,

it was pretty much designed on the male

physiology on the male body and then

women were an afterthought. So there

wasn't any real in-depth look of well

women are different from birth or in

utero XX is different from XY. So all

the research has just been generalized

to women. Even things like aspirin for

heart attacks and thinning blood

>> inhibitors. Yeah, all of this all of

this was done on men and then just

generalized to women and now that we're

having this global conversation on

women's health, people are like, well,

where is the information specific for

women? And there's just a very small

subset. So, we're looking and trying to

expand that, but we have a lot of

catching up to do. And that's primarily

not only because of what you said, but

the shocking statistic is that not until

1993

were women required to be represented in

studies. 1993,

I mean, we were all far into our our

lives in research by then.

>> Isn't that a shocking?

>> That's crazy.

>> And there were still loopholes where

people were finding ways to exclude

women and then

>> right, we're still not at 50%. No,

>> we're harder to study. You have

menstrual cycle, hormonal fluctuations,

even menopause, pre even the animal

models.

>> It's not that we're harder to study. It

just makes it presumed harder to study.

There's more variables at play,

>> right? It's more of a complexity to the

research, but it's not more difficult.

And this is where I bring it in. It's

like if a woman had a seat at the table

when all the study designs were started,

it wouldn't be a question. It would just

have been assimilated in. because we've

been so drawn into we have a crossover,

here's one week crossover, next week

because of male physiology. When you add

women's hormone fluctuations and people

like, "Oh, it's too complex."

>> Right? But it's not.

>> What is it that makes, and this is a

super dumb question, but an important

one. What is it that makes men and women

different from a physiological

standpoint? Because to understand why

research would need to be done

separately, we need to understand the

differences.

>> Yeah. Well, I mean, we can look from a

morphological standpoint where men have

more of our fast twitch fibers. Women

are born with more endurance fibers,

>> which is muscle, right?

>> Uh when we're talking about muscle.

Yeah. So, uh men have more of the

ability to do power and and really fast

energetic type activities or women are

more attuned to endurance type

activities. And this affects metabolism.

It affects blood glucose homeostasis.

And when we're looking at bone and bone

density, men have stronger bones. Uh

they can acquire more load. They hold on

to it better than women do. We see

smaller lungs, smaller heart, less

hemoglobin in women than men. And that's

an offshoot of what testosterone does.

So there are just basic physiological

differences between XX and XY that

people don't really assimilate and

understand. And the way I like to say it

is you go into a shop and you have a

men's section and a women's section and

there are touch points on the external

that really identify gender andor sex.

But when you look intrinsically no one

is identifying those touch points until

now. Also when we look at how we disease

so in cardiovascular disease is is

aththeroscerotic disease is the best

example. Men tend to have their

blockages. So aththeroscerotic disease

is basically the plaques that build up

in the coronary arteries around the

heart. Men tend to develop their plaques

very early right as those arteries exit

the aorta and dive into the heart

muscle. So we get what we call the

widowmaker. Okay? It's called that for a

reason because men die and they make a

widow. And so that's the left anterior

descending artery. Women by and large

tend to not have these larger artery

blockages, but their blockages are

diffuse and microvascular deeper into

the heart muscle, which is why we

present with a heart attack much

differently than a man does. And those

we're not teaching our, you know, we're

not educating our clinicians as to these

differences. Women are considered to

have atypical chest pain. Dr. Wright,

51% of the population is female. Why are

why is my heart attack atypical

>> and a man's typical? But this happens

not only at the organ level. It makes

sense that if we have a population with

XX chromosomes, a population with XY

genetically and the way we express those

genes are differently. But I think we

miss the fact that down to a cellular

level, every cell from an XX is

expresses these tissue changes, tissue

manifestations differently than an XY.

Our lab used to study, we called them

muscle derived stem cells so 20 years

ago. Now they're called satellite cells.

But when we harvested them and asked

them to behave and in different

environments,

satellite cells from XX people and XX

animals, women, females were better

under the same circumstances

experimentally

at making cartilage and muscle. XY male

were better under the same circumstances

in making bone. So down to a cellular

level, we express our genes differently.

It should be no mystery to us or anybody

else that there are differences. And yet

there is the propensity just to lump us

all in the same basket and almost say I

almost sometimes feel as pjorative to

say, oh the women are different. Of

course they're different. Yeah,

>> we're genetically different

>> down to every cell in our body.

>> Every cell. So, it should be no surprise

to anybody, but it it seems to be a

surprise.

>> Seems to be a surprise all the time.

Yeah. I get pushed back all the time.

There's no difference. Yes, there is.

There is. And it's not just bad. It's

just is.

>> Yeah. There's Yeah.

>> Because at one point that was quite a

controversial thing to say, wasn't it?

To point at the differences between men

and women.

>> Mhm. Outside of, you know, our different

organs. Yeah. You know.

>> Yeah. And because of this research gap

and the bias in medicine, um, women have

been misunderstood by their male

counterparts in a number of ways. I

remember I think it was you, Mary, that

was telling me about this whiny women

thing that you were exposed to.

>> When I was in training and and you all

may have similar stories and I just

heard a new one the other day, my first

patient in gynecology clinic, I'm an

intern. I'm very excited. You know, we

have our stacks of charts. That's how

old I am. We had paper charts. I pick up

the chart, open it up. It's a

40-year-old woman with multiple vague

complaints. She's gained some weight.

She's a little bit depressed. Her libido

is off. Her blood pressure is a little

bit up. Her cholesterol is starting to

rise. And she's seen family medicine.

Like we're the third or fourth doctor at

this point. And so my upper level who

happened to be male this, you know, it

could have been anyone. Walks down the

hall in his cowboy boots cuz Texas. And

um and he's like, "What you got?" And I

said, "Well, I have Miss Smith,

whomever, you know, she's a 40-year-old

woman with." And I list the complaints.

And he goes, "Did you check her thyroid?

Family medicine did. Did you check this,

you know, a few simple labs?" And he

goes, "Hm,

you got a WW."

And I said, "What's I don't know this,

you know." And he said, "Uh, don't write

this in the chart, but we call that a

whiny woman around here."

>> Oh my gosh.

>> And I said, "Okay." He said, "Listen,

women just tend to go through this at

this age, and we're not really going to

be able to help her. pat her on the

knee, tell her to have some wine, go on

date night, you know, she'll get better,

but we're not going to be able to help

her. And that stayed with me. Now, I

was, you know, a good girl. I did what I

was told. You know, it took me 20 years

of internalization to realize this, you

know, I don't want to blame him. He's

not a bad guy. This was taught to him.

But this kind of thinking, I mean, I saw

this in the ER. I saw this in the O. I

saw this in every clinic. And so I've

asked other clinicians around the

country and I've heard whiny gyne status

Hispanicus total TBD total body delore

like in different regional areas there

was a name for this kind of vague

complaints from this middle-aged woman

and we couldn't quite put our finger on

it and I realized this was systemic bias

built into the system where women and

there's historical you know precedent

for this the wandering uterus the

hysteria you know these were real

medical terms just until like not even a

generation ago.

>> Yeah. They used to put women into

asylums.

>> Yeah.

>> Because of hysteria and it was hot

flashes, all the things that that are

now known with permenopause. They used

to think it was some kind of insanity

and put women into insane asylums to

lock them down.

>> But this is pervasive. Not just an OB.

You're not the only guilty. It's every

medical subsp specialty has some

culture

of for lack of better words blowing

women off it right. We're not having the

curiosity that defines medicine. We are

supposed to be curious people. But yet

when it comes to this, why do we stop at

just seems to be something that happens

to middle-aged women, right? it that

that's written in the orthopedic

literature seems to happen to

middle-aged. Where's the curiosity?

>> Where was it?

>> Yeah. Well, in X-fist text, you always

had the representative of him or they

and the vuvius man and all the angles of

the male body, but there was never

representation of women. The only time

you heard about a female athlete was all

the pathophysiology. You know, the iron

deficiency, the female athlete triad,

which we now call um relative energy

deficiency in sport.

>> And when you're looking at the

historical idea of sport, the only way

women were actually included and

accepted is when they were amenic

because then they were quote more like

men and then there wasn't a problem with

training them and then they could work

as hard. But we know that that's not

appropriate. That's a sign of of illness

and overtraining under recovery. So, it

is pervasive everywhere. It's not just

the medical, but it goes into when you

think about what it means to be

successful in sport. It's the power.

It's the aggression. It's the

unfallibility of being human. And a

woman having a menstrual cycle was

deemed a fallibility. So, they're trying

to push it aside. This is so systemic

though that women downplay their own

complaints. They gaslight themselves. It

takes them a long time to seek care

because they're afraid of the response.

They are not always honest with what's

going on in their body. I'll say, "Do

you have pain?" "Oh, no more than

regular." They downplay everything. You

have to really ask. And it's almost the

society, I don't want to be viewed as

this way. I don't want to be not taken

seriously. And it causes them an to have

an even harder time to get to a

diagnosis because they don't feel

comfortable sharing some of these

symptoms or they've downplayed them in

their life so much. This is why they

have to get so sick to often present to

even try to get care. And they come to

me almost to a woman after I'm talking

about whatever muscularkeeletal thing

they'll say even before they want to

describe it to me. They'll say, "But you

know, I have a really high pain

tolerance." Yes. Mhm.

>> Like it's a badge because we've been

conditioned to not come for any pain.

But I've suffered. I've tried. That's

why your arm doesn't move anymore. I've

got such a high pain tolerance, but I

couldn't take it anymore. I didn't want

to come. And I feel like why does it

have to be that way?

>> So, you train treating both males and

females. I I was locked in a room with

women for 25 years, you know, and so

it's so fascinating to me to hear how

men and women come in with the same

complaint in your clinic, in your

fellowship, all those years you spent

training, and yet you were taught to

treat them differently, you know, and

the urologists say the same thing, you

know, who

>> I don't think I was aware of it.

>> Yeah.

>> There was just that's

so much bias. Yeah.

>> I didn't realize. I didn't either

>> because like you, until I went through

my own pmenopause,

I might not have paid it attention to

it.

>> Yeah,

>> I may have been less sensitive.

>> I was a terrible menopause.

>> I see messages all the time in the

comments section that some of you didn't

realize you didn't subscribe. So, if you

could do me a favor and double check if

you're a subscriber to this channel,

that would be tremendously appreciated.

It's the simple, it's the free thing

that anybody that watches this show

frequently can do to help us here to

keep everything going in this show in

the trajectory it's on. So, please do

double check if you've subscribed and uh

thank you so much because it's strange

where you are you're part of our history

and you're on this journey with us and I

appreciate you for that. So, yeah, thank

you. Is that in part because we know

very little about hormones as well. When

I was speaking to our audience, we asked

a thousand women to submit their

questions ahead of this conversation.

And one of the most asked questions, all

the most asked questions sort of related

to understanding hormones. I think the

conversation around hormones is quite a

new one in society and I actually think

it's been driven a lot by a heightened

understanding of menopause generally. I

think the the conversation of hormones

around outside of fertility and the

general menstrual cycle. I can right now

draw from memory the exactly what's

going to happen in a normal menstrual

cycle. We were taught that, you know,

very very well. But when I saw maybe 3

years ago an academic paper that showed

all of the locations of the G-coupled

estrogen receptors in the human body,

>> what's that?

>> I lost my mind. So basically, where are

the estrogen receptors in the human

body? And they're everywhere. The brain,

the bones, the muscle, the gut, you

know, the the every almost nothing. The

the the endothelial, the lining of the

individual blood vessels around our

heart, you know, it's really radical to

me to think about how all these sex

hormones are the progesterone, estrogen,

testosterone, hormones are everywhere.

>> What is a hormone?

>> They're not actually sex hormones.

hormones are your body's communication

system, right? So, it is really how your

body is sending out messengers to

communicate. So, a hormone is dictating

an action and I think there's going to

be a lot of great discussion. But one

thing that I think is very important to

your point, Stephen, is even things that

we were readily taught about the

menstrual cycle and estrogen,

progesterone, testosterone, the public

is now becoming aware of because we've

not done a good job at public education

that this is what's really happening in

your body. this is what your menstrual

cycle is. This is what happens when you

go through menopause. This is what

happens when you're trying to train for

a sport. We haven't had these

discussions publicly that we are seeing.

And I think that is highlighting

interest in all of this even if some of

us were taught some of this. But when it

comes to hormones there, everybody wants

really easy fast. Draw my level. Tell me

what to do. Give me a medicine. Fix it.

And I think the most important thing to

understand is that by definition, your

hormones are dynamic. Your body is

responding to the hormonal signal it

sees and determining what next signal to

send out. So constant fluctuation

throughout the day in response to

multiple stimuli. And that's how it's

supposed to be. If we didn't do that,

we'd all be dead.

>> It's a symphony. But that makes it

really hard for somebody to understand

on the other end who's not in medicine

who says, "Well, is it my hormones?"

Because there's no one test that's going

to give you one answer. You have to

really interpret it in context of the

full body. And it makes it really hard

for practitioners who do not understand

the hormones as well. And we see a lot

of mismanagement of hormonal scenarios

and situations right now that are

actually detrimental to patients. So,

I'm glad you're having this discussion

because that's not a stupid question.

What is a hormone? Many people don't

really understand that.

>> What is the I really want to make sure

that if someone for both the men that

probably have less understanding but

also from our conversations I've

realized and the feedback I've gotten a

lot of women don't understand their own

hormones and their own menstrual cycles.

What is the most basic level that we

have to start at to give people an

understanding that we can then build on

of what's going on here?

>> I was say I want to get rid of this

graph.

>> Okay. So that leave it out. Leave it

out. But it it shows just a textbook of

what a menstrual cycle is is, but it

doesn't show the daily perturbations of

estrogen and the luteinizing hormone

pulses and all the things that go as

Natalie is saying to make it to make it

work.

>> You see two organs there, the ovary and

the endometrial lining. You're not

seeing the muscle, the bone, the brain.

All of those organs are affected by

these normal monthly fluctuations.

>> Yeah. And the conversation that we're

having now in research methodology is

the fact that there is no real

definition of normal cuz every woman's

cycle is variable. So when we look at

this, everyone thinks that this is

normal but we don't actually know if

that is for the fact that a woman's

variation

this can change cycle to cycle. This can

change cycle to cycle. Sometimes we have

an ovulatory cycles. So until a woman

can identify what her own normal is, we

can't rely on this graph to actually

explain to them.

>> How does a woman know what their normal

is versus, you know, because a lot of

women are on birth control pills since a

very young age. So I think my partner

Melanie, she's she was on birth control

for about a decade. So she like didn't

have her cycle and then it came back and

it was every I don't know 60 90 days.

>> Mhm.

>> And then she changed her diet a little

bit and it kind of went down to 30 days

over time. But I don't think she knew

what normal was. Is there such thing as

normal?

>> I mean there is what should be normal

for you. So you should have a regular

predictable period which means that you

are having a menstrual bleed at a

predictable interval. It can range

person to person but for you really it

should be within a couple days

monthtomonth. I always tell patients I

should be able to give you a calendar.

You should be able to take your finger

pick when your next period is coming and

within a few days be accurate. Now

usually that range is somewhere between

25 and 35 days for the average person.

when it starts to get shorter or longer,

it can be a warning sign that something

is going on. When it comes to the

menstrual cycle, because I think we're

going to talk about these hormones

really well, and I talk about this every

day, let's give a one minute

explanation. If we think about to

Stacy's point from the brain, the brain

is sending out pulses of hormones, but

FSH drives egg growth. It's called

follicle stimulating hormone, and each

egg is inside a follicle. So, you have a

group of follicles inside the ovary. FSH

comes from the brain, grabs one of them

and gets it to grow and it makes

estrogen and this estrogen from the

ovary as the egg is growing is called

estradiol and it's the primary type of

estrogen in your body. So it is rising

and when it gets to a peak level and the

body is so fascinating because it's 200

pogs for 50 hours is a very exact

amount. Then the brain says we must have

a mature egg and it kicks out a surge of

luteinizing hormone or LH and that is

going to allow the follicle to rupture

the egg to be released and the follicle

to reform and then become a corpus

ludium and then the brain's going to

send out pulses of LH giving you pulses

of progesterone. So Stacy's point

>> that's an average and those numbers on

the little graph are nowhere near

accurate because progesterone goes up

and down the entire second half of the

cycle known as the ludial phase. What's

progesterone?

>> Progesterone is also made from the

ovary. So, the two main hormones when it

comes to a premenopausal female are

going to be estrogen and progesterone.

Progesterone is the progesterational

hormone or progreg. It is going to

change the endometrial lining and it is

essential to get pregnant. It opens and

closes the implantation window within

the uterus and it completely changes the

physiology of your body. And we're going

to talk a lot that is why in the ludal

phase your body works differently when

you have progesterone

>> and the lutial phases

>> after ovulation when you have a corpus

ludium. So when LH is coming from the

brain you have a corpus ludium it makes

progesterone. This is the second half of

the cycle known as the ludal phase. The

first half when you have estrogen only

is the follicular phase. So you have an

estrogen dominant phase and then you

have a phase where you have both

estrogen and progesterone. And your body

is made Yes. So we have our estrogen

dominant phase, the follicular phase,

and then we have we have both estrogen

and progesterone here in the ludial

phase. And your body is made to function

differently in these because in the

progesterone side, it's preparing you

for a pregnancy. It thinks every month

you might get pregnant and it starts to

change how your body's going to work on

a cellular level. But if you don't get

pregnant, that progesterone level is

going to drop and the cycle starts back

over.

>> And from um like a exercise and sports

>> Yeah. point of view. When we get into

this, the progesterone's job is to build

this lush endometrial lining and it

creates a lot of glycogen storage. So,

we often hear about glycogen in the

muscle and that's what we're using for

fuel. It has a way of shuttling a lot of

the carbohydrate away and storing it

into the endometrial lining, which is

why we see differences in intensity and

the way that a woman can respond to

exercise if she has ovulated. So is this

in preparation of a potential baby?

>> Yeah, correct. Yeah. In the second half

of the cycle, your core body temperature

increases, your resting heart rate is

higher, your heart rate variability is

lower, you have increase in fatigue, you

have an increased appetite, your body is

shifting function in case an embryo

comes in so that it can start to divert

energy and change what it is doing right

down to your immune system changes.

>> And that's roughly from day 14 roughly.

>> Roughly. Yeah. Yeah. At ovulation, it's

about 3 days after whatever day. If

you'd like to be specific, it's about 3

days after ovulation until when you get

your next period.

>> Yeah.

>> You all talk about how our menstrual

cycles can be a broader sign of whole

body health.

>> Mhm.

>> And um so should if someone's menstrual

cycle is irregular, should they be

concerned?

>> Yes.

>> Yes.

>> I thought you were going to say no.

>> How irregular? What's like if I'm not

getting my menstrual cycle?

>> Absolutely not good. You should go see a

doctor. Yeah, if your cycle is

irregular, if the calendar trick, you're

putting your finger and it's nowhere

near when your cycle's coming. Or I have

women who say, "Oh, there's no way I

could predict it." Or, "I know it will

come, but it'll come every 4 to 6

weeks." Your body's meant to work like

clockwork when it comes to your your

hormones and your menstrual cycle. And

yes, you can always have one abnormal

month, always. But when you consistently

are having irregularity, that is a sign

that something else is going on. It's

one of the biggest red flags that we

have for early hormonal health or

systemic problems. But to your earlier

point, Stephen, we have a generation of

women on contraceptive options who are

not tracking their cycles. We have women

who are not taught how to track their

cycles. They don't know when ovulation

occurs. They don't know how long their

ludal phase is. If I say the first sign

of ovulatory dysfunction or having a

problem with your cycle is a short ludal

phase, well, you only know that if

you're tracking when ovulation occurs

because otherwise you could still have a

regular cycle, but you don't know that

something's abnormal.

>> And that lut your phase again is the

last the last half of your your cycle.

>> Exactly. But I think that the

conversation that's happening now is so

not just at this table but in society

that our monthly cycle is so much more

than getting ready to have a baby

because I think that none of us knew

this.

>> No.

>> Because at 17 I wasn't that interested

in having a baby. So it didn't occur to

me that I should care.

>> Right.

>> Right. And it's the only time if you're

thinking about it in that way that

you're worried about your period is if

you don't have one and pregnancy, right?

And so if we're shifting the

conversation to this is physiology, this

is has to do with every part of female

physiology,

maybe it will be easier for people to

know,

right?

>> Yeah. I often put it with u my athletes

that it's a marker of health that if you

are able to take on the load of

training, the load of travel and

maintain your normal menstrual cycle,

then you are robust enough to be able to

progress. But if there becomes a misstep

in your menstrual cycle, then we need to

look at all the stressors that are and

the allosic load and pull you back and

see what do we need to address? Do you

need to eat more? Do you need to recover

more? what are the things that are

missing to bring you back to normal?

>> I was diagnosed with polycystic ovarian

syndrome in medical school and so like

every medical student of course it was

like gloom and doom and I you know

thought I had the most extreme case ever

known to mankind. It was really just

garden variety PCOS and I had very

serious boyfriend quickly engaged you

know looking forward to having a family

with him starting a family with him and

the terror around my infertility and

what the impact was. What was never

taught to me and what I didn't

understand until much later was the

metabolic impact. Like PCOS is a

symptom. There's nothing wrong with my

ovaries. They're just responding to this

high insulin level I was born with. And

no one really sat me down and talked to

me about my first research project was

women with irregular periods and the

risk of developing gestational diabetes

and and you know I didn't even know what

insulin resistance was at the time. And

now we're coming to understand that, you

know, when these young women are coming,

you know, I only do menopause now, but

before I left that practice, you know,

when women were coming with the regular

cycles and we were making these

diagnosis, immediately I was launching

into the discussion about her metabolic

health long term and what this, you

know, it's a gift to know this. So now

we can start making interventions,

nutrition, diet, exercise to give you a

better system to deal with this thing

that you were born with and her

fertility. Of course,

>> a huge amount of women have PCOS and I

think that's one of the leading one of

the leading one of the top causes of

having irregular menstrual cycles. You

you mentioned insulin resistance and

metabolic dysfunction there. And you

said something like diabet gestational

diabetes,

>> diabetes in pregnancy. So someone who

was non-diabetic before pregnancy and

then develops diabetes. So her blood

sugars have now reached a threshold

where they are higher than normal and

can cause you know problems for her

pregnancy and herself long term. And up

to 50% of those patients de who develop

diabetes in pregnancy will develop type

2 diabetes within 10 to 15 years after

that gestation after being pregnant. And

so what we know now is like we have

warning signs of this well before

pregnancy where we can set these women

up for success. Before it's just we wait

till we make the diagnosis, everybody

gets their glucose test and off you go.

But now with this PCOS diagnosis, we are

monitoring earlier. We're starting her

on the nutrition. You know, we're

treating her like a diabetic with

nutrition and exercise recommendations

rather than waiting till she she reaches

the criteria. Stephen, having

infertility, this is a scary statistic.

It predisposes you to many medical

problems later in life, including an 80%

higher chance of having a heart attack,

75% higher chance having metabolic

syndrome, higher risk of cancer, and

early death. Why infertility? Well, it's

not exactly that infertility is causing

this, but it's that for many women,

we'll use Dr. Haver's example, you're

healthy until you get this diagnosis.

It's one of the first warning signs your

body's giving you that there might be

inflammation and insulin resistance or

something impacting your hormones, your

menstrual cycle, your ability to

conceive that if it is not corrected now

is setting you up for many problems down

the road. PCOS is a example of this

because in PCOS you have a lot of eggs

inside the ovary. It's actually

something that genetically runs in

families. likely there's something that

happens when you're a baby inside your

mom that predisposes your ovary to not

lose as many eggs as it should and it

changes how they respond to insulin. So

what happens is you end up having more

eggs on an average. Your brain doesn't

know this and sends out the average

signals but that gets diluted amongst

all the eggs and so you're not getting

into these ovulatory stages of Stacy's

favorite graph here. Well, what happens

from there is that you're actually in a

relatively lower in estrogen phase than

you should be. You never see the

progesterone. And what happens is you

start to completely shift. The ovary

itself actually becomes insulin

resistant. And what this means is that

throughout your entire body, you start

to develop high glucose, which is the

blood, right? That's your blood sugar.

Your blood sugar is the fuel for all

your cells. All your cells need glucose.

Well, insulin is the hormone that helps

that glucose go from the bloodstream

into your cells. Well, in insulin

resistance, when your body sees high

glucose all the time, it starts to send

out more insulin saying, "Hey, we need

to get this into cells, but the cells

start to, oh, I'm used to insulin being

here, so I'm not going to respond." It's

going to take a higher insulin signal to

get the cell to open up the door and let

glucose comes in. This becomes very

problematic especially in we'll say PCOS

because that insulin is very

inflammatory causes you to get extra fat

stored in different places. It also just

completely changes how your body your

metabolic health in general but also

your hormonal health and in your brain

because your brain sees this and says

why are we keeping glucose in our in our

bloodstream is what's going on heightens

everything. And so this resistance to

insulin actually shifts how your brain's

going to respond to hormones, therefore

the hormones it's sending out. And it's

a self-perpetuating cycle. And a lot of

when we talk about lifestyle mechanisms

to improve hormonal health, which I know

that we all will, a lot of that is

targeting improving insulin resistance

and combating inflammation because those

two players, a lot of it is controlled

by the world around us and what we do to

some degree. And especially if you have

an underlying diagnosis like PCOS,

>> endometriosis, which is a chronic

inflammatory disease, autoimmune

disease, you're at even higher risk. I

always say your scale is already tipped

in a way that's going to be really hard

for you. You have to make active steps

to fight what is happening inside your

body.

>> We'll talk about some of the ways one

can reverse their PCOS, if that's even a

possibility. Um, but again on the causal

factors, is it something So my

girlfriend's got PCOS. She's been very

public about that. Um, is it something

she did? Is it something she ate? Is it

>> She was Is this the way she was born?

So, she was born with a predisposition

of having too many eggs. You lose most

of the eggs inside your body when you're

a baby inside your mother's womb. You

lose the next biggest set before you

ever have your first period. Now, if you

don't lose them for some reason, you're

born with more and it interferes with

how your hormones are supposed to

communicate leading to this metabolic

issue and this insulin resistance. She

did nothing to cause this. Nobody with

PCOS caused it. However, what you said

earlier, oh, she changed how she ate and

her cycles got more regular.

>> You can influence the severity of the

symptoms that you experience with it. So

even if you don't cause your disease cuz

you did not,

>> choices you make can make it absolutely

can make it better or worse, just like

any disease.

>> And when you use the word insulin, I I

think of or insulin resistance, I think

of sugar.

>> Mhm.

>> Yeah. Because glucose is sugar

essentially. And many people, and I'll

have patients tell me this, I don't need

to worry about insulin resistance

because I don't have diabetes or it's

not in my family. And we've so we've

ingrained this word insulin resistance

or talking about glucose or checking

glucose with a diabetic or pre-diabetic

state. But the world around us honestly

promotes insulin resistance. It's it

that's how our bodies we live in this

obesogenic environment. I mean there's

no doubt at least in the US you know and

most industrialized nations our

environment is what we call obesogenic

insulin you know and insulin resistant

so it you have to fight against kind of

the systems that are in place now for

most of us unless we have some genetic

predisposition to just be you know

magical um to because the way we process

food the way food is delivered to

communities the way you know our lack of

exercise you know everyone's working

from home now just just modern life is

is really you have to fight against.

>> One of the questions that came in from

the audience was I would like to know

how best to manage my PCOS.

>> When it comes to managing your PCOS,

targeting those two factors that we

talked about earlier, insulin resistance

and inflammation are really the key. And

I'll let these two speak to a little bit

of some of the exercise changes that we

can try to impact. But what I'll say is

that the best way to decrease

inflammation in your body is going to be

to start by focusing on your gut. Your

gut health controls a lot of the

inflammatory burden that your body sees.

The foods you choose to eat, they can be

both helpful if they have a lot of fiber

in them. They can feed your gut

microbiome, which is important in

estrogen metabolism, but they can also

be very harmful if they are

ultrarocessed foods that are even

causing more inflammation, not feeding

your gut microbiome at all and

worsening. So, I always say it's like a

scale. If you think every little food I

eat, it can make my insulin or it can

make my inflammation better, it can make

it worse. And so how we structure the

food that we put in our body is one of

the biggest changes the majority of

people can make that is going to make a

difference. And that's going to be a

very plantforward diet. Doesn't mean

it's plant only, but plants have fiber.

Fruits and vegetables have fiber. So we

have to make sure we're getting fiber as

a big change. That's what we see. I see

a lot of patients with PCOS specifically

being told I shouldn't eat fruit. I

shouldn't do this. I I need to avoid

>> do the ketogenic. You need to do keto.

Yes. So, we see people avoiding certain

food groups. And I always say it's not a

really sexy diet, but it's a it's a diet

we all know.

>> Lots of whole foods, fruits and

vegetables, healthy fats, healthy

sources of protein, avoiding the

ultrarocessed foods. That's going to be

probably the biggest change most people

can make. In addition to foundational

changes of your day, which is going to

be sleep more, that is when your body

fights inflammation, fights insulin

resistance. work on decreasing chronic

stress. To Stacy's point, you're not

running from the bear. So, your body is

not using that challenge, but you get a

email. You get stressed and your body

releases a lot of glucose so it can have

sugar and fuel to run from a bear and

there's no bear, right? And previous

days that would happen and then you'd go

run and that glucose would go into all

of your muscles and your body would go

back to normal. But now, we're

chronically stressed. So, actively

decreasing stress and then exercise,

building and using skeletal muscle is

one of the most effective ways to combat

insulin resistance that exists. And

since 80% of patients with PCOS have

insulin resistance, a large portion of

women with infertility, even without

PCOS, have insulin resistance, that is a

huge thing that people are missing,

especially when it comes to the exercise

discussion. And I know you guys probably

have things to add on that one. No, but

based on what you just I just took a

phone call this morning from a patient

when and it's just such a typical

conversation. She doesn't like the way

her body looks.

>> Her solution is not to eat. It's this

happens almost every day when I'm

talking to people. It's we're having

coffee for breakfast. We don't eat till

midday when we do eat. So the the gut

reaction because of the way many women

are raised is that we're going to starve

ourselves which is the opposite of good

when it comes to physiologic wholeness

and then you don't have the energy to do

the kind of exercise you need or on the

other side the response is I am going to

work so hard every single day that you

actually increase your stress there is

over there is overtraining

>> so you're just getting behind the

eightball with starving yourself and

overtraining. None of which are going to

solve either the core problem due to

PCOS or the core problem in any stage of

a woman's life. Right.

>> And this is where we look at the

socioultural effect of what a woman is

supposed to look like.

>> Yeah.

>> And that's the thing that I really

pushing out. It's like we want to think

about how strong we can be and how much

muscle we can build because muscle is a

massive metabolic help. Mhm.

>> And as as well as bone, right? So, we

talk about it and then when I get the

push back of, oh, I'm going to do fasted

training or I'm going to fast till noon.

I'm like, wait a second. Not only were

we going to interfere with our circadian

rhythm and our hormone pulses, we're

also acutely interfering with our

appetite hormones because if we're

looking at gerolin, which is our active

form of of our appetite, makes us

hungry. It's elevated with cortisol. And

so if we're thinking about that

elevation and we're not doing anything

to drop it and tell our body we have

food, then it goes in and directly

affects our neuropeptides, which then

affects our hormone, our hormone pulses.

So when a woman's like, I'm just having

coffee for breakfast and I'm going to

hold my fast. It's like, okay, well,

here we go. Cortisol is going up. As

Gary, you're going to get hungrier. Then

you're going to learn not to respond to

that hunger. You're going to hold your

fast. And we see from the research that

women who do that end up craving more

simple carbohydrates in the afternoon

moving incidentally less and

contributing to poor sleep because

they've now phase shifted. So when we're

talking about sleep and how important

sleep is, we also have to think about

the circadian rhythm and how it is

affected by food intake, light,

darkness, and all of the things. And we

need women to understand we want to

build muscle. We want to sleep well and

that requires food. Well, and it this

goes back this whole thing you just said

goes back to very early in this

conversation where I was talking about

sometimes we like to focus on the bright

shiny gadgets

>> when we haven't taken our health from

fine to optimize because everything you

just talked about

>> it isn't a gadget it's basic lifestyle

>> in the medical model of PCOS when I'm

talking about what we're taught and how

we train our clinicians.

We go into the, you know, we we aren't

taught a lot about disease prevention or

and I hate to use the term root cause

because I think it's been usurped by

certain members of, you know, the

wellness community.

>> Take it back.

>> Yeah, we're going to take it back. And

so, especially for PCOS, I was taught to

give a patient birth control pills or

Clomid when she's ready to get pregnant.

And so nothing nothing around nutrition,

exercise, lowering inflammation and I

was a program director until 2018 and

there was nothing in the curriculum

around this which affects at least 10%

of women probably more this condition

that how important lifestyle is. You

know, she went on for 10 minutes about

all the lifestyle change, which is

amazing.

>> Which is amazing.

>> But but patients,

>> but I'm sitting there thinking birth

control pills, birth control pills. I

mean, that was a knee-jerk reaction. I

mean, I was treated for my own

polycystic ovarian syndrome for 20 years

with oral contraceptive agents. And I

learned online through chat rooms about

the nutrition end of it.

>> Yeah. when I have athletes because we

see a higher percentage of PCOS in

successful female athletes.

>> Why

>> like what do I do? And it's looking at

what kind of training they're doing. So,

we're putting this more short, sharp,

high intensity to get that post exercise

response of anti-inflammatory,

growth hormone response, all of these

things that then bring down total body

inflammation. And then we're very

careful about food intake and when we're

doing it and what kinds of food so that

they don't have to go down the route of

oral contraceptive pills because that to

them has an effect on their performance.

When we're talking about the top end and

when we bring it back down into

recreational female athletes, we can do

the same thing. It's just we have to

educate and say these are our lifestyle

choices and then these are our medical

choices and what's optimal for your life

at this point. Mhm.

>> It's important to say at this table, and

we all talked about it last night, you

need to have a period if you're not

preventing a period with hormonal

contraception and you're in your

reproductive years. Because very often

women with PCOS or hypothalamic

amenorhea will say, I don't have a

period, but I didn't really like that

anyway, so it doesn't bother me, right?

How many women have said, well, I didn't

get my period for a year, but that was

fine by me. But that's not fine by your

body. That is hypoestrogenic time. It is

low estrogen.

>> Yeah. Very low estrogen. It's bad for

your body on so many reasons to be low

estrogen during these crucial bone

building years. But for we're talking

about how your hormones communicate

back. It's very harmful to long-term

health to have low estrogen

at all.

>> Brain health.

>> But yeah, but especially in young years

when you're still developing.

>> Why would a woman say that she didn't

want to have her period? I mean, this is

a super naive question as a guy, but I

understand it's painful.

>> I mean, do you want to bleed from

>> Do you want that?

>> I mean, if it was a choice now,

>> actually knowing now what I know now

>> and for my own young daughters, I'm

like, we have got to make sure you have

a period. But when I was young, I was a

dancer and an athlete. I had very low

body fat and I wouldn't have periods for

6 to9 months. And I'm like, yes.

>> Do you know what's interesting? I was

thinking of Mel.

She because of what she's been through

and also because she's listened to the

conversations I've had with all of you

and she understands the value and

importance of her period, she now

celebrates it. It's like a celebration

in our house when it arrives because

>> because if you understand the importance

that it has in sort of full body health

and the role it's playing, then the

pain, the downside

>> is weighted against your understanding

of the upside, which to her means she's

healthy, she's fat,

>> hormonal health is working, things are

great. And that's the conversation shift

that I'm hoping is gonna instead of

being a detriment and a downer and

talked about she must be on whatever

derogatory yes derogatory things are

said about us that oh my gosh she is so

healthy.

>> Yeah. I remember sitting in a high

performance meeting just maybe three

years ago and the leading athletics

coach stood up and said I know when my

athletes are ready to perform on the

world stage when their periods stop. And

all of us went what?

It's like no, that's the time where like

we have to really look at your athlete

is getting ready to crack and be

injured.

>> And it's still this pervasive idea and

it's still pervasive even in the fitness

industry that losing your period is okay

cuz that means you're training harder.

>> They actually are very resistant to

getting it back.

>> Yes. Like it's a sign of failure of

their sport or their athletic endeavor

because this is is so pervasive. And I

think that's why it's important to have

these discussions. And I love hearing

that Mel now says, "Yay, my period is

here." Because that's a sign of hormonal

health and things are working well

because that is how we should feel. But

I think the other part of it is for

women who have mayoria or heavy bleeding

and heavy cramping. They don't realize

that they can get help with that as

well. Mhm.

>> And that's a conversation that isn't

followed through when we're like, "Yes,

get your period, but if you're someone

who suffers from really bad cramps, we

also have to educate that there are

things that we can do to help with that.

>> Does the size of the bleed matter?"

Because she turned around to me the

other day and she said with her last

cycle, she said that she didn't bleed

much and she seemed slightly concerned.

Obviously, I had no idea what to say to

that.

>> It depends.

>> Congratulations. Well done. I'm so

sorry. minora. So we have definitions

and there are you know we don't walk

around with measuring cups generally

between our legs to measure how much

blood's coming out each month. But

>> but women know

>> but women know your period should not

cause you with modern you know period

products your cycle shouldn't cause you

any stress in your life. You should just

roll with it, right? And so that's when

I'm like when is it a problem?

>> Shouldn't bleed through your clothes.

>> You should be able to sleep through the

night. You should be able to get through

an athletic performance. You should be

able to do X, Y, and Z. Now when we do

start measuring and you should not be

anemic. So I'm not waiting till anemia.

I am anemia is low red blood cell count

you know to the point where your

performance is affected. Your ability to

carry oxygen is effective. So the red

blood cells are what carries oxygen in

our bodies. And women who have heavy

periods however that's defined can lead

to anemia. But the first thing that we

notice is their feritin is dropping.

That's the first sign my do my daughter

we just had some blood work done. She

was feeling a little fatigued and her

ferotin and iron saturations were really

low and I was like talk to me about your

period. Turns out she's not eating a lot

of iron rich foods. So we're dealing

with that. But you know we can get so

far ahead of this and looking at these

ferotin levels the transfer you know

these iron studies before she's actually

anemic which is like the last thing that

happens when her red blood cell count

drops or they become so small and what

we call microitic. you know, we are we

need to do a better job at recognizing

these things. We're not going to walk

around and measure how much blood's

coming out because I could maybe squeak

out 200 cc's, you know, a period and you

could be 300 and we're both doing fine.

You know, we both have great. So, I

think it's really looking at, you know,

how much bleeding is too much. Now, how

little is too much? That that's probably

better in your

>> Yeah. Is any change from what you

consider normal? We would all say this

is a normal amount. So if it gets

heavier than that or less than that and

it stays that way, that is concerning.

You can always have a one-off. Estrogen

is the driver of growing the uterine

lining. So if you have a lighter bleed

one month, we are concerned that you did

not grow as thick of a lining. Your body

didn't see as much estrogen. Most the

time you ovulated earlier that cycle,

your cycle came a little bit sooner than

you're used to it coming, and it's not

quite a big deal. But this can be

concerning if we see consistently light

periods, especially if we have history

of progesterone contraception, which

progesterone thins out the lining and

estrogen grows it. So progesterone

actually stabilizes it, but for the sake

of the discussion, we'll say estrogen

grows it, progesterone thins it. When

you only see progesterone, like a

progesterone IUD, the progesterone shot,

even continuous birth control pills,

because they give you a type of

synthetic estrogen and progesterone

every day, your uterine lining gets

thinner and thinner and thinner. And so

we see it can take months to return to

normal after coming off of hormonal

contraception. You also can get damage

to the endometrial lining. There's stem

cells in the endometrium that regenerate

every month after you bleed. They

regenerate so that the next group can

grow in response to estrogen. And this

can get damaged from typically anything

inside the uterus. So most commonly this

is post birth, you know, a traumatic

birth, a retained placenta, a DNC

procedure, which is sometimes used after

birth or in a miscarriage or even IUDs

or intrauterine surgery. and it can form

scar tissue in the uterus that can cause

a light period. So if you said, "Oh, Mel

had a miscarriage and had this procedure

and now her periods are lighter." I'm

highly concerned.

>> Versus amen.

>> Yeah. So that is concerning for scar

tissue in the uterus.

>> Okay.

>> If you said, "Oh, she was on a birth

control pill for a while and now it's a

little bit lighter." I'm less concerned

that's probably going to get better. or

if this period came closer together

>> or if you traveled around the world

three times this last month or

>> so one one off is no big deal but a

change from your baseline can be

concerning in addition we should say

that that graph is beautiful but you

know your thyroid your pituitary gland

it makes prolactin prolactin also

changes the endometrium so there's

subtle signs of other hormonal issues

that your menstrual cycle is the first

warning sign that something is off

>> what about pain She 2 months ago she had

like excruciating pain that I've never

seen before during her menstrual cycle.

>> Well, it's not pleasant to have your

uterus contract and expel its contents

in any form.

>> But what if it's like way above the

norm?

>> One time way above the norm is probably

situational based on other things that

are contributing to inflammatory burden

or response. your body is also healing

from a the corpus ludium's a cyst on

your ovary that can also feel painful

and at the time of your period it is

also healing so there's multiple things

that can cause pain

to Vonda's point so many people say I

have a high pain tolerance this is okay

because we don't talk about our own pain

so I don't know if my pain is normal

compared to somebody else's your pain

should not keep you out of your

activities of daily living you shouldn't

call in sick to school call in sick to

work, cancel dinner plans with friends

consistently. Again, everybody can have

a one-off month where something is off.

But if this happens every month, oh,

it's my period. I'm going to cancel

that. That is a warning sign that

something else could be going on.

Endometriosis, adnomiiosis, and uterine

fibroids.

>> You mentioned the word iron a second

ago, Dr. Mary. What is iron got to do

with this? And what is iron? So iron is

an element that is in our diets and we

do tend to store quite a bit of iron in

our bodies and it's an essential when we

look at the structure of the red blood

cell and of hemoglobin specifically. So

hemoglobin is the actual molecule that

is inside of the red blood cell that

carries the oxygen. So iron is really

critical to the formation of healthy you

know iron carrying red blood cells and

we we store iron in our bodies and so

and a lot in the bone marrow and in and

it's stored in this particular molecule

called feritin. So when we're measuring

ferotin levels in the blood that is you

know the first sign that your iron

stores are getting low is when we see

these low feritin levels. Are women more

iron deficient than one would think?

Like is the general population iron

deficient or what do you tend to see

when you run lab tests?

>> A menstruating woman. Yes.

>> A menstruating woman is is often

iron deficient.

>> Yes. And I we I do see it in our post

post-menopausal patients as well. That's

usually nutritional and inflammation

related. So ferotin is also something

that will decrease in in times of

chronic inflammation. And so you're not

able to utilize the iron that's coming

in and store it because this

inflammatory state is kind of inhibiting

that. So in a menstruating patient, I'm

always thinking is she bleeding too much

the first time, you know, and is that

bleeding menstrual? Is it coming from

her rectum? Is it coming from her

gastrointestinal tract? You know, does

she have gastritis or, you know, we have

to go through the, you know, the

algorithm of why that might happen. In a

post-menopausal patient, we can remove

vaginal bleeding from the issue, you

know, uterine bleeding, a period, but

then now I'm looking at nutrition. And

I'm looking at exercise. I'm looking at

inflammation as causitive factors.

>> And the global pitch here is the World

Health Organization estimates that

roughly 30% of women aged 15 to 49

worldwide are anemic with iron

deficiency being the leading cause. And

in some reason regions of South Asia and

subsaharan Africa prevalence can be up

to 50% of women are anemic with iron

deficiency being the leading cause. H

>> you noticed the norms have changed.

>> So it depends on who you read.

>> Yeah. again, you know, when you're

looking at male male normative curves

versus what you know, we're we're tend

to accept lower levels for a female. But

now that we're looking at performance

and, you know, looking at other factors

besides just what is this feritin level,

>> um there's a lot great new research

coming out that we are looking at this

differently and that that we're in our

clinic, we are looking for 60 to 100 for

a feritin level to be considered

optimal. very different than, you know,

the baseline for, you know, keeping you

out of out of a hospital versus you

functioning at your absolute best.

>> Yeah. Because the norms that often get

measured for us

>> because they tripled, right? They were

15 and then they went up to to 40.

>> So now they're saying 20 and above is

normal. And when I look at a lot of

women who are sitting 20 to 30, they

can't get help.

>> They cannot get help. And it's like,

whoa, it was maybe four or five years

ago. If you were below 50, then we would

look to get help. But now with the norms

that have shifted with the sicker

population,

we can't get women help unless they are

below 20. So when we say normal, I think

this is important for everybody watching

or listening. Normal in medicine means

common,

>> not non-pathological,

>> okay?

>> Not bad, you know, doesn't mean it's not

bad. And so norms shifting meaning we're

getting sicker as a population and we're

willing to accept lower levels although

they're not optimal for health. The lab

reference range what they say when you

get your blood work drawn and you see

the reference range is based on

population averages. And so if the

population is more anemic this is going

to accept a lower levels being normal

even though they're by no means optimal.

And I think that's one thing we all talk

about is well how are you feeling your

symptomology? What do we see? And you

have to interpret blood work in context

of the whole person and what is

happening. And that is one issue we do

see with getting your own blood work

drawn or these online companies when

nobody's interpreting it or helping you

interpret it on the other end. You see

something that is in a normal range but

it's not at all optimal for you and it

could be the reason why insurance. Yeah,

exactly. I want to talk about

endometriosis. I we have a team member

who's been with the Davosio since the

very beginning called Liv.

>> Yes.

>> Are you familiar with Liv?

>> I am.

>> So at age 13, she had her first period

and she experienced agonizing pain with

heavy bleeding.

>> At age 14, she was put on the pill to

manage the symptoms. Between age 15 and

24, she continued to have severe stomach

pain which resulted in multiple A&E

visits. She was often dismissed as

having gastriisitis.

>> Mhm. And it led to having her appendix

removed.

>> Oh my god.

>> Why'd you say oh my god

>> can get surgery?

>> But she had major surgery and

>> um I' I've seen this course before and

it's it's devastating cuz she's going

years and years and years now of

>> Yeah. age 25 she came off the pill to

see how she felt without it but her

periods worsened and she fainted from

the pain. So she went to accident and

emergency. At age 26, she got an

ultrasound which suggested

endometriosis, but no NHS diagnosis was

given.

We ultimately had a conversation with

you on the podcast, Natalie, and she

felt very heard and she was actually

there. And so afterwards, Jamaima in the

team, who you you guys know, um told Liv

to come and speak to me. And Liv told me

after you left about um the symptoms,

did she speak directly to you at that

time? She did. Okay. So, she came and

she spoke to us about her endometriosis,

which is the first time I'd ever heard

of it. Um, and then we offered to help

support her privately so she could get

private support with it. Um, and she got

an MRI scan privately, which confirmed

stage 4 infiltrating endometriosis.

>> Oh gosh.

>> Liv then pushed um on with her NHS

appointments, the National Health

Service in the UK, but the pain was so

much that she took me up on my offer to

pay for it privately. So, we paid for it

privately. Uh, and the endometriosis by

that point had spread to her bowels and

pelvis. And I've got this picture of

this four cm cyst. If you're all

faint-hearted, I mean, I don't know

where we'll put this on the screen, but

this is from her operation.

>> Yeah. It's called an endometrioma. It's

huge.

>> For anyone that can't see, it kind of

looks like a tumor.

>> Yeah.

>> Um, next to her ovaries

>> and it had spread at that point to her

bow and pis pelvis. It had become about

4 cm big. Her ovaries were stuck

together and attached to her womb and

her bowels. She then needed to book an

appointment for surgery. And before the

surgery, because of the scale of her

endometriosis, she had her eggs frozen

to protect her future fertility, which I

guess came from your advice. This

process took her 7 years and she was in

pain for 17 years because she did not

get a diagnosis.

>> Her story is unfortunately not uncommon.

This is a very typical story for

somebody who suffers from endometriosis.

Endometriosis is an inflammatory

condition. And the way I like to explain

it is when your body responds abnormally

to a normal process. You have immune

dysfunction as well. So let's think of

it as an autoimmune disease and a

chronic inflammatory disease. When you

have your period, you bleed out

indometrial cells in your menstrual

blood. We're used to that. In everybody,

you also have some indometrial cells

that will escape out the fallopian

tubes. That's not a big deal. If you

take out somebody's appendix while

they're on their period, you'll actually

see menstrual blood in their abdominal

cavity. In the regular person without

endo, your body says, "Oh, she's just on

her period." In the person who has

endometriosis, this creates a huge

inflammatory response where your body

starts to attack indometrial cells and

you get these implants throughout the

what's called the peritineal cavity or

the abdominal cavity of indometriallike

tissue that gets worse every time your

body sees estrogen which because it's

feeding the endometrium just like it

would in the uterus and so it gets worse

over time. The more ovulatory cycles you

have the disease gets worse. It's so

inflammatory that it's not uncommon to

get extensive

organ scarring. You get anatomical

distortion. These are some of the

toughest surgical cases in addition to

managing lifelong health but also

fertility as well.

>> Just obliterate the anatomy like because

the infiltration you'll these implants

will start growing into other organs

because they'll find new blood supply.

They'll steal blood, you know, blood

supply from from the bowel from because

all of our pelvic organs are just

sitting there on top of each other, the

bladder, the bowel, the c, you know, and

so

>> it sounds like it's alive, like it's a

cancer or something.

>> Think of it like velcro is what I say

almost these little patches of velcro

and they just start sticking together.

And that's what inflammation and

scarring does throughout your whole

body. And what happens here is that

because the primary symptoms of

endometriosis is pain. So again, back to

women's pain being taken seriously.

>> That's one of the issues and why the

average time to diagnosis is 7 to 10

years. Truly 17 years in this case from

when she had pain.

>> But the other symptoms do include

sometimes also pain with intercourse.

Typically though, that is very hard to

ascertain from somebody, but it's

usually with certain positions. Deep

penetration tends to be what really

stimulates pain. But you also see a lot

of GI manifestations that we don't talk

about. So if I have somebody who has

painful periods and they say they have

irritable bowel syndrome or a lot of

vague GI complaints,

that is a really big red flag to me

because like you said, these little

indometrial implants on the bowel, the

intestine, this high inflammation that's

happening irritates your intestine and

you get this GI response as well. One of

the hardest things about indometriosis

is that it's a surgical diagnosis only.

To be honest, we can means

>> have to do surgery to fully see and

diagnose that you have this.

>> It's one of those no meat, no treat, you

know, in in in medicine where you can't

make the diagnosis until you have a

tissue sample. So meat means you go and

take a biopsy.

>> Okay. See? Okay.