S03_E02_The Menstrual Cycle As a Vital Sign: Audio automatically transcribed by Sonix

S03_E02_The Menstrual Cycle As a Vital Sign: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.

Kristyn Hodgdon:
Hi. I'm Kristyn Hodgdon, an IVF mom, proud fertility advocate, and co-founder of Rescripted.

Staci Tanouye:
And I'm Dr. Staci Tanouye, a board-certified OB-GYN striving to make reproductive and sexual health fun and empowering for all.

Kristyn Hodgdon:
Welcome to Dear Infertility. This season, we're going back to the basics. From menstrual cycle red flags to what you need to know before you start trying, we're giving you the tools you need to take control of your overall health and fertility.

Staci Tanouye:
Does birth control cause infertility? Do painful periods mean that I have endometriosis? We're here to answer all of your real life questions and provide you with patient centric advice and support so that you can be your own best health advocate.

Kristyn Hodgdon:
Now let's dive in and talk about everything sex ed failed to fill you in on.

Kristyn Hodgdon:
Hi everyone, and welcome back to Dear Infertility. I'm your host, Kristyn, and I'm here with Dr. Staci Tanouye. Hi, Dr. Tanouye!

Staci Tanouye:
Hi, how are you, Kristyn?

Kristyn Hodgdon:
I'm doing well. Really excited to be back with you to discuss all things periods. As someone that has never had a regular period, I'm excited to to talk about how the menstrual cycle can be sort of a vital sign when it comes to your overall health and fertility. So we received a ton of questions from our community about what is a normal menstrual cycle and and what are some common red flags there, so excited to dive in. So one question that I'm curious about is what are the different phases of the menstrual cycle, like the follicular, ovulation, luteal phase like? Can you kind of go into the full month?

Staci Tanouye:
Yes, I love this question because this question, as it's presented on the Internet and social media, drives every single OB-GYN absolutely fucking insane because everyone else, non-medical, gets this totally wrong. You will see everywhere, in every single social media post and every single internet article, you will see the headline there are four phases of the menstrual cycle. Like literally everywhere, everything you'll pull up, you'll, you will see that and that's wrong.

Kristyn Hodgdon:
Wow.

Staci Tanouye:
That's the sign of someone non-medical writing and trying to oversimplify the menstrual cycle.

Kristyn Hodgdon:
Yeah, I mean, that's a great point because I do see a lot of, I don't want to generalize but like nutritionists, and you know, saying you should eat differently throughout your different weeks of your menstrual cycle or you should exercise differently. And I'm always like, if I did that, would I get a normal period?

Staci Tanouye:
Right.

Kristyn Hodgdon:
But is that actually true? I have no idea.

Staci Tanouye:
I mean, all this stuff drives us absolutely bonkers. Like it really, really does. So to go back as like, four, like are there four phases of menstrual cycle? Like, not exactly. That's not totally accurate. It's like half accurate, but not completely. And the bigger truth of it is the menstrual cycle is comprised of two different organ cycles, okay? Because your ovaries and your uterus work together, but they have their own phases. So the ovaries have their own cycle and the uterus has its own cycle. And yes, they kind of talk back and forth and they depend on each other to function and they kind of align. But when people, when people are saying there are four phases, they're intertwining and mixing those up together, which if we really want to understand our fertility and ovulation, it's really important to separate those so we can understand how they interact with each other. So there's not four phases of the menstrual cycle. Those four phases that people talk about are actually the two different organ cycles. So the ovarian cycle has its own three phases and the uterine cycle has its own three phases, and they correspond and interact with each other, but they're separate. So the ovarian cycle starts with the first half of the cycle is the follicular phase, where your ovaries are developing all the follicles and the hormones are telling the ovary to create a follicle that you want to ovulate. The second phase is the actual ovulation phase, and the third phase is that luteal phase. The after ovulation, leftover follicle does to support that ovulation and then tell the uterus what to do. So the ovarian cycle has three phases follicular, ovulation, luteal. Then you have the endometrial or uterine cycle and that has three phases and that is your menstrual cycle, which is the first, you know, 5 to 7-ish days of your cycle, followed by proliferation, followed by the secretory space. So again, the endometrial phases are menses, proliferation and secretory.

Kristyn Hodgdon:
And what are these last two? I don't think I'm familiar with those.

Staci Tanouye:
Right. So that's what the uterus or endometrial lining does in response to the ovarian phases. So when your ovaries are in the follicular phase, those same hormones are also telling the uterus to proliferate or to build up its endometrial lining so that that first part right after your menses, your uterus, your endometrium lining should be kind of building and fluffing itself up to get ready for ovulation. And so the proliferative phase of the endometrium corresponds partly with the follicular phase of the ovary, and then ovulation happens and then the uterus goes into the secretory phase while the ovary goes into the luteal phase. So the luteal phase of the ovary is also releasing hormones that's now telling the endometrium to, okay, we don't need to proliferate anymore, we don't need to fluff ourselves up anymore, we need to stabilize this lining because we need to support the implantation of this egg. And so each of these phases is these the separate organs, the ovary and the uterus. But they talk to each other and they correspond with each other. So two organ systems, two cycles, each cycle has three phases of its own. There's not four phases.

Kristyn Hodgdon:
Wow. I just learned so much and I want to unfollow a lot of people on social media.

Staci Tanouye:
Yeah. So someone's telling you that there's four phases, they are totally oversimplifying and like intertwining those two cycles that we really need to keep separate to understand how everything works. I promise you there, doctors would never do that.

Kristyn Hodgdon:
Well, awesome. So I know, what constitutes a normal menstrual cycle because there is a range, right?

Staci Tanouye:
Yeah, there is a range. And we do have pretty specific criteria of what we consider quote-unquote, normal, normal menstrual cycle from day one of one period to day one of the next period should be somewhere between 21 and 35 days. Ideally, most people should fall into a little tighter range for that. So normal is 21 to 35. But really, if we want to be ovulating in a healthy, normal way, that's probably going to be closer to 26 to 32 in a little tighter range. And the more consistent you are month to month is probably more important than anything. So if you have a slightly shorter cycle, that's 25 days, but you are consistent at 25 to 26 days every single month, that's pretty reliable and healthy and good and we like that. So that's cycle length. Besides that, when we think of just actual period, bleeding, should last less than seven days. We should be changing a pad or a tampon that's fully soaked, no more than kind of 3 to 6 to 7 times a day. If we're changing fully soaked pads or tampons every 1 to 2 hours, that's probably too much. And your period should be not too painful. Like cramping, yes, is normal. But what I usually tell patients to gauge period pain and what's normal versus not normal is if you have cramping, if you do like normal at home over the counter stuff, you take some ibuprofen and your pain gets really tolerable, you can kind of go on your day and be okay, that's probably normal period pain, that's probably normal period cramping. If it is resolved with a warm bath, heating pad, and some ibuprofen and you can kind of go on with the rest of your day and not be interrupted by pain, you are okay. If your period pain is to the point where it's not controlled by those normal simple things and you can't go on with your day without being completely like or not, I shouldn't say completely, but even partially incapacitated or just super uncomfortable if it's, if your period pain is getting in the way despite all of those over-the-counter and home things, that's too much and that needs to be evaluated.

Kristyn Hodgdon:
Yeah, that's such an important point because I've seen a lot of people on either social media or in real life say that they've had painful periods their whole lives and not necessarily not ever taken seriously, but just like it was never made into like looked into as anything more than it was.

Staci Tanouye:
Right and period pain is not, doesn't always necessarily mean that something bad is going on. Period pain that's excessive doesn't always equate to scary things like we think of like endometriosis, doesn't always equate to that, but we do need to talk about this. So if it does seem out of proportion to what's normal, we can evaluate it and we can kind of give better suggestions of how to treat it, because if we can treat and manage pain pretty easily, then we can be fairly reassured that there's really nothing serious going on that we need to be concerned about. If we can't easily treat pain, then we need to dig a little deeper.

Kristyn Hodgdon:
Got it. So that brings me to what are some common menstrual cycle red flags in addition to painful periods?

Staci Tanouye:
Right. If you have persistent cycles that are too short, less than 21 days from day one to day one, you need to be evaluated. If you have persistent cycles that are longer than 45 days, that needs to be evaluated. If you have, at any time have a cycle that's more than or miss periods for more than three months or 90 days, we need to see you. And heavy or excessive bleeding, like we talked about, if you're changing like something fully soaked, a pad or tampon every 1 to 2 hours, not normal, we need to see you for that. And again, the excessive pain, we want to see you for that, too.

Kristyn Hodgdon:
When there is heavy bleeding and pain, do you typically screen for endometriosis or how do you sort of rule that out?

Staci Tanouye:
Yeah, we kind of look at the full picture, right? And endometriosis is really hard to diagnose because if you've ever looked into endometriosis and what it is, you know, that the only definitive diagnosis is surgery, right? And not everyone needs to undergo surgery to actually get a piece of tissue to send it to the pathologist to confirm that yes, this is endo. Endometriosis can often be assumed by a really good, thorough clinical history. So if I can gain a lot of detail of your entire medical menstrual history, then a lot of times I can suspect if this is endo versus not endo, and if I'm really suspecting that it's endo that makes us push further and further and going down kind of the diagnosis rabbit hole, if there are different characteristics that don't make, that, that are not characteristic of endometriosis, then I might go down a different rabbit hole of what we're doing to diagnose and treat pain. So it's history and physical exam are really important to kind of teasing out what could potentially be causing pain. We use ultrasound pretty liberally in GYN as well to just look at simple structures of the uterus and the ovaries too, that can give us some idea of what's going on, but an ultrasound is not always going to be diagnostic either. So it's a little bit a combination of all the information that we can gain from each patient.

Kristyn Hodgdon:
And does it matter also like if the patient is trying to conceive, would that prompt you to maybe look into it a little bit further on the endometriosis side of things?

Staci Tanouye:
Yes, definitely. Like if someone is actively trying to conceive and if they've been trying and, or have been unsuccessful and they have really heavy periods, those are little pieces of the puzzle that kind of point towards endometriosis, right? Because endometriosis, we know, is associated with this inflammatory state that for whatever reason, makes pregnancy more difficult to achieve. And so those are all of those little pieces of the puzzle that we put together to say, does this kind of fit into an endometriosis box or is this not at all fitting into an endometriosis box and I have to shift gears? So, yes, all of those pieces of the puzzle really are important.

Kristyn Hodgdon:
Got it. That makes sense. So you mentioned bleeding more frequently than every 21 days. What could that be a sign of?

Staci Tanouye:
So if you're bleeding more frequently than every 21 days, I mean, it could be a lot of different things, but you might not be ovulating regularly because your bleeding pattern might be what we call an anovulatory bleeding pattern, meaning you're not ovulating and you're bleeding just irregularly for some other reason. Or it could mean that you are ovulating, but that ovulation is not quite happening at a great time, and those phases and that hormonal, kind of like, I talked about that hormonal dance of talking of all of the different organ systems in the brain talking to each other, something is not matching up quite right there. So maybe you are ovulating, but there's some sort of ovulatory dysfunction that's not matching up. And so, again, there's a lot of different things and there's a lot of nuance that goes into what we're thinking about with what we call our differential diagnosis, but all of these little pieces go into what we think about as possibilities for the reasons.

Kristyn Hodgdon:
So could the same be the case for longer, more infrequent cycles?

Staci Tanouye:
Yeah, pretty much the exact same. It could be that you're not ovulating at all, and that's why you're never getting your period or your periods are happening super far apart. Or it could be some sort of ovulatory dysfunction. You are ovulating, but something else is like is not matching up well.

Kristyn Hodgdon:
And how do you sort of diagnose or figure out, figure that out whether the person's ovulating or not?

Staci Tanouye:
Sometimes it's really easy and sometimes it's really hard. So ... And there's nothing straightforward with how we evaluate menstrual cycles. It can be really tough because, again, we talked kind of in the last episode about hormone testing and that sort of stuff. And that stuff is hard because our hormones swing very wildly through the different phases of our cycle. And so there's very wide ranges of normal that might not necessarily be helpful for us in diagnosis. There's a couple of things that we can look for when we're evaluating if someone's ovulating or not. Number one, I'm typically asking someone for their menstrual calendar. Like if you are tracking on an app, I am stealing their phones from them and scrolling through their calendar to look at their app and to see exactly what their bleeding pattern is. So that's the number one thing that's going to help me. If I really want to look further, I'm doing laboratory testing, so I'm testing, if you're producing progesterone in the second half of your cycle because if you are ovulating, after ovulation your ovary is going to start, that follicle is going to start producing progesterone. And that's what supports a potential implanted pregnancy. If you're not producing progesterone, you, it's unlikely that you have ever ovulated at all. And so that's another test we can do, we can test your progesterone in the second half of your cycle. And then beyond that, I'm asking people to not only track their periods, but I need you to track your symptoms too. So a period tracker, if you're using a period tracker app, you shouldn't just be tracking your bleeding, you should also be recording all of your other symptoms that kind of seem to happen cyclically throughout the month. Your mood changes, am I getting cramping and my feeling a little cramp in my pelvis? What's my bladder habits doing? What are my bowel habits doing? What are my sleep patterns doing? What, I mean literally everything, because I want to see what cyclical changes of other symptoms that you're feeling, so I can understand where your hormones are throughout the month. So it's not just bleeding, I want to know everything else that goes along with it too. And all of those, again, all of those pieces of the puzzle we put together to kind of figure out if someone's actually ovulating or not.

Kristyn Hodgdon:
Absolutely. I'm one of those people that never gets a period, so how do you sort of, so would you then sort of screen for PCOS? How does that work?

Staci Tanouye:
Yeah, there's a lot of things that we would screen for, like, that gets into kind of the bigger evaluation of what is causing us to just not get a period to not ovulate, to not bleed, because there's a couple of different things. Less likely it would be something structural, so we're getting ultrasounds to look at that. But is it something else like PCOS or is it related to your pituitary or your thyroid or something else going on? And that's when we would start digging into kind of laboratory testing, other pieces of your history, looking at other symptoms, what else are you experiencing and that sort of thing to again tease out, to which category do we fit into of why we're skipping periods? Oh, and don't forget an actual pregnancy test, because we've seen those, too.

Kristyn Hodgdon:
Absolutely. And how do you sort of, besides inducing a period with provera or progesterone, how, is there a way for patients to kind of induce their cycle naturally? I feel like that's another thing that kind of goes around online a lot where it's like your diet and exercise and you'll just get your period back, and I'm really? I don't know.

Staci Tanouye:
Right. Yeah. Everyone wants the magic fix, right? To be like just take the supplement and you will automatically ovulate. And in reality is, is most of the time it's a lot harder than that. Yes, what I usually talk to my patients about when we're talking about some sort of ovulatory dysfunction, whether it's PCOS or something else, we're usually talking about optimizing kind of the whole picture, right? And that's what I think a lot of these like nutritionist and exercise accounts and everything like that, I wish they would get that, to that in a more broader sense rather than being so damn specific about it, because not everyone is going to respond to that recipe, right? Not everyone you are, follow so and so, personal trainer and they're like, oh, if you just exercise like this, you will get your period. Or if you just exercise like this, you will optimize your, your performance during whatever phase or anything. And same thing with some of the dieticians, and there's great dieticians out there who get this, so don't get me wrong, but we all know the ones who who don't, and they're saying you have to have this diet and you have to eat broccoli at this time. And I think it's, it's putting people into two types of little categories. It's narrowing down what we think we have to do far too much, and I think for some people that can work and that can be helpful for us to try to control that environment and for a lot of people, that's not going to work and it's going to make us feel out of control and it's going to make us even more crazy, right? Like if we start losing control or feel like we're losing control, it makes us feel crazy and we do not want that. We always want to feel in control, right? Like that's the ultimate thing. And so any time we feel like we're losing that control, it makes us feel really bad inside. And I think if we're narrowing it down too much, that's just setting up more people for, for failure and for feeling like they're out of control because someone's telling you this will control everything for you. And when it doesn't, which it won't for a lot of people, then that category of people is already kind of excluded from whatever they're selling. So yes, there are great things, but I think the bigger picture of that is far more important than you have to eat this or exercise this at this point in your cycle to make you ovulate or to make your period healthy. It's the overall what are you putting into your body? What is your overall diet look like? Are we getting a good nutrient dense sort of diet but still feel good about what we're eating and how we're fueling our body? How does our body feel with what we are eating and fueling it with? And same thing with exercise, what are we doing in terms of movement and to move our bodies and to feel strong? And how does that make our bodies feel at different points in our cycle? Because everyone is going to be a little bit different and I hate the pigeonholing into these small little categories. I think that really does a disservice to the vast majority of people. It's going to help some people, and so if it helps you, like by all means, like if you feel in control with doing whatever program that you're doing, kudos, like do it, like I want you to feel in control. But we also have to know that that's probably not going to work for the majority of people, and for the majority of the people, they need a much broader sense of what we're doing for health, which includes diet, exercise, sleep, stress management, and then may include medications or supplements on top of that, but there's no one magic recipe for anyone.

Kristyn Hodgdon:
Yeah, I like that you, kind of, promote like just being aware, really in tune with your body. And if you're not getting to your body and pay attention to your symptoms throughout the month and pay attention to how food and exercise makes your body feel because you know your body better than anyone else. I was experiencing like really crushing fatigue about a year and a half ago and it turns out I had hypothyroidism and Hashimoto's.

Staci Tanouye:
Yeah!

Kristyn Hodgdon:
And it's like, wait, I don't feel right, but maybe it's just.

Staci Tanouye:
Maybe it's just your exercise pattern, like just exercise and you will get better.

Kristyn Hodgdon:
Totally ... autoimmune disease! But yeah, it always speak up if you feel like something's wrong and, and talk to your provider about it.

Staci Tanouye:
Yeah. Like you mentioned before, like is there a specific way you should exercise or eat during specific points in your cycle? And there is some research out there about those topics, don't get me wrong. But again, like if there is research that says, oh, doing high intensity stuff during the first half is better for you, does that mean you have to follow that script? If that's not what your body is feeling at that time? Or does that mean that I have to do yoga during the second half or during my period because I'm supposed to do low intensity during this time? No. Like if you, if your body feels like it needs to scale back or do something a little lower intensity when someone else is telling you, no, at that point in your cycle, you should be doing high intensity. Like, don't force yourself to do something that doesn't feel good for what your body needs. Some people do really great doing a lot of exercise during their periods, and that could help their period pain, it can help their bleeding pattern and some people do not. And so I think we have to get away from these really scripted regimens of what is going on out there. Listen to some of those details, put it back and tuck it into the corner of something I might try sometime, but what trumps everything is listening to your body, what your body needs, and how your body is responding to different things. And that may not correspond with whatever so-and-so is telling you to do.

Kristyn Hodgdon:
Absolutely. So lastly, I kind of wanted to demystify PMS. So what exactly is it? I think we all are like, oh, I definitely am moody before my period, I definitely want to eat, my stomach is a bottomless pit, but what what does PMS really and how do you typically recommend dealing with it?

Staci Tanouye:
Yeah, PMS or premenstrual syndrome is that constellation of just those those unpleasant symptoms that we may or may not notice, or maybe those around us are noticing it more than we ourselves are. It's the, the mood changes, that irritability, the bloating, the appetite stimulation, the fatigue, it's all of that, and that usually happens about a week before your period starts and maybe for the first couple of day or so or a couple of days of your period. And what's happening there is if you had ovulated, after you ovulate your progesterone starts rising. And somewhere around kind of that peak of that progesterone is usually a where PMS symptoms start because progesterone is an appetite stimulant for a lot of people, progesterone can make people fatigued a lot of the times, and it can do a lot of these things. And then after that progesterone peaks, both your hormones, all your hormones start dropping off. And then our bodies feel that and don't like that, like big dip off. And then we respond to that with all of these same symptoms. And so that's usually what is triggering PMS is this peak of progesterone and then everything just falling off and kind of causing all of these other symptoms.

Kristyn Hodgdon:
Okay. And how do you typically recommend dealing with it? It's just something you have to push through?

Staci Tanouye:
I mean, there's lots of different things. Again, you can start from the most minimal, just like we talked about optimizing everything else in your life, optimizing how your diet is treating your body, how you feel with that. Optimizing exercise, sleep is super, super important. No one talks about sleep and stress, so you can diet and exercise all you want, if you are not sleeping well and if your stress levels are through the roof, that diet and exercise is literally going to do nothing for you. So it's got to be the whole package. So all of that put together plus things like mindfulness and meditation can really be helpful for that time. If that is not enough, there's obviously more that we can do medically. We can do, send people to a therapist for things like cognitive, specific cognitive behavioral therapy. We can start talking about medications to really kind of control those hormonal levels and those neurotransmitter levels during that time. So things like SSRIs or antidepressants, anti-anxiety medications can be helpful in some people. Things like birth control pills can be helpful in some people to try to regulate kind of or more tightly regulate kind of the hormones and the neurotransmitters that are leading to those symptoms. Not everyone needs medication, but some people do, so we do have options out there.

Kristyn Hodgdon:
Awesome, that's so good to know. So lastly, you know, I like to ask how would you rescript the way we understand the menstrual cycle as a vital sign?

Staci Tanouye:
I think, just like we started off at the beginning, like there are not four phases of the menstrual cycle, there are two different cycles that talk to each other, and each of those organ cycles have three phases. And this is a finely tuned dance and talk between those two organs and those hormones that it needs, your body just needs to be in tune with every single piece, that it's not just one thing or the other, it's everything put together. So if we are not optimizing every single piece of our body, we are not optimizing our food, our, our exercise, our movements, if we are not optimizing our sleep and our stress levels, then we're not going to achieve this normal, healthy cycle like we want to. So get yourself out of the pigeonholed little narrow box, get yourself off of these strict regimens of during this part you have to do this, and start listening to yourself. Start tracking not just your periods, but all of the above, all of these symptoms, and put them on your menstrual calendar to see what symptoms are cycling with my cycle, what symptoms happen at the first half, versus during ovulation, versus the second half, what can I do to alter that or optimize that? And so yeah, I would rescript all of that, the phases and the understanding of how we optimize our cycles and our periods.

Kristyn Hodgdon:
Well, awesome. I think that's the theme of this podcast is that we just rescript everything about how we as people with ovaries understand our bodies and just being more aware. So thank you so much, Dr. Tanouye. Until next time.

Staci Tanouye:
Thank you so much.

Kristyn Hodgdon:
Thank you for tuning into this episode of Dear Infertility. We hope it left you feeling more educated and empowered about your reproductive and sexual health. Whatever you're currently struggling with. Rescripted is here to hold your hand every step of the way. If you like today's episode and want to stay up to date on our podcast, don't forget to click Subscribe and to join Rescripted's Free Fertility Support Community. Head to Rescripted.com.

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