Women's health doctors: How medicine dismisses female pain

1. 0:00 – 5:30

   Intro

   1. SBSteven Bartlett0:00

      If someone's menstrual cycle is irregular, should they be concerned?

   2. NCDr Natalie Crawford0:02

      Yes. Yes. Yes. Yes. Your body's meant to work like clockwork.

   3. VWDr Vonda Wright0:06

      And our monthly cycle is so much more than getting ready to have a baby.

   4. SSDr Stacy Sims0:11

      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.

   5. NCDr Natalie Crawford0:18

      Brain health.

   6. VWDr Vonda Wright0:19

      Mental health. Low energy.

   7. SSDr Stacy Sims0:20

      Mood. And libido. And I don't want the younger generations to have to go through the stuff that we've gone through.

   8. NCDr Natalie Crawford0:25

      No.

   9. SSDr Stacy Sims0:25

      So it's an important discussion that we need to have.

   10. NANarrator0:28

       We are joined by four leading female health experts from very different fields.

   11. 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.

   12. SBSteven Bartlett0:40

       We asked 1,000 women to submit their questions ahead of this conversation, and I got so many questions around fertility, understanding hormones, PCOS, birth control pill, miscarriage.

   13. SSDr Stacy Sims0:48

       And I'll say this, Steven, it's because we haven't had these discussions publicly. When we look at funding in women's health, it's horrible.

   14. VWDr Vonda Wright0:54

       Like less than 1% is spent on women over 40.

   15. NCDr Natalie Crawford0:57

       Women are living 20% more of our lives with chronic disease or mental health disorders.

   16. SSDr Stacy Sims1:02

       I mean, 50% of patients with unexplained infertility have endometriosis, but yet it takes women seven 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.

   17. VWDr Vonda Wright1:18

       And patients will say, "But I have a really high pain tolerance."

   18. SSDr Stacy Sims1:21

       Yes.

   19. VWDr Vonda Wright1:22

       Like it's a badge.

   20. SSDr Stacy Sims1:23

       And so they gaslight themselves.

   21. NCDr Natalie Crawford1:25

       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.

   22. SBSteven Bartlett1:29

       And then I wanna talk about menopause.

   23. NCDr Natalie Crawford1:31

       So in medical school, menopause just gets shoved into a tiny box.

   24. SSDr Stacy Sims1:34

       This is a scary statistic. So... Oh my God.

   25. SBSteven Bartlett1:38

       It's crazy.

   26. SSDr Stacy Sims1:38

       I just think it's insane.

   27. NCDr Natalie Crawford1:39

       This is why we need to create change.

   28. SBSteven Bartlett1:44

       This might be one of the most important conversations we ever have on The Diary of a CEO 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 gonna talk about today with their menstrual cycles, PCOS, endometriosis, with diet, with understanding how to exercise as a woman. It's probably never gonna be the case again that these four individuals that are 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 interlinked. For me, the understanding that I got from this conversation at this table with these four women has fundamentally changed my life. It's gonna 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. Ladies, we should start with some introductions. Could you give me a brief introduction, Stacey, 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.

   29. SSDr Stacy Sims3:14

       I come from the exercise phys 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 com- body composition, all of those things. I've worked with and still work with, uh, this 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.

   30. SBSteven Bartlett3:55

       Nathalie?
2. 5:30 – 10:51

   We Need To Talk About Women's Health

   1. SBSteven Bartlett5:30

   2. VWDr Vonda Wright5:30

      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 musculoskeletal 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 gonna 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 gonna 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.

   3. SBSteven Bartlett6:22

      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?

   4. VWDr Vonda Wright6:30

      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.

   5. MHDr Mary Claire Haver6:39

      Mm-hmm.

   6. VWDr Vonda Wright6:39

      And yet often our health, our healthcare 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 spent on research in this country alone, less than 1% is spent on women over 40.

   7. MHDr Mary Claire Haver7:05

      Hmm.

   8. VWDr Vonda Wright7:05

      And yet, we are nearly 90 million people and we make 80% of all the healthcare 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.

   9. MHDr Mary Claire Haver7:23

      Mm-hmm.

   10. VWDr Vonda Wright7:23

       We're living an average of six years longer than men. But as all of us talk about all the time, women suffer longer.

   11. MHDr Mary Claire Haver7:30

       Yeah. Mm-hmm.

   12. SSDr Stacy Sims7:31

       We're living 20% more of our lives versus our male counterparts in poor health with chronic disease or mental health disorders. And so McKinsey 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.

   13. MHDr Mary Claire Haver8:05

       Yeah. 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.

   14. SBSteven Bartlett8:36

       Why isn't the research there? Why, why don't they research if women are the m- majority of the population, why is all the funding going to researching men?

   15. MHDr Mary Claire Haver8:45

       You have to think about who was in the room when medicine and science f- first started. So if you think about back when the Industrial Revolution and the modernization of what we know as medicine, women were pushed out 'cause 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 d- 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." Mm-hmm. So, all the research has just been generalized to women, even things like aspirin for heart attacks and thinning blood w-

   16. SSDr Stacy Sims9:28

       ACE inhibitors.

   17. MHDr Mary Claire Haver9:29

       Yeah. All of this...

   18. SSDr Stacy Sims9:30

       Statins.

   19. MHDr Mary Claire Haver9:30

       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.

   20. VWDr Vonda Wright9:47

       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...

   21. MHDr Mary Claire Haver10:03

       Research.

   22. VWDr Vonda Wright10:03

       ... our lives and research by then. Isn't that as shocking?

   23. SBSteven Bartlett10:06

       That's crazy.

   24. MHDr Mary Claire Haver10:07

       And there were still loopholes where people were finding ways to exclude women. And then-

   25. SSDr Stacy Sims10:11

       Right. We're still not at 50%.

   26. MHDr Mary Claire Haver10:13

       No. We're harder to study.

   27. VWDr Vonda Wright10:14

       We're not at critical mass.

   28. MHDr Mary Claire Haver10:15

       You have menstrual cycle, hormonal fluctuations, menopause, pre-

   29. SSDr Stacy Sims10:19

       Even the animal models.

   30. MHDr Mary Claire Haver10:21

       It's not that we're harder to study, it just makes it-
3. 10:51 – 12:12

   The Female Body Is Adapted for Endurance Exercise

   1. MHDr Mary Claire Haver10:51

   2. SBSteven Bartlett10:51

      What is it that make... 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.

   3. MHDr Mary Claire Haver11:04

      Yeah. Uh, well, I mean, we can look from a morphological standpoint where men have more of our fast-twitch fibers. Women are born with more enduring fibers.

   4. SBSteven Bartlett11:14

      Which is muscle, right?

   5. MHDr Mary Claire Haver11:15

      Uh, when we're talking about muscle, yeah.

   6. SBSteven Bartlett11:16

      Yeah.

   7. MHDr Mary Claire Haver11:17

      So, uh, men have more of the ability to do power and, and really fast energetic type activities. Women are more attuned to enduring 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 onto 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 and/or sex. But when you look intrinsically, no one is identifying those touch points until now.

4. 12:12 – 14:51

   Why Women's Heart Attacks Are Considered 'Atypical'

   1. SSDr Stacy Sims12:12

      ... also, when we look at how we disease. So, in cardiovascular diseases is atherosclerotic disease is the best example. Men tend to have their blockages, so atherosclerotic 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 widow maker, okay? It's called that for a reason, because men die and they make a widow.

   2. MHDr Mary Claire Haver12:39

      Mm-hmm.

   3. SSDr Stacy Sims12:40

      And so, that's the left interior 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, uh, 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-

   4. MHDr Mary Claire Haver13:10

      Right.

   5. SSDr Stacy Sims13:10

      ... and a man's typical?

   6. VWDr Vonda Wright13:12

      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 exp- 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 lo- 20 years ago. Now, they're called satellite cells. But when we harvested them and asked them to behave 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 it's pejorative to say, "Oh, the women are different." Of course, they're different.

   7. MHDr Mary Claire Haver14:33

      Yeah.

   8. VWDr Vonda Wright14:34

      We're genetically different.

   9. SSDr Stacy Sims14:35

      Down to every cell in our body.

   10. VWDr Vonda Wright14:36

       Every cell. So, it should be no surprise to anybody, but it is, seems to be a surprise.

   11. SSDr Stacy Sims14:41

       Seems to be a surprise all the time. Yeah. I get pushback all the time. "There's no difference." Yes, there is. There is, and it's not just me saying it. It's-

   12. VWDr Vonda Wright14:49

       And it's not bad. It just is.

   13. SSDr Stacy Sims14:50

       Yeah.

   14. VWDr Vonda Wright14:50

       Yes.

   15. SSDr Stacy Sims14:50

       There's... Yeah.

5. 14:51 – 19:14

   The Research Gap on Women's Health

   1. SBSteven Bartlett14:51

      I guess at one point, that was quite a controversial thing to say, wasn't it? To point at the differences between men and women?

   2. MHDr Mary Claire Haver14:56

      Mm-hmm.

   3. SSDr Stacy Sims14:57

      Outside of, you know, our different organs.

   4. SBSteven Bartlett14:59

      Yeah.

   5. SSDr Stacy Sims14:59

      You know?

   6. MHDr Mary Claire Haver15:00

      Yeah.

   7. SBSteven Bartlett15:01

      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-

   8. SSDr Stacy Sims15:11

      Yeah.

   9. SBSteven Bartlett15:11

      ... were exposed to.

   10. SSDr Stacy Sims15:13

       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's off. Her blood pressure's a little bit up, her cholesterol's 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, could've been anyone, walks down the hall in his cowboy boots 'cause Texas, and um-

   11. MHDr Mary Claire Haver15:49

       (laughs)

   12. SSDr Stacy Sims15:50

       ... and he's like, "What you got?" And I said, "Well, I have Ms. 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, "Hmm, 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."

   13. MHDr Mary Claire Haver16:13

       Oh my gosh. (laughs)

   14. SSDr Stacy Sims16:15

       And I said, "Okay." He said, "Listen, women just tend to go through this at this age, and we're not really gonna be able to help her. Pat her on the knee, tell her to have some wine, go on a date night, you know, she'll get better, but we're not gonna 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, 'cause I don't wanna 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 OR, I saw this in every clinic. And so I've asked other clinicians around the country and I've heard whiny gynie, status Hispanicus, total, TBD, total body dolor. 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... 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.

   15. MHDr Mary Claire Haver17:22

       Yeah, they used to put women into asylums-

   16. SSDr Stacy Sims17:24

       Yeah.

   17. MHDr Mary Claire Haver17:25

       ... because of hysteria. And it was hot flashes, all the things that, that are now known with perimenopause. They used to think it was some kind of insanity and put women into insane asylums to lock them down.

   18. VWDr Vonda Wright17:38

       But this is pervasive, not just in OB. You are not the only guilty one.

   19. SSDr Stacy Sims17:41

       It's everywhere.

   20. VWDr Vonda Wright17:42

       It's every medical subspecialty has some culture of, for lack of better words, blowing women off. It... Right? For 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 (laughs) to middle-aged women." Where's the curiosity?

   21. MHDr Mary Claire Haver18:13

       ... where was it? Yeah.

   22. Yeah. Well, in ex phys texts, you always had the representative of him or they and the Vesuvius man-

   23. Oh, yeah.

   24. ... 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-

   25. Mm-hmm.

   26. ... which we now call, um, relative-

   27. Yes. Mm-hmm.

   28. ... 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 amenorrheic, because then they were, quote, "More like men," and then there wasn't a problem with training them and then they c- work as hard. But we know that that's not appropriate. That's a sign of, of illness-

   29. (laughs)

   30. ... and over-training 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 infallibility of being human. And a woman having a menstrual cycle was deemed a fallibility, so they're trying to push it aside.

6. 19:14 – 21:54

   Why Women Downplay and Gaslight Themselves About Pain

   1. MHDr Mary Claire Haver19:14

   2. 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 wanna be viewed as this way."

   3. Whiny.

   4. "I don't wanna be not taken seriously." And it causes them n- 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.

   5. VWDr Vonda Wright19:57

      And they come to me, almost to a woman, after I'm talking about whatever musculoskeletal thing. They'll say, even before they wanna describe it to me, they'll say, "But you know, I have a really high pain tolerance."

   6. MHDr Mary Claire Haver20:11

      Yes. Mm-hmm.

   7. VWDr Vonda Wright20:12

      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 wanna come." And I feel like, why does it have to be that way?

   8. MHDr Mary Claire Haver20:29

      So you train treating both males and females.

   9. VWDr Vonda Wright20:32

      I do.

   10. MHDr Mary Claire Haver20:33

       I, I was locked in a room with women-

   11. VWDr Vonda Wright20:34

       Yeah.

   12. MHDr Mary Claire Haver20:34

       ... for 25 years, you know. And so, it's so fascinating to me to hear how man and woman come in with the same complaint in your clinic and 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 treat...

   13. VWDr Vonda Wright20:52

       I don't think I was aware of it.

   14. MHDr Mary Claire Haver20:54

       Yeah.

   15. VWDr Vonda Wright20:54

       There was just, that's so much bias-

   16. MHDr Mary Claire Haver20:58

       Yeah.

   17. VWDr Vonda Wright20:59

       ... I didn't realize.

   18. MHDr Mary Claire Haver21:00

       I didn't either.

   19. VWDr Vonda Wright21:00

       Because like you, until I went through my own perimenopause, I might not have paided attention to it.

   20. MHDr Mary Claire Haver21:08

       Yeah.

   21. VWDr Vonda Wright21:08

       I may have been less sensitive.

   22. MHDr Mary Claire Haver21:11

       I was a terrible menopausal doctor.

   23. VWDr Vonda Wright21:13

       Yeah.

   24. SBSteven Bartlett21:13

       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 in a strange way, 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 re- all the most asked questions sort of related

7. 21:54 – 26:26

   Why Don’t We Understand Hormones?

   1. SBSteven Bartlett21:54

      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, a heightened understanding of menopause generally.

   2. MHDr Mary Claire Haver22:05

      I think the, the conversation a- of hormones around, outside of fertility and the general menstrual cycle, I can right now draw from memory the, exactly what's gonna happen in a normal menstrual cycle. We were taught that, you know, very, very well. But when I saw, maybe three years ago, an academic paper that showed all of the locations of the G-coupled estrogen receptors in the human body-

   3. SBSteven Bartlett22:30

      What's that?

   4. MHDr Mary Claire Haver22:30

      ... 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, e- every, n- 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, or the progesterone, estrogen, testosterone hormones are everywhere.

   5. SBSteven Bartlett22:57

      What is a hormone?

   6. VWDr Vonda Wright22:58

      They're not actually sex hormones.

   7. MHDr Mary Claire Haver22:59

      It's a hard... It-

   8. NCDr Natalie Crawford22:59

      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 gonna be a lot of great discussion. But one thing that I think is very important, and to your point, Steven, is even things that we weren't 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, they're, 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 de- definition, your hormones are dynamic. Your body is responding to the hormonal signal it sees-

   9. MHDr Mary Claire Haver24:03

      Mm-hmm.

   10. NCDr Natalie Crawford24:04

       ... 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.

   11. MHDr Mary Claire Haver24:16

       Mm-hmm.

   12. VWDr Vonda Wright24:16

       It's a symphony.

   13. NCDr Natalie Crawford24:17

       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 gonna 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.

   14. SBSteven Bartlett24:48

       What is the... I really wanna 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.

   15. NCDr Natalie Crawford24:59

       Mm-hmm.

   16. SBSteven Bartlett25:00

       What is the most basic level that we have to start at to give people a- an understanding that we can then build on of what's going on here?

   17. MHDr Mary Claire Haver25:07

       As I say, I wanna get rid of this graph.

   18. SBSteven Bartlett25:10

       Okay. So- so-

   19. NCDr Natalie Crawford25:10

       Stop. I don't have that graph.

   20. MHDr Mary Claire Haver25:11

       No, no. No. Leave it out.

   21. NCDr Natalie Crawford25:12

       (laughs)

   22. MHDr Mary Claire Haver25:12

       Leave it out. But it- it shows just a textbook of what a menstrual cycles 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-

   23. NCDr Natalie Crawford25:27

       Yeah. And- and it's-

   24. MHDr Mary Claire Haver25:27

       ... to make it- to make it work.

   25. NCDr Natalie Crawford25:29

       It's an average.

   26. You see two organs there, the ovary and the endometrial lining. You're not seeing the muscle-

   27. Hmm.

   28. ... the bone, the brain. All of those organs are affected by these normal monthly fluctuations.

   29. Yeah.

   30. MHDr Mary Claire Haver25:40

       And the conversation that we're having now in research methodology is the fact that there is no real definition of normal 'cause 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 c- this can change cycle to cycle. This can change cycle to cycle. Sometimes we have anovulatory cycles. So, until a woman can identify what her own normal is, we can't rely on this graph to actually explain to them.
8. 26:26 – 28:35

   What a Normal Period Should Be Like

   1. SBSteven Bartlett26:26

      and it was every, I don't know, 60, 90 days?

   2. NCDr Natalie Crawford26:28

      Mm-hmm.

   3. SBSteven Bartlett26:29

      And then she changed her diet a little bit and it kinda went down to 30 days over time, but I don't think she knew what normal was. Is there such thing as normal? Is-

   4. NCDr Natalie Crawford26:37

      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 of days month-to-month. I always tell patients-

   5. MHDr Mary Claire Haver26:51

      Exactly.

   6. NCDr Natalie Crawford26:51

      ... 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 gonna 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 picograms for 50 hours. It's 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 luteum. And then the brain's gonna 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-

   7. Mm-hmm.

   8. ... because progesterone goes up and down the entire second half of the cycle known as the luteal phase.

   9. SBSteven Bartlett28:22

      What's progesterone?

   10. NCDr Natalie Crawford28:23

       Progesterone is also made from the ovary. So, the two main hormones when it comes to a premenopausal female are gonna be estrogen and progesterone. Progesterone is the progestational hormone or pro-pregnancy.

9. 28:35 – 33:45

   What Is Progesterone?

   1. NCDr Natalie Crawford28:35

      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 gonna talk a lot... That is why in the luteal phase, your body works differently when you have progesterone.

   2. SBSteven Bartlett28:52

      And the luteal phase is?

   3. NCDr Natalie Crawford28:53

      It's after ovulation when you have a corpus luteum. So, when LH is coming from the brain, you have a corpus luteum. It makes progesterone. This is the second half of the cycle known as the luteal phase. The first half when you have estrogen only is the folicular 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 ma-

   4. (laughs)

   5. Yes.

   6. (laughs)

   7. So, we have our estrogen-dominant phase, the folicular phase, and then we have where we have both estrogen and progesterone here in the luteal phase. And your body is made to function differently in these because in the progesterone side, it's preparing you for pregnancy. It thinks every month you might get pregnant and it starts to change how your body's gonna work on a cellular level. But if you don't get pregnant, that progesterone level's gonna drop and the cycle starts back over.

   8. MHDr Mary Claire Haver29:39

      And from, um, like an exercise and sports-

   9. NCDr Natalie Crawford29:42

      Yeah.

   10. MHDr Mary Claire Haver29:43

       ... point of view, when we get into this, progesterone's job is to build this lush endometrial lining and it creates a lot of glycogen stores. 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.

   11. SBSteven Bartlett30:10

       So, is this in preparation of a potential baby?

   12. NCDr Natalie Crawford30:13

       Mm-hmm.

   13. MHDr Mary Claire Haver30:13

       Mm-hmm.

   14. NCDr Natalie Crawford30:14

       Yeah.

   15. Correct.

   16. 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.

   17. Lower.

   18. 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.

   19. MHDr Mary Claire Haver30:33

       Right down to your immune system changes.

   20. SBSteven Bartlett30:35

       And that's roughly from day 14, roughly?

   21. NCDr Natalie Crawford30:38

       Roughly.

   22. MHDr Mary Claire Haver30:39

       Yeah.

   23. NCDr Natalie Crawford30:39

       At ovulation.

   24. It's about three days after ovulation.

   25. Whatever day you are. Like-

   26. If you'd like to be specific, it's about three days after ovulation until when you get your next period.

   27. MHDr Mary Claire Haver30:46

       Yeah.

   28. SBSteven Bartlett30:46

       You all talk about how our menstrual cycles can be...... a, a broader sign of whole-body health.

   29. NCDr Natalie Crawford30:52

       Mm-hmm.

   30. SBSteven Bartlett30:53

       And, um, so should, if someone's menstrual cycle is irregular, should they be concerned?
10. 33:45 – 35:15

    The Underlying Cause of PCOS

    1. SSDr Stacy Sims33:46

       And I had a 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.

    2. NCDr Natalie Crawford34:03

       Mm-hmm.

    3. SSDr Stacy Sims34:03

       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, w- 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 irregular cycles and we were making these diagnoses, immediately, I was launching into the discussion about her metabolic health long-term-

    4. NCDr Natalie Crawford34:39

       Mm.

    5. SSDr Stacy Sims34:39

       ... and w- 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.

    6. SBSteven Bartlett34:53

       A huge amount of women have PCOS, and I think that's one of the leading, one of the leading c- one of the top causes of having irregular menstrual cycles. You, you mentioned insulin resistance and metabolic dysfunction there, and you said something like diabe- just gestational diabetes?

    7. SSDr Stacy Sims35:08

       Diabetes in pregnancy, so someone who was nondiabetic before pregnancy, and then develops

11. 35:15 – 39:36

    Developing Diabetes During Pregnancy

    1. SSDr Stacy Sims35:15

       diabetes. So her blood sugars have now reached a threshold where they are higher than normal and, and can cause, you know, problems for her pregnancy and herself long-term. And up to 50% of those patients dev- 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 til 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.

    2. NCDr Natalie Crawford36:02

       Steven, 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 of 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 m- Dr. Haver as the 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 m- more eggs on an average. Your bo- 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.

    3. SBSteven Bartlett37:21

       Mm-hmm.

    4. NCDr Natalie Crawford37:21

       Well, what happens from there is that you're actually in a relatively lower en- 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 s- "Oh, I'm used to insulin being here, so I'm not going to respond." It's gonna 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 gonna 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-

    5. SBSteven Bartlett39:08

       Mm-hmm.

    6. NCDr Natalie Crawford39:08

       ... endometriosis, which is a chronic inflammatory disease, autoimmune disease, you're at even higher risk. I would 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.

    7. SBSteven Bartlett39:23

       We'll talk about some of the ways one can reverse their PCOS, if that's even a possibility.

    8. NCDr Natalie Crawford39:28

       Mm-hmm.

    9. SBSteven Bartlett39:29

       Um, but again, on the causal factors, is it something... So, my girlfriend's got PCOS.

    10. NCDr Natalie Crawford39:34

        Yeah.

    11. SBSteven Bartlett39:34

        And she's been very public about that. Um,

12. 39:36 – 47:47

    What Causes PCOS and How to Reduce It

    1. SBSteven Bartlett39:36

       is it something she did?

    2. NCDr Natalie Crawford39:37

       No.

    3. SBSteven Bartlett39:37

       Is it something she ate? Is it, is it-

    4. NCDr Natalie Crawford39:39

       She was b- this is 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 m- 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."

    5. SBSteven Bartlett40:11

       Mm-hmm.

    6. NCDr Natalie Crawford40:12

       You can influence the severity of the symptoms that you experience with it. So, even if you don't cause your disease, 'cause you did not, choices you make can make it, absolutely can make it better or worse.

    7. SBSteven Bartlett40:24

       Right.

    8. NCDr Natalie Crawford40:24

       Just like any disease.

    9. SBSteven Bartlett40:25

       Yeah. And when you use the word insulin, I, I think of, or insulin resistance, I think of sugar. Mm-hmm.

    10. NCDr Natalie Crawford40:30

        Yeah, 'cause glucose is sugar, essentially. And s- many people, and I'll have patients tell me this, "I don't need to worry about insulin resistance 'cause I don't have diabetes," or, "It's not in my family." We've so, we've ingrained this word insulin resistant or talking about glucose or checking glucose with a diabetic or pre-diabetic state. But the world around us honestly promotes insulin resistant. It's a-

    11. SBSteven Bartlett40:54

        Yeah.

    12. NCDr Natalie Crawford40:55

        It, it, that's how our bodies have adapted to-

    13. SBSteven Bartlett40:57

        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 insul- you know, and insulin resistant -agenic. 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."

    14. NCDr Natalie Crawford41:39

        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 gonna 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 ultra-processed 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 or it can make it worse."

    15. SBSteven Bartlett42:33

        Mm-hmm.

    16. NCDr Natalie Crawford42:33

        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 gonna be a very plant-forward 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, "Oh, you shouldn't eat fruit. I shouldn't do this. I, I need to avoid-"

    17. SBSteven Bartlett43:01

        Now you can do the ketogenic diet?

    18. NCDr Natalie Crawford43:02

        "I need to do keto." Yes.

    19. SBSteven Bartlett43:04

        (laughs)

    20. NCDr Natalie Crawford43:04

        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.

    21. SBSteven Bartlett43:10

        Yeah.

    22. NCDr Natalie Crawford43:10

        Lots of whole foods, fruits and vegetables, healthy fats, healthy sources of protein, avoiding the ultra-processed foods. That's gonna 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 Stacey'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-

    23. VWDr Vonda Wright43:41

        (laughs)

    24. NCDr Natalie Crawford43:42

        ... 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? In 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.

    25. VWDr Vonda Wright44:26

        No. But based on what you just said, 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.

    26. NCDr Natalie Crawford44:37

        Hmm.

    27. VWDr Vonda Wright44:38

        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 'til midday when we do eat. So there, the gut reaction, because of the way many women are raised, is that we're gonna 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 gonna work so hard every single day," that you actually increase your stress. There is over, there is over-training.

    28. NCDr Natalie Crawford45:18

        Mm-hmm.

    29. VWDr Vonda Wright45:18

        So you're just getting behind the eight-ball with starving yourself and over-training, none of which are gonna solve either the core problem due to PCOS or the core problem in any stage of a woman's life, right?

    30. MHDr Mary Claire Haver45:31

        And this is where we look at the sociocultural effect of what a woman is supposed to look like.
13. 47:47 – 52:48

    The Pill Is Not the Only Help for PCOS

    1. SSDr Stacy Sims47:47

       to use the term root cause 'cause I think it's been usurped by certain members of, you know, the wellness community.

    2. NCDr Natalie Crawford47:52

       Let's take it back.

    3. MHDr Mary Claire Haver47:52

       Yeah.

    4. SSDr Stacy Sims47:53

       We're gonna take it back.

    5. NCDr Natalie Crawford47:53

       Take it back.

    6. SSDr Stacy Sims47:54

       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 ch- Well, which is amazing.

    7. NCDr Natalie Crawford48:25

       Oh. (yawing) Which is amazing. But these, but patients aren't told that.

    8. SSDr Stacy Sims48:27

       But, and I'm sitting there, thinking, "Birth control pills, birth control pill-" 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.

    9. NCDr Natalie Crawford48:43

       Hmm. Yeah. When I have athletes, because we see a higher percentage of PCOS in successful female athletes-

    10. SBSteven Bartlett48:51

        Why?

    11. NCDr Natalie Crawford48:51

        ... like what, what do I do? And it's looking at what kind of training they're doing. So we're t- putting in some more short, sharp, high intensity to get that post-exercise response of anti-inflammatory growth hormone response, all of these things that then n- 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. And 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?"

    12. VWDr Vonda Wright49:34

        Mm-hmm.

    13. NCDr Natalie Crawford49:35

        It's important to say, at this table, and we all talked about it last night-

    14. MHDr Mary Claire Haver49:39

        ... you need to have a period if you're not preventing a period with hormonal contraception-

    15. NCDr Natalie Crawford49:44

        Exactly.

    16. MHDr Mary Claire Haver49:44

        ... and you're in your reproductive years. Because very often, women with PCOS or hypothalamic amenorrhea will say, "I don't have a period, but I didn't really like that anyway-

    17. NCDr Natalie Crawford49:54

        Hey. Yeah. (laughs)

    18. MHDr Mary Claire Haver49:54

        ... so it doesn't bother me."

    19. NCDr Natalie Crawford49:55

        Exactly.

    20. MHDr Mary Claire Haver49:56

        Right? How many women have said, "Oh, I didn't get my period for a year, but I, I, that was fine by me"? But that's not fine by your body. That is hypoestrogenic time. It is-

    21. NCDr Natalie Crawford50:05

        Low estrogen.

    22. MHDr Mary Claire Haver50:06

        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-

    23. NCDr Natalie Crawford50:14

        Mm-hmm.

    24. MHDr Mary Claire Haver50:14

        ... we're talking about how your hormones communicate back, it's very harmful to long-term health to have low estrogen, like, at all.

    25. NCDr Natalie Crawford50:22

        Second brain health. (laughs)

    26. MHDr Mary Claire Haver50:23

        But yeah, but especially in young years when you're still developing.

    27. NCDr Natalie Crawford50:28

        Mm-hmm.

    28. SBSteven Bartlett50:28

        Wh- 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.

    29. MHDr Mary Claire Haver50:33

        I mean, do you wanna bleed for a month out of the-

    30. NCDr Natalie Crawford50:34

        I mean, do you want that?
14. 52:48 – 57:42

    How Do We Know If It's a Normal Flow, Too Much, or Too Little?

    1. NCDr Natalie Crawford52:48

       someone who suffers from really bad cramps, we also have to educate that there are things that we can do to help with that.

    2. MHDr Mary Claire Haver52:53

       Yeah.

    3. SBSteven Bartlett52:53

       But 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. (laughs)

    4. MHDr Mary Claire Haver53:04

       It depends.

    5. SBSteven Bartlett53:05

       Congratulations, well done, I'm so sorry. (laughs)

    6. MHDr Mary Claire Haver53:07

       So menorrhagia, 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-

    7. NCDr Natalie Crawford53:15

       But women know.

    8. MHDr Mary Claire Haver53:16

       But women know.

    9. NCDr Natalie Crawford53:16

       Yeah.

    10. MHDr Mary Claire Haver53:17

        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?

    11. SBSteven Bartlett53:28

        Right.

    12. MHDr Mary Claire Haver53:28

        And so that's when I'm like, "When is it a problem?"

    13. NCDr Natalie Crawford53:30

        Shouldn't bleed through your clothes, yeah.

    14. MHDr Mary Claire Haver53:31

        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 'til anemia.

    15. SBSteven Bartlett53:43

        What's ane-

    16. MHDr Mary Claire Haver53:43

        I am, anemia's low red blood cell count, you know, to the point where your performance is affected, your ability to carry oxygen is affected. 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 ferritin is dropping. That's the first sign. My daught- my daughter, we just had some blood work done. She was feeling a little fatigued, and her ferritin 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 ferritin levels, the transferrin, 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 microcytic. You know, we are, we need to do a better job at recognizing these things. W- we're not gonna walk around and measure how much blood's coming out, because I could maybe squeak out 200 ccs, 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- Yeah, like, 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-

    17. NCDr Natalie Crawford55:42

        ... progesterone thins it. When you only see progesterone, like a progesterone IUD, the progesterone shot, even continuous birth control pills 'cause they give you es- 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 D&C 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.

    18. SSDr Stacy Sims56:46

        Mm-hmm.

    19. NCDr Natalie Crawford56:47

        Versus-

    20. SSDr Stacy Sims56:47

        Asherman Syndrome.

    21. NCDr Natalie Crawford56:48

        Yeah. So that is concerning for scar tissue in the uterus.

    22. SBSteven Bartlett56:51

        I agree.

    23. NCDr Natalie Crawford56:52

        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 gonna get better. Or if this period came closer together.

    24. SSDr Stacy Sims57:03

        Or if you traveled around the world three times-

    25. NCDr Natalie Crawford57:05

        Mm-hmm, exactly. Yeah.

    26. SSDr Stacy Sims57:05

        ... last month or had stress at work.

    27. NCDr Natalie Crawford57:06

        So a one, a 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.

    28. SBSteven Bartlett57:28

        What about pain? She, two months ago, she had like excruciating pain that I've never seen before during her menstrual cycle.

    29. NCDr Natalie Crawford57:35

        Well, it's not pleasant to have your uterus contract and expel its contents in any form.

    30. SBSteven Bartlett57:41

        But what if it's like

15. 57:42 – 1:00:43

    How to Know If You're Experiencing Abnormal Period Pain

    1. SBSteven Bartlett57:42

       way above the norm?

    2. NCDr Natalie Crawford57:44

       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 luteum'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. Uh, this is okay because we don't talk about our own pain."

    3. SSDr Stacy Sims58:11

       Mm-hmm.

    4. NCDr Natalie Crawford58:11

       "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 gonna cancel that," that is a warning sign that something else could be going on. Endometriosis, adenomyosis, and uterine fibroids.

    5. SBSteven Bartlett58:39

       You mentioned the word iron a second ago, Dr. Merry. Wh- wh- what has iron got to do with this and what is iron?

    6. SSDr Stacy Sims58:46

       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 r- 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 ferritin. So when we're measuring ferritin levels in the blood, that is, you know, the first sign that your iron stores are getting low is when we see these low ferritin levels.

    7. SBSteven Bartlett59:29

       Are women more iron deficient than one would think? Like is the general population m- iron deficient, or what do you tend to see when you run lab tests?

    8. SSDr Stacy Sims59:39

       A menstruating woman, yes.

    9. SBSteven Bartlett59:40

       A menstruating woman is, is often iron deficient?

    10. SSDr Stacy Sims59:44

        Yes. And I, we, I do see it in our post, post-menopausal patients as well. That's usually nutritional and inflammation-related. So ferritin is also something that will decrease in s- in times of chronic inflammation. 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?" Or, 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 a- you know, the algorithm of why that might happen. In a post-menopausal patient, we can remove vaginal bleeding from the issue, you know, u- uterine bleeding of the period, but then now I'm looking at nutrition, I'm looking at exercise, I'm looking at inflammation as causative factors.

    11. SBSteven Bartlett1:00:29

        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 Sub-Saharan Africa, prevalence can be up to 50%

16. 1:00:43 – 1:03:58

    Anemia in Women and the Issues With Lab Results

    1. SBSteven Bartlett1:00:43

       of women are anemic with iron deficiency being the leading cause. Hmm. No idea.

    2. SSDr Stacy Sims1:00:48

       Have you noticed the norms have changed? So it depends on who you read.

    3. NCDr Natalie Crawford1:00:54

       Yeah.

    4. SSDr Stacy Sims1:00:54

       Again, you know, when you're looking at mal- 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, w- looking at other factors besides just what is this ferritin level-

    5. NCDr Natalie Crawford1:01:09

       Mm-hmm.

    6. SSDr Stacy Sims1:01:09

       ... um, there's a lot great new research coming out that we are looking at this differently and that the, we're, in our clinic, we are looking for 60 to 100 for a ferritin level to be considered optimal. Very different than, you know, the baseline for, you know, keeping you out of, out of a hospital-

    7. NCDr Natalie Crawford1:01:28

       Mm-hmm.

    8. SSDr Stacy Sims1:01:29

       ... versus you functioning at your absolute best.

    9. NCDr Natalie Crawford1:01:32

       Yeah, because the norms that often get measured for us, eh-

    10. SSDr Stacy Sims1:01:37

        'Cause they tripled, right? They were 15 and then they went up to, to 40.

    11. NCDr Natalie Crawford1:01:40

        So now they're saying-

    12. SSDr Stacy Sims1:01:42

        45.

    13. NCDr Natalie Crawford1:01:42

        ... 20 and above is normal.

    14. SSDr Stacy Sims1:01:44

        And when I look at a lot of women who are sitting 20 to 30, they can't get help.

    15. NCDr Natalie Crawford1:01:48

        Mm-mm.

    16. SSDr Stacy Sims1:01:49

        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.

    17. NCDr Natalie Crawford1:02:05

        So-

    18. SSDr Stacy Sims1:02:06

        When we say normal, I think this is important for everybody watching or listening, normal in medicine means common.

    19. NCDr Natalie Crawford1:02:13

        Mm.

    20. SSDr Stacy Sims1:02:14

        Not non-pathological.

    21. SBSteven Bartlett1:02:15

        Okay.

    22. SSDr Stacy Sims1:02:16

        Not that, 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.

    23. NCDr Natalie Crawford1:02:28

        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 sh- accept a l- 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 symptomatology, 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-

    24. SSDr Stacy Sims1:03:12

        False reassurance. Yeah.

    25. NCDr Natalie Crawford1:03:13

        Yeah, exactly.

    26. SBSteven Bartlett1:03:14

        I wanna talk about endometriosis. I, we have a team member who's been with the Diary of a CEO since the very beginning called Liv.

    27. NCDr Natalie Crawford1:03:19

        Yes.

    28. SBSteven Bartlett1:03:20

        Are you familiar with Liv?

    29. SSDr Stacy Sims1:03:21

        I am.

    30. SBSteven Bartlett1:03:22

        So at age 13, she had her first period and she experienced agonizing pain with heavy bleeding.
17. 1:03:58 – 1:09:17

    People Suffer Silently With Endometriosis for Years

    1. SSDr Stacy Sims1:03:58

       it's devastating 'cause she's going years and years and years now of-

    2. SBSteven Bartlett1:04:01

       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, Jemima 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 p- private support with it. Um, and she got an MRI scan privately, which confirmed stage 4 infiltrating endometriosis.

    3. NCDr Natalie Crawford1:04:53

       Oh my gosh.

    4. SBSteven Bartlett1:04:55

       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-centimeter cyst. If you're faint-hearted, I mean, I don't know whether we'll put this on the screen, but this is from her operation.

    5. NCDr Natalie Crawford1:05:18

       Yeah, it's called an endometrioma. It's huge.

    6. SBSteven Bartlett1:05:21

       For anyone that, uh, can't see, it kinda looks like a tumor.

    7. SSDr Stacy Sims1:05:24

       Yeah.

    8. SBSteven Bartlett1:05:25

       Um, next to her ovaries. And it had spread at that point to her bowel, bowel and peveris, pelvis. It become about four centimeters 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 sh- she had her eggs frozen to protect her future fertility, which, uh, I guess came from your advice. This process took her seven years, and she was in pain for 17 years because she did not get a diagnosis.

    9. NCDr Natalie Crawford1:05:55

       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 endometrial cells in your menstrual blood. We're used to that. In everybody, you also have some endometrial cells that will escape out the fallopian tubes, and 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 endometrial cells and you get these implants throughout the, what's called the peritoneal cavity or the abdominal cavity, of endometrial-like 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-

    10. SSDr Stacy Sims1:07:20

        Mm-hmm.

    11. NCDr Natalie Crawford1:07:20

        ... in addition to managing lifelong health, but also fertility as well.

    12. SSDr Stacy Sims1:07:25

        You can 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 f- you know, blood supply from, from the bowel, from... 'Cause all, all of our pelvic organs are just sitting there on top of each other, the bladder, the bowel, the col, you know? And so it-

    13. SBSteven Bartlett1:07:44

        It sounds like it's alive, like it's a cancer or something.

    14. NCDr Natalie Crawford1:07:46

        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 y- again, back to women's pain being taken seriously.

    15. SSDr Stacy Sims1:08:05

        Marginalized, yeah.

    16. NCDr Natalie Crawford1:08:05

        That's one of the issues...

    17. SSDr Stacy Sims1:08:06

        Mm-hmm.

    18. NCDr Natalie Crawford1:08:06

        ... and why the average time to diagnosis is seven 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 endometrial 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 endometriosis is that it's a surgical diagnosis only, to be honest. We can su-

    19. SBSteven Bartlett1:08:59

        Which means?

    20. NCDr Natalie Crawford1:09:00

        Have to do surgery to fully see and diagnose that you have the disease.

    21. SSDr Stacy Sims1:09:04

        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.

    22. SBSteven Bartlett1:09:13

        I case it, okay.

    23. SSDr Stacy Sims1:09:14

        So you can suspect it based on imaging.

18. 1:09:17 – 1:12:27

    The Real Reason There's No Treatment for Endometriosis

    1. SSDr Stacy Sims1:09:17

       We're not great at this. And Dr. Crawford, w- why don't we have a cure?

    2. NCDr Natalie Crawford1:09:21

       Mm-hmm. Well, because it hasn't been studied is one of, is the primary answer. Uh, the secondary answer is that often the, the goals are tough with endo because if estrogen feeds it, we all are gonna sit at this table and talk about how important estrogen is for your body. And a l- a lot of the treatments that exist for endometriosis take estrogen away to try to not feed these lesions, and that has a slew of other symptoms and long-term health implications as well. Truly, we don't even give women option to try to feel better. They are given birth control pills because hey, I'm gonna stop the ovulatory cycle. I'm going to ha- you're gonna have less what we call unopposed estrogen days.

    3. SSDr Stacy Sims1:10:04

       We do have symptomatic relief.

    4. NCDr Natalie Crawford1:10:06

       Yeah, but we have s- and that's gonna help hopefully with some of your symptoms, and it can for some women. It doesn't reverse disease, it doesn't cure it, it doesn't make anything better, but it can slow down the progression, any of these treatments that do halt the ovulatory process. But it severely impacts, I mean, beyond so many layers of your, your mental, your emotional health, your relationships, but your fertility. Stage three or four disease, regardless of your age, you're gonna have a less than a 20% chance of conceiving naturally over the course of your life if you have stage three or four disease. Every stage is impactful to your fertility because of the inflammation. Once you have anatomical distortion and endometrioma or cyst inside the ovary, removing that cyst is going to decrease your egg count. That, that's gonna have a major implication on your potential. That's why we froze eggs before we took a cyst out so that we could get those eggs, at least some that we could out of the body, before we went and did something that was going to destroy part of the ovarian tissue. What you said, Steven, is it seems like endometriosis is alive, and that's a really great analogy because it does just feed into tissue and it's highly destructive.

    5. SSDr Stacy Sims1:11:16

       And if it distorts the anatomy, we need a healthy floppy fallopian tube generally that can swing around and pick up this egg that's floating around our abdominal cavity for pr- and then you need a place for the egg and sperm to meet, which is generally a healthy non-inflamed fallopian tube. So they're also at increased risk for infertility, but ectopic pregnancies, that's where I see them. You know, is when I was a hospitalist is in the OR, you know, emergently from a ruptured fallopian tube from this. You know, and I go in and I'm making, not only is she's lost a wanted pregnancy, now I, and I'm making the diagnosis of endometriosis at the same time and they are just devastated.

    6. VWDr Vonda Wright1:11:55

       I just feel sitting here not being anywhere within this field thinking, wait a minute, 'cause I was a cancer nurse first, right, before I did this. Wait a minute, there's got to be a cell surface marker that's unique to the endometrium that we could make a monoclonal antibody against.

    7. NCDr Natalie Crawford1:12:10

       (laughs) Yeah.

    8. VWDr Vonda Wright1:12:11

       There's got to be a cell surface marker and-

    9. NCDr Natalie Crawford1:12:13

       I will say the, there are people now doing lovely and wonderful research on a cellular level of endometriosis-

    10. VWDr Vonda Wright1:12:19

        Mm-hmm.

    11. NCDr Natalie Crawford1:12:19

        ... trying to look at the endometrium itself, what cell markers are similar in endometrial implants, can you diagnose this

19. 1:12:27 – 1:15:22

    Could We Create a Cellular Marker for Endometriosis?

    1. NCDr Natalie Crawford1:12:27

       on an endometrial biopsy in somebody?

    2. VWDr Vonda Wright1:12:29

       Mm-hmm.

    3. NCDr Natalie Crawford1:12:30

       W- we haven't seen it get to the point where it needs to, but at least people are paying attention. So I do think we might have emergent technology that will change the course of this for people.

    4. VWDr Vonda Wright1:12:40

       Mm-hmm.

    5. NCDr Natalie Crawford1:12:41

       Right now, I think awareness is key. And one thing I always say is that especially as a teenager, because women adjust, you accommodate to the world around you. That's one of the things that I think makes women so resilient. I mean, if you have pain every single month of your life, you are going to convince yourself this is normal for a degree of time because what other option do you have? Has to get so bad. But when you're a teenager, you d- don't know that. And so if when you are a teen, you would stay home from school, you would not go to the football game or go out to dinner with friends, that to me has, is a huge red flag, but it actually is a very high predictive marker that you do have endometriosis. So pain out of proportion to being able to complete your normal life as a teenager is a really big warning flag. I ask every patient about that when we talk about their periods because 50% of patients with unexplained infertility have endometriosis. It is so hard to diagnose and underdiagnosed, yet impactful to our body.

    6. SBSteven Bartlett1:13:43

       26 years old, the advice given to her by the NHS was to go back on the pill.

    7. ... to solve for the, the pains that she was getting?

    8. NCDr Natalie Crawford1:13:52

       We certainly have a lot of dismissive doctors and people who don't take pain seriously. But also, a disease that is underfunded and not researched, we do have limited options for how you can help somebody. And I think we have to acknowledge that both things can be right. Now, getting to the root cause of your pain is always gonna be really important versus just saying, "Here's a birth control pill. That should take care of it." Some women with endometriosis love being on the birth control pill. It does highly improve their symptom profile, and it's an important part of their treatment regimen. Other women do not find any benefit from it, and it's really important to have the discussion, especially with endometriosis, in regards to your family planning goals. Do you want kids? When is that going to be? What might this look like? Because we know if you have a higher rate of infertility, higher rate of needing IVF, do we need to intervene sooner? But that's gonna impact some of the treatment options we're able to give you, because some of them do delay ovulation from a, for a prolonged period of time.

    9. SSDr Stacy Sims1:14:50

       What I find in the patients, you know, when we made the diagnosis was they're forced into making these kind of life-changing decisions about, around their fertility and ability to conceive before there were ever, uh, before their peers are even thinking about it.

    10. SBSteven Bartlett1:15:05

        Mm-hmm.

    11. SSDr Stacy Sims1:15:06

        And it's pretty devastating.

    12. NCDr Natalie Crawford1:15:08

        It is. We have some pilot data looking at taking some of the nuances of recovery and looking at how to dampen inflammation. So we have some pilot data that's showing when women do cold exposure-

    13. SSDr Stacy Sims1:15:20

        Mm-hmm.

    14. NCDr Natalie Crawford1:15:21

        ... that

20. 1:15:22 – 1:20:49

    How to Ease Pain Symptoms Before Your Period Naturally

    1. NCDr Natalie Crawford1:15:22

       it dampens inflammation and improves their symptomatology. So I'm always thinking on the outside, like, what other things can we do to dampen inflammation in a positive way to improve symptomatology?

    2. SSDr Stacy Sims1:15:34

       How does that work?

    3. NCDr Natalie Crawford1:15:35

       So if we're thinking about the responses to cold exposure-

    4. SSDr Stacy Sims1:15:39

       Mm-hmm.

    5. NCDr Natalie Crawford1:15:40

       We're not talking about ice. We're talking about cold water exposure. It creates a cascade of immune responses that kind of protects the body. So we're reducing inflammation. We're improving parasympathetic, which reduces stress.

    6. SSDr Stacy Sims1:15:54

       Mm-hmm.

    7. NCDr Natalie Crawford1:15:54

       So if we're timing it and they know when their period is and they can go, "Okay, well, for the next, or the 10 to 14 days before my period starts, I'm gonna have 10 minutes of cold water exposure." And over the course of three to four months, that immune response becomes learned, so it reduces symptomatology. So it becomes one of the treatment options that we have for some of our athletes that have endo and interferes with their training.

    8. SSDr Stacy Sims1:16:22

       Mm-hmm.

    9. NCDr Natalie Crawford1:16:22

       So I mean, the cold water exposure's available there, so that's how we started the pilot study. Um, trying-

    10. SSDr Stacy Sims1:16:28

        Cold. Like if someone wanted to do this at home?

    11. NCDr Natalie Crawford1:16:30

        10 degrees Celsius. So what is that? About f-

    12. SSDr Stacy Sims1:16:33

        Thir-, 44?

    13. NCDr Natalie Crawford1:16:34

        ... 44? Feels cold. Yeah, it feels cold.

    14. SSDr Stacy Sims1:16:36

        (laughs) Really cold.

    15. SBSteven Bartlett1:16:36

        But not an ice bath.

    16. NCDr Natalie Crawford1:16:37

        Not an ice bath.

    17. SSDr Stacy Sims1:16:38

        Right.

    18. NCDr Natalie Crawford1:16:38

        Because ice is-

    19. SBSteven Bartlett1:16:39

        Ice is not good for women.

    20. SSDr Stacy Sims1:16:40

        Can you get that in the shower?

    21. NCDr Natalie Crawford1:16:42

        You, you need to submerge. This is, like, cold submergence.

    22. SBSteven Bartlett1:16:44

        Yes, yeah.

    23. SSDr Stacy Sims1:16:45

        Can you do that at a home tub, just with-

    24. NCDr Natalie Crawford1:16:46

        Yeah.

    25. SSDr Stacy Sims1:16:46

        ... turning on the spigot?

    26. NCDr Natalie Crawford1:16:48

        Y- you could.

    27. SSDr Stacy Sims1:16:48

        You could get that cold?

    28. NCDr Natalie Crawford1:16:48

        If you get really cold, yeah, you might wanna add a little bit of ice and let it melt.

    29. SSDr Stacy Sims1:16:52

        Okay.

    30. NCDr Natalie Crawford1:16:52

        But, um, not ice baths that we see in all the popular media, because that is way too cold for a woman's body. It does the opposite. It's a severe stress and causes a stress response rather than a parasympathetic calming response that we want.

Episode duration: 3:34:07