Women's health doctors: How medicine dismisses female pain

Steven Bartlett 0:00 If someone's menstrual cycle is irregular, should they be concerned?

Dr Natalie Crawford 0:02 Yes. Yes. Yes. Yes. Your body's meant to work like clockwork.

Dr Vonda Wright 0:06 And our monthly cycle is so much more than getting ready to have a baby.

Dr Stacy Sims 0:11 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.

Dr Natalie Crawford 0:18 Brain health.

Dr Vonda Wright 0:19 Mental health. Low energy.

Dr Stacy Sims 0:20 Mood. And libido. And I don't want the younger generations to have to go through the stuff that we've gone through.

Dr Natalie Crawford 0:25 No.

Dr Stacy Sims 0:25 So it's an important discussion that we need to have.

Narrator 0:28 We are joined by four leading female health experts from very different fields.

0:32 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.

Steven Bartlett 0:40 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.

Dr Stacy Sims 0:48 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.

Dr Vonda Wright 0:54 Like less than 1% is spent on women over 40.

Dr Natalie Crawford 0:57 Women are living 20% more of our lives with chronic disease or mental health disorders.

Dr Stacy Sims 1:02 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.

Dr Vonda Wright 1:18 And patients will say, "But I have a really high pain tolerance."

Dr Stacy Sims 1:21 Yes.

Dr Vonda Wright 1:22 Like it's a badge.

Dr Stacy Sims 1:23 And so they gaslight themselves.

Dr Natalie Crawford 1:25 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.

Steven Bartlett 1:29 And then I wanna talk about menopause.

Dr Natalie Crawford 1:31 So in medical school, menopause just gets shoved into a tiny box.

Dr Stacy Sims 1:34 This is a scary statistic. So... Oh my God.

Steven Bartlett 1:38 It's crazy.

Dr Stacy Sims 1:38 I just think it's insane.

Dr Natalie Crawford 1:39 This is why we need to create change.

Steven Bartlett 1:44 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.

Dr Stacy Sims 3:14 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.

Steven Bartlett 3:55 Nathalie?

Dr Natalie Crawford 3:56 I'm a fertility doctor, and every day I help patients with IVF, get pregnant, 'cause I have an IVF clinic. But my big passion has always been natural fertility after I experienced my own pregnancy losses, trying to understand how we interact with the world and how that changes our hormones and help women understand what their hormones are, what natural fertility is, what happens as we age to our bodies, our eggs and our hormones, and let them be better stewards of their own fertility and their own health decisions.

Steven Bartlett 4:25 Mary?

Dr Stacy Sims 4:26 I have a background in general OB-GYN, so I'm considered to be a women's health specialist, and it wasn't until I kind of went through my own menopause that I realized that there was significant gap in my training. You know, hearing, watching Dr. Sims on, um, I think your podcast talking about how women are not little men really struck such a chord with me and made me realize I was siloing women's health to the reproductive organs, the breasts, the uterus, the ovaries, the vagina, and that if I really did wanted to make a difference in a woman's whole health life, this last 30 years, 30, 40 years of her life, I needed to refocus what we were thinking about women's health for the long term. So I come from a background in academics. I was a professor for 20 years. I was a residency program director. Stepped away from that so I could focus on the lack of my own education and knowledge in menopause care, and now I want to step back into the academic world to bring everything I've learned and change the way we educate our providers.

Steven Bartlett 5:28 Vanda.

Dr Vonda Wright 5:30 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.

Steven Bartlett 6:22 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?

Dr Vonda Wright 6:30 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.

Dr Mary Claire Haver 6:39 Mm-hmm.

Dr Vonda Wright 6:39 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.

Dr Mary Claire Haver 7:05 Hmm.

Dr Vonda Wright 7:05 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.

Dr Mary Claire Haver 7:23 Mm-hmm.

Dr Vonda Wright 7:23 We're living an average of six years longer than men. But as all of us talk about all the time, women suffer longer.

Dr Mary Claire Haver 7:30 Yeah. Mm-hmm.

Dr Stacy Sims 7:31 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.

Dr Mary Claire Haver 8:05 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.

Steven Bartlett 8:36 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?

Dr Mary Claire Haver 8:45 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-

Dr Stacy Sims 9:28 ACE inhibitors.

Dr Mary Claire Haver 9:29 Yeah. All of this...

Dr Stacy Sims 9:30 Statins.

Dr Mary Claire Haver 9:30 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.

Dr Vonda Wright 9:47 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...

Dr Mary Claire Haver 10:03 Research.

Dr Vonda Wright 10:03 ... our lives and research by then. Isn't that as shocking?

Steven Bartlett 10:06 That's crazy.

Dr Mary Claire Haver 10:07 And there were still loopholes where people were finding ways to exclude women. And then-

Dr Stacy Sims 10:11 Right. We're still not at 50%.

Dr Mary Claire Haver 10:13 No. We're harder to study.

Dr Vonda Wright 10:14 We're not at critical mass.

Dr Mary Claire Haver 10:15 You have menstrual cycle, hormonal fluctuations, menopause, pre-

Dr Stacy Sims 10:19 Even the animal models.

Dr Mary Claire Haver 10:21 It's not that we're harder to study, it just makes it-

Dr Stacy Sims 10:23 Presumed harder to study.

Dr Mary Claire Haver 10:24 Right.

Dr Stacy Sims 10:24 There's more variables at play.

Dr Mary Claire Haver 10:25 Right. It's more of a complexity to the research, but it's not more difficult. And this is where I bring it in, it's like if a woman had a seat at the table when all the study designs were started-

Dr Vonda Wright 10:35 Yes.

Dr Mary Claire Haver 10:36 ... it wouldn't be a question. It would just have been assimilated in. But because we've been so drawn into we have a crossover, here's one week crossover, next week because of male physiology, when you add women's hormone fluctuations in, people are like, "Oh, it's too complex."

Dr Stacy Sims 10:50 Right.

Dr Mary Claire Haver 10:50 But it's not.

Steven Bartlett 10:51 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.

Dr Mary Claire Haver 11:04 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.

Steven Bartlett 11:14 Which is muscle, right?

Dr Mary Claire Haver 11:15 Uh, when we're talking about muscle, yeah.

Steven Bartlett 11:16 Yeah.

Dr Mary Claire Haver 11:17 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.

Dr Stacy Sims 12:12 ... 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.

Dr Mary Claire Haver 12:39 Mm-hmm.

Dr Stacy Sims 12:40 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-

Dr Mary Claire Haver 13:10 Right.

Dr Stacy Sims 13:10 ... and a man's typical?

Dr Vonda Wright 13:12 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.

Dr Mary Claire Haver 14:33 Yeah.

Dr Vonda Wright 14:34 We're genetically different.

Dr Stacy Sims 14:35 Down to every cell in our body.

Dr Vonda Wright 14:36 Every cell. So, it should be no surprise to anybody, but it is, seems to be a surprise.

Dr Stacy Sims 14:41 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-

Dr Vonda Wright 14:49 And it's not bad. It just is.

Dr Stacy Sims 14:50 Yeah.

Dr Vonda Wright 14:50 Yes.

Dr Stacy Sims 14:50 There's... Yeah.

Steven Bartlett 14:51 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?

Dr Mary Claire Haver 14:56 Mm-hmm.

Dr Stacy Sims 14:57 Outside of, you know, our different organs.

Steven Bartlett 14:59 Yeah.

Dr Stacy Sims 14:59 You know?

Dr Mary Claire Haver 15:00 Yeah.

Steven Bartlett 15:01 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-

Dr Stacy Sims 15:11 Yeah.

Steven Bartlett 15:11 ... were exposed to.

Dr Stacy Sims 15:13 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-

Dr Mary Claire Haver 15:49 (laughs)

Dr Stacy Sims 15:50 ... 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."

Dr Mary Claire Haver 16:13 Oh my gosh. (laughs)

Dr Stacy Sims 16:15 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.

Dr Mary Claire Haver 17:22 Yeah, they used to put women into asylums-

Dr Stacy Sims 17:24 Yeah.

Dr Mary Claire Haver 17:25 ... 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.

Dr Vonda Wright 17:38 But this is pervasive, not just in OB. You are not the only guilty one.

Dr Stacy Sims 17:41 It's everywhere.

Dr Vonda Wright 17:42 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?

Dr Mary Claire Haver 18:13 ... where was it? Yeah.

18:14 Yeah. Well, in ex phys texts, you always had the representative of him or they and the Vesuvius man-

18:20 Oh, yeah.

18:20 ... 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-

18:32 Mm-hmm.

18:32 ... which we now call, um, relative-

18:34 Yes. Mm-hmm.

18:35 ... 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-

18:55 (laughs)

18:55 ... 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.

Dr Mary Claire Haver 19:14 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."

19:39 Whiny.

19:39 "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.

Dr Vonda Wright 19:57 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."

Dr Mary Claire Haver 20:11 Yes. Mm-hmm.

Dr Vonda Wright 20:12 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?

Dr Mary Claire Haver 20:29 So you train treating both males and females.

Dr Vonda Wright 20:32 I do.

Dr Mary Claire Haver 20:33 I, I was locked in a room with women-

Dr Vonda Wright 20:34 Yeah.

Dr Mary Claire Haver 20:34 ... 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...

Dr Vonda Wright 20:52 I don't think I was aware of it.

Dr Mary Claire Haver 20:54 Yeah.

Dr Vonda Wright 20:54 There was just, that's so much bias-

Dr Mary Claire Haver 20:58 Yeah.

Dr Vonda Wright 20:59 ... I didn't realize.

Dr Mary Claire Haver 21:00 I didn't either.

Dr Vonda Wright 21:00 Because like you, until I went through my own perimenopause, I might not have paided attention to it.

Dr Mary Claire Haver 21:08 Yeah.

Dr Vonda Wright 21:08 I may have been less sensitive.

Dr Mary Claire Haver 21:11 I was a terrible menopausal doctor.

Dr Vonda Wright 21:13 Yeah.

Steven Bartlett 21:13 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

Steven Bartlett 21:54 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.

Dr Mary Claire Haver 22:05 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-

Steven Bartlett 22:30 What's that?

Dr Mary Claire Haver 22:30 ... 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.

Steven Bartlett 22:57 What is a hormone?

Dr Vonda Wright 22:58 They're not actually sex hormones.

Dr Mary Claire Haver 22:59 It's a hard... It-

Dr Natalie Crawford 22:59 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-

Dr Mary Claire Haver 24:03 Mm-hmm.

Dr Natalie Crawford 24:04 ... 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.

Dr Mary Claire Haver 24:16 Mm-hmm.

Dr Vonda Wright 24:16 It's a symphony.

Dr Natalie Crawford 24:17 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.

Steven Bartlett 24:48 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.

Dr Natalie Crawford 24:59 Mm-hmm.

Steven Bartlett 25:00 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?

Dr Mary Claire Haver 25:07 As I say, I wanna get rid of this graph.

Steven Bartlett 25:10 Okay. So- so-

Dr Natalie Crawford 25:10 Stop. I don't have that graph.

Dr Mary Claire Haver 25:11 No, no. No. Leave it out.

Dr Natalie Crawford 25:12 (laughs)

Dr Mary Claire Haver 25:12 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-

Dr Natalie Crawford 25:27 Yeah. And- and it's-

Dr Mary Claire Haver 25:27 ... to make it- to make it work.

Dr Natalie Crawford 25:29 It's an average.

25:29 You see two organs there, the ovary and the endometrial lining. You're not seeing the muscle-

25:34 Hmm.

25:34 ... the bone, the brain. All of those organs are affected by these normal monthly fluctuations.

25:40 Yeah.

Dr Mary Claire Haver 25:40 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.

Steven Bartlett 26:13 How does a woman know what their normal is versus... You know, 'cause a lot of women are on birth control pills since a very young age. So, I think my partner, Melanie, she's b- she was on birth control for about a decade, so she, like, didn't have her cycle and then it came back

Steven Bartlett 26:26 and it was every, I don't know, 60, 90 days?

Dr Natalie Crawford 26:28 Mm-hmm.

Steven Bartlett 26:29 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-

Dr Natalie Crawford 26:37 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-

Dr Mary Claire Haver 26:51 Exactly.

Dr Natalie Crawford 26:51 ... 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-

28:16 Mm-hmm.

28:17 ... because progesterone goes up and down the entire second half of the cycle known as the luteal phase.

Steven Bartlett 28:22 What's progesterone?

Dr Natalie Crawford 28:23 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.

Dr Natalie Crawford 28:35 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.

Steven Bartlett 28:52 And the luteal phase is?

Dr Natalie Crawford 28:53 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-

29:14 (laughs)

29:14 Yes.

29:15 (laughs)

29:15 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.

Dr Mary Claire Haver 29:39 And from, um, like an exercise and sports-

Dr Natalie Crawford 29:42 Yeah.

Dr Mary Claire Haver 29:43 ... 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.

Steven Bartlett 30:10 So, is this in preparation of a potential baby?

Dr Natalie Crawford 30:13 Mm-hmm.

Dr Mary Claire Haver 30:13 Mm-hmm.

Dr Natalie Crawford 30:14 Yeah.

30:14 Correct.

30:14 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.

30:23 Lower.

30:23 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.

Dr Mary Claire Haver 30:33 Right down to your immune system changes.

Steven Bartlett 30:35 And that's roughly from day 14, roughly?

Dr Natalie Crawford 30:38 Roughly.

Dr Mary Claire Haver 30:39 Yeah.

Dr Natalie Crawford 30:39 At ovulation.

30:39 It's about three days after ovulation.

30:40 Whatever day you are. Like-

30:41 If you'd like to be specific, it's about three days after ovulation until when you get your next period.

Dr Mary Claire Haver 30:46 Yeah.

Steven Bartlett 30:46 You all talk about how our menstrual cycles can be...... a, a broader sign of whole-body health.

Dr Natalie Crawford 30:52 Mm-hmm.

Steven Bartlett 30:53 And, um, so should, if someone's menstrual cycle is irregular, should they be concerned?

Dr Natalie Crawford 30:57 Yes.

Dr Vonda Wright 30:58 Yes.

Steven Bartlett 30:59 I thought you were gonna say no.

Dr Natalie Crawford 31:00 (laughs)

Dr Vonda Wright 31:01 (laughs)

Steven Bartlett 31:02 How irregular? What's like, if I'm not getting my menstrual cycle...

Dr Natalie Crawford 31:05 Absolutely not good. You should go see a doctor.

Dr Vonda Wright 31:07 Yeah.

Dr Natalie Crawford 31:08 If your cycle is irregular, if the calendar trick, you're putting your finger and it's nowhere near when your cycle's coming, or I have women who say, "Oh, there's no way I could predict it," or, "I know it will come, but it'll come every four to six weeks." Your body's meant to work like clockwork when it comes to your, your hormones and your menstrual cycle. And yes, you can always have one abnormal month, always. But when you consistently are having irregularity, that is a sign that something else is going on. It's one of the biggest red flags that we have for early hormonal health or systemic problems. But to your earlier point, Steven, we have a generation of women on contraceptive options who are not tracking their cycles. We have women who are not taught how to track their cycles.

Dr Vonda Wright 31:48 Mm-hmm.

Dr Natalie Crawford 31:49 They don't know when ovulation occurs. They don't know how long their luteal phase is. If I say, "The first sign of ovulatory dysfunction, or having a problem with your cycle, is a short luteal phase," well, you only know that if you're tracking when ovulation occurs. Because otherwise, you could still have a regular cycle, but you don't know that something's abnormal.

Steven Bartlett 32:09 And that luteal phase, again, is the last, the last half of your cy- your cycle.

Dr Natalie Crawford 32:13 Exactly.

Dr Vonda Wright 32:14 But I think that the conversation that's happening now is s- not just at this table, but in society, that our monthly cycle is so much more than getting ready to have a baby.

Dr Natalie Crawford 32:26 Mm-hmm.

Dr Vonda Wright 32:26 Because I think that none of us knew this-

Dr Natalie Crawford 32:29 No.

Dr Vonda Wright 32:30 ... because, at 17, I wasn't that interested in having a baby, so it didn't occur to me that I should care.

Dr Natalie Crawford 32:36 Right.

Dr Vonda Wright 32:36 Right? And it's, the only time, if you're thinking about it in that way, that you're worried about your period is if you don't have one, and pregnancy, right?

Dr Natalie Crawford 32:46 Well, I-

Dr Vonda Wright 32:46 And so if we're shifting the conversation to this is physiology, this, uh, has to do with every part of female physiology, maybe it will be easier for people to know, right?

Dr Natalie Crawford 33:01 Yeah, I often put it with, uh, my athletes that it's a marker of health, that if you are able to take on the load of training, the load of travel, and maintain your normal menstrual cycle, then you are robust enough to be able to progress. But if there becomes a misstep in your menstrual cycle, then we need to look at all the stressors that are in the allostatic load and pull you back and see what do we need to address? Do you need to eat more? Do you need to recover more? What are the things that are missing to bring you back to normal?

Dr Stacy Sims 33:32 I was diagnosed with polycystic ovarian syndrome in medical school. And so, like every medical student, of course, it was like gloom and doom, and I, I, you know, thought I had the most extreme case ever known to mankind. It was really just garden variety PCOS.

Dr Stacy Sims 33:46 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.

Dr Natalie Crawford 34:03 Mm-hmm.

Dr Stacy Sims 34:03 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-

Dr Natalie Crawford 34:39 Mm.

Dr Stacy Sims 34:39 ... 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.

Steven Bartlett 34:53 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?

Dr Stacy Sims 35:08 Diabetes in pregnancy, so someone who was nondiabetic before pregnancy, and then develops

Dr Stacy Sims 35:15 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.

Dr Natalie Crawford 36:02 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.

Steven Bartlett 37:21 Mm-hmm.

Dr Natalie Crawford 37:21 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-

Steven Bartlett 39:08 Mm-hmm.

Dr Natalie Crawford 39:08 ... 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.

Steven Bartlett 39:23 We'll talk about some of the ways one can reverse their PCOS, if that's even a possibility.

Dr Natalie Crawford 39:28 Mm-hmm.

Steven Bartlett 39:29 Um, but again, on the causal factors, is it something... So, my girlfriend's got PCOS.

Dr Natalie Crawford 39:34 Yeah.

Steven Bartlett 39:34 And she's been very public about that. Um,

Steven Bartlett 39:36 is it something she did?

Dr Natalie Crawford 39:37 No.

Steven Bartlett 39:37 Is it something she ate? Is it, is it-

Dr Natalie Crawford 39:39 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."

Steven Bartlett 40:11 Mm-hmm.

Dr Natalie Crawford 40:12 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.

Steven Bartlett 40:24 Right.

Dr Natalie Crawford 40:24 Just like any disease.

Steven Bartlett 40:25 Yeah. And when you use the word insulin, I, I think of, or insulin resistance, I think of sugar. Mm-hmm.

Dr Natalie Crawford 40:30 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-

Steven Bartlett 40:54 Yeah.

Dr Natalie Crawford 40:55 It, it, that's how our bodies have adapted to-

Steven Bartlett 40:57 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."

Dr Natalie Crawford 41:39 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."

Steven Bartlett 42:33 Mm-hmm.

Dr Natalie Crawford 42:33 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-"

Steven Bartlett 43:01 Now you can do the ketogenic diet?

Dr Natalie Crawford 43:02 "I need to do keto." Yes.

Steven Bartlett 43:04 (laughs)

Dr Natalie Crawford 43:04 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.

Steven Bartlett 43:10 Yeah.

Dr Natalie Crawford 43:10 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-

Dr Vonda Wright 43:41 (laughs)

Dr Natalie Crawford 43:42 ... 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.

Dr Vonda Wright 44:26 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.

Dr Natalie Crawford 44:37 Hmm.

Dr Vonda Wright 44:38 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.

Dr Natalie Crawford 45:18 Mm-hmm.

Dr Vonda Wright 45:18 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?

Dr Mary Claire Haver 45:31 And this is where we look at the sociocultural effect of what a woman is supposed to look like.

Dr Vonda Wright 45:35 Mm-hmm.

Dr Natalie Crawford 45:36 Yeah.

Dr Mary Claire Haver 45:36 And that's the thing that I'm really pushing on. It's like we want to think about how strong we can be and how much muscle we can build, because muscle is a massive metabolic help.

Dr Vonda Wright 45:48 Mm-hmm.

Dr Mary Claire Haver 45:49 And as, as well as bone, right? (laughs)

Dr Natalie Crawford 45:52 As well as bone.

Dr Mary Claire Haver 45:52 And though, we talk about it, and then when I get the pushback of, "Oh, I'm gonna do fasted training," or, "I'm gonna fast 'til noon," I'm like, "Wait a second. Not only are we going to interfere with our circadian rhythm and our hormone pulses, we're also acutely interfering with our appetite hormones." Because if we're looking at acylated ghrelin, which is our active form of, of our appetite-

Dr Natalie Crawford 46:13 Right.

Dr Mary Claire Haver 46:13 ... and makes us hungry-

Dr Vonda Wright 46:14 Mm-hmm.

Dr Mary Claire Haver 46:15 ... it's elevated with cortisol. And so if we're thinking about that elevation and we're not doing anything to drop it and tell our body we have food-

Dr Vonda Wright 46:22 Mm-hmm.

Dr Mary Claire Haver 46:22 ... then it goes in and directly affects our neuropeptides, which then affects our hormone, our hormone pulses. So when a woman's like, "I'm just having coffee for breakfast. I'm gonna hold my fast," it's like, okay, well here we go. Cortisol is going up, acylated ghrelin, you're gonna get hungrier, then you're gonna learn not to respond to that hunger. You're gonna hold your fast. And we see from the research that women who do that end up craving more simple carbohydrates in the afternoon, moving incidentally less, and contributing to poorer sleep because they've now phase shifted. So when we're talking about sleep and how important sleep is, we also have to think about the circadian rhythm and how it is affected by food intake-

Dr Natalie Crawford 46:59 Mm-hmm.

Dr Mary Claire Haver 46:59 ... light, darkness, and all of the things. And we need women to understand we wanna build muscle, we wanna sleep well, and that requires food.

Dr Vonda Wright 47:07 Well, and it, this goes back, this whole thing you just said goes back to very early in this conversation where I was talking about sometimes we like to focus on the bright, shiny gadgets-

Dr Mary Claire Haver 47:20 Mm-hmm.

Dr Vonda Wright 47:20 ... when we haven't taken our health from fine to optimized. Because everything you just talked about, it isn't a gadget.

Dr Natalie Crawford 47:30 Hmm-mm.

Dr Vonda Wright 47:30 It's basic lifestyle.

Dr Stacy Sims 47:33 In the medical model of PCOS, when I'm talking about what we're taught and how we train our clinicians, we go into the, you know, we w- we aren't taught a lot about disease prevention or, and I hate

Dr Stacy Sims 47:47 to use the term root cause 'cause I think it's been usurped by certain members of, you know, the wellness community.

Dr Natalie Crawford 47:52 Let's take it back.

Dr Mary Claire Haver 47:52 Yeah.

Dr Stacy Sims 47:53 We're gonna take it back.

Dr Natalie Crawford 47:53 Take it back.

Dr Stacy Sims 47:54 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.

Dr Natalie Crawford 48:25 Oh. (yawing) Which is amazing. But these, but patients aren't told that.

Dr Stacy Sims 48:27 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.

Dr Natalie Crawford 48:43 Hmm. Yeah. When I have athletes, because we see a higher percentage of PCOS in successful female athletes-

Steven Bartlett 48:51 Why?

Dr Natalie Crawford 48:51 ... 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?"

Dr Vonda Wright 49:34 Mm-hmm.

Dr Natalie Crawford 49:35 It's important to say, at this table, and we all talked about it last night-

Dr Mary Claire Haver 49:39 ... you need to have a period if you're not preventing a period with hormonal contraception-

Dr Natalie Crawford 49:44 Exactly.

Dr Mary Claire Haver 49:44 ... 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-

Dr Natalie Crawford 49:54 Hey. Yeah. (laughs)

Dr Mary Claire Haver 49:54 ... so it doesn't bother me."

Dr Natalie Crawford 49:55 Exactly.

Dr Mary Claire Haver 49:56 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-

Dr Natalie Crawford 50:05 Low estrogen.

Dr Mary Claire Haver 50:06 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-

Dr Natalie Crawford 50:14 Mm-hmm.

Dr Mary Claire Haver 50:14 ... we're talking about how your hormones communicate back, it's very harmful to long-term health to have low estrogen, like, at all.

Dr Natalie Crawford 50:22 Second brain health. (laughs)

Dr Mary Claire Haver 50:23 But yeah, but especially in young years when you're still developing.

Dr Natalie Crawford 50:28 Mm-hmm.

Steven Bartlett 50:28 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.

Dr Mary Claire Haver 50:33 I mean, do you wanna bleed for a month out of the-

Dr Natalie Crawford 50:34 I mean, do you want that?

Steven Bartlett 50:35 I mean, if it was a choice, no.

Dr Natalie Crawford 50:36 (laughs)

Steven Bartlett 50:37 (laughs)

Dr Mary Claire Haver 50:37 (laughs)

Dr Natalie Crawford 50:37 Actually, knowing now what I know now-

Dr Mary Claire Haver 50:40 Mm-hmm.

Dr Natalie Crawford 50:41 ... and for my own young daughters, I'm like, "We have got to make sure you have a period."

Dr Mary Claire Haver 50:45 Yeah.

Dr Natalie Crawford 50:45 But when I was young, I was a dancer and an athlete. I had very low body fat, and I wouldn't have periods for six to nine months, and I'm like, "Yes."

Steven Bartlett 50:54 You know what's interesting? I was thinking of Mel. She, because of what she's been through and also because she's listened to the conversations I've had with all of you, and she understands the value and importance of her period, she now celebrates it. It's like a celebration in our house when it arrives-

Dr Mary Claire Haver 51:11 Yes.

Steven Bartlett 51:11 ... because, because if you understand the importance that it has and sort of-

Dr Mary Claire Haver 51:14 Mm-hmm.

Steven Bartlett 51:15 ... full body health and the role it's playing, then the pain, the downside is weighted against your understanding of the upside, which to her means she's healthy, she's feeling-

Dr Mary Claire Haver 51:24 Hormonal health is working.

Dr Natalie Crawford 51:26 Yeah.

Dr Mary Claire Haver 51:26 Things are great.

Dr Natalie Crawford 51:27 And that's the conversation shift-

Dr Mary Claire Haver 51:29 Exactly.

Dr Natalie Crawford 51:29 ... that I'm hoping is gonna, instead of being a detriment and a downer and talked about, "She must be on whatever derogatory-"

Dr Mary Claire Haver 51:35 Crack?

Dr Natalie Crawford 51:35 Yes. Derogatory things are said about us, that, "Oh, my gosh, she is so healthy."

Dr Mary Claire Haver 51:41 Yeah. I remember sitting in a high performance meeting just maybe three years ago, and the leading athletics coach stood up and said, "I know when my athletes are ready to perform on the world stage when their periods stop." And all of us went, "What?" (laughs) It's like, no, that's the time where, like, we have to really look at your athlete is getting ready to crack and be injured.

Dr Natalie Crawford 52:04 Mm-hmm.

Dr Mary Claire Haver 52:04 And it still is pervasive idea, and it's still pervasive even in the fitness industry that losing your period is okay 'cause that means you're training harder.

Dr Natalie Crawford 52:13 Actually are very resistant to getting it back.

Dr Mary Claire Haver 52:15 Yes. Like, it's a sign of failure of their sport or their athletic-

Dr Natalie Crawford 52:19 Right.

Dr Mary Claire Haver 52:19 ... endeavor because this is, is so pervasive. And I think that's why it's important to have-

Dr Natalie Crawford 52:24 That we-

Dr Mary Claire Haver 52:24 ... these discussions. And I love hearing that Mel now says, "Yay, my period is here," because that's a sign of hormonal health and things are working well, because that is how we should feel, but-

Dr Natalie Crawford 52:34 I think the other part of it is for women who have menorrhagia or heavy bleeding and heavy cramping, they don't realize that they can get help with that as well.

Dr Mary Claire Haver 52:43 Mm-hmm.

Dr Natalie Crawford 52:43 And that's a conversation that isn't followed through when we're like, "Yes, get your period." But if you're

Dr Natalie Crawford 52:48 someone who suffers from really bad cramps, we also have to educate that there are things that we can do to help with that.

Dr Mary Claire Haver 52:53 Yeah.

Steven Bartlett 52:53 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)

Dr Mary Claire Haver 53:04 It depends.

Steven Bartlett 53:05 Congratulations, well done, I'm so sorry. (laughs)

Dr Mary Claire Haver 53:07 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-

Dr Natalie Crawford 53:15 But women know.

Dr Mary Claire Haver 53:16 But women know.

Dr Natalie Crawford 53:16 Yeah.

Dr Mary Claire Haver 53:17 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?

Steven Bartlett 53:28 Right.

Dr Mary Claire Haver 53:28 And so that's when I'm like, "When is it a problem?"

Dr Natalie Crawford 53:30 Shouldn't bleed through your clothes, yeah.

Dr Mary Claire Haver 53:31 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.

Steven Bartlett 53:43 What's ane-

Dr Mary Claire Haver 53:43 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-

Dr Natalie Crawford 55:42 ... 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.

Dr Stacy Sims 56:46 Mm-hmm.

Dr Natalie Crawford 56:47 Versus-

Dr Stacy Sims 56:47 Asherman Syndrome.

Dr Natalie Crawford 56:48 Yeah. So that is concerning for scar tissue in the uterus.

Steven Bartlett 56:51 I agree.

Dr Natalie Crawford 56:52 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.

Dr Stacy Sims 57:03 Or if you traveled around the world three times-

Dr Natalie Crawford 57:05 Mm-hmm, exactly. Yeah.

Dr Stacy Sims 57:05 ... last month or had stress at work.

Dr Natalie Crawford 57:06 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.

Steven Bartlett 57:28 What about pain? She, two months ago, she had like excruciating pain that I've never seen before during her menstrual cycle.

Dr Natalie Crawford 57:35 Well, it's not pleasant to have your uterus contract and expel its contents in any form.

Steven Bartlett 57:41 But what if it's like

Steven Bartlett 57:42 way above the norm?

Dr Natalie Crawford 57:44 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."

Dr Stacy Sims 58:11 Mm-hmm.

Dr Natalie Crawford 58:11 "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.

Steven Bartlett 58:39 You mentioned the word iron a second ago, Dr. Merry. Wh- wh- what has iron got to do with this and what is iron?

Dr Stacy Sims 58:46 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.

Steven Bartlett 59:29 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?

Dr Stacy Sims 59:39 A menstruating woman, yes.

Steven Bartlett 59:40 A menstruating woman is, is often iron deficient?

Dr Stacy Sims 59:44 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.

Steven Bartlett 1:00:29 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%

Steven Bartlett 1:00:43 of women are anemic with iron deficiency being the leading cause. Hmm. No idea.

Dr Stacy Sims 1:00:48 Have you noticed the norms have changed? So it depends on who you read.

Dr Natalie Crawford 1:00:54 Yeah.

Dr Stacy Sims 1:00:54 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-

Dr Natalie Crawford 1:01:09 Mm-hmm.

Dr Stacy Sims 1:01:09 ... 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-

Dr Natalie Crawford 1:01:28 Mm-hmm.

Dr Stacy Sims 1:01:29 ... versus you functioning at your absolute best.

Dr Natalie Crawford 1:01:32 Yeah, because the norms that often get measured for us, eh-

Dr Stacy Sims 1:01:37 'Cause they tripled, right? They were 15 and then they went up to, to 40.

Dr Natalie Crawford 1:01:40 So now they're saying-

Dr Stacy Sims 1:01:42 45.

Dr Natalie Crawford 1:01:42 ... 20 and above is normal.

Dr Stacy Sims 1:01:44 And when I look at a lot of women who are sitting 20 to 30, they can't get help.

Dr Natalie Crawford 1:01:48 Mm-mm.

Dr Stacy Sims 1:01:49 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.

Dr Natalie Crawford 1:02:05 So-

Dr Stacy Sims 1:02:06 When we say normal, I think this is important for everybody watching or listening, normal in medicine means common.

Dr Natalie Crawford 1:02:13 Mm.

Dr Stacy Sims 1:02:14 Not non-pathological.

Steven Bartlett 1:02:15 Okay.

Dr Stacy Sims 1:02:16 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.

Dr Natalie Crawford 1:02:28 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-

Dr Stacy Sims 1:03:12 False reassurance. Yeah.

Dr Natalie Crawford 1:03:13 Yeah, exactly.

Steven Bartlett 1:03:14 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.

Dr Natalie Crawford 1:03:19 Yes.

Steven Bartlett 1:03:20 Are you familiar with Liv?

Dr Stacy Sims 1:03:21 I am.

Steven Bartlett 1:03:22 So at age 13, she had her first period and she experienced agonizing pain with heavy bleeding.

Dr Natalie Crawford 1:03:26 Mm.

Steven Bartlett 1:03:27 At age 14, she was put on the pill to manage the symptoms. Between age 15 and 24, she continued to have severe stomach pain, which resulted in multiple A&- A&E visits. She was often dismissed as having gastritis.

Dr Stacy Sims 1:03:42 Mm-hmm.

Dr Natalie Crawford 1:03:42 Mm-hmm.

Steven Bartlett 1:03:42 And it led to having her appendix removed.

Dr Stacy Sims 1:03:45 Oh my God.

Steven Bartlett 1:03:47 Why'd you say, "Oh my God"?

Dr Stacy Sims 1:03:48 Well, endo can get appendix.

Dr Natalie Crawford 1:03:48 It's surgery.

Dr Stacy Sims 1:03:50 But she had major surgery, and-

Dr Natalie Crawford 1:03:53 (coughs)

Steven Bartlett 1:03:53 Hmm.

Dr Stacy Sims 1:03:53 Um, I've, I've seen this course before and it's,

Dr Stacy Sims 1:03:58 it's devastating 'cause she's going years and years and years now of-

Steven Bartlett 1:04:01 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.

Dr Natalie Crawford 1:04:53 Oh my gosh.

Steven Bartlett 1:04:55 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.

Dr Natalie Crawford 1:05:18 Yeah, it's called an endometrioma. It's huge.

Steven Bartlett 1:05:21 For anyone that, uh, can't see, it kinda looks like a tumor.

Dr Stacy Sims 1:05:24 Yeah.

Steven Bartlett 1:05:25 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.

Dr Natalie Crawford 1:05:55 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-

Dr Stacy Sims 1:07:20 Mm-hmm.

Dr Natalie Crawford 1:07:20 ... in addition to managing lifelong health, but also fertility as well.

Dr Stacy Sims 1:07:25 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-

Steven Bartlett 1:07:44 It sounds like it's alive, like it's a cancer or something.

Dr Natalie Crawford 1:07:46 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.

Dr Stacy Sims 1:08:05 Marginalized, yeah.

Dr Natalie Crawford 1:08:05 That's one of the issues...

Dr Stacy Sims 1:08:06 Mm-hmm.

Dr Natalie Crawford 1:08:06 ... 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-

Steven Bartlett 1:08:59 Which means?

Dr Natalie Crawford 1:09:00 Have to do surgery to fully see and diagnose that you have the disease.

Dr Stacy Sims 1:09:04 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.

Steven Bartlett 1:09:13 I case it, okay.

Dr Stacy Sims 1:09:14 So you can suspect it based on imaging.

Dr Stacy Sims 1:09:17 We're not great at this. And Dr. Crawford, w- why don't we have a cure?

Dr Natalie Crawford 1:09:21 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.

Dr Stacy Sims 1:10:04 We do have symptomatic relief.

Dr Natalie Crawford 1:10:06 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.

Dr Stacy Sims 1:11:16 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.

Dr Vonda Wright 1:11:55 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.

Dr Natalie Crawford 1:12:10 (laughs) Yeah.

Dr Vonda Wright 1:12:11 There's got to be a cell surface marker and-

Dr Natalie Crawford 1:12:13 I will say the, there are people now doing lovely and wonderful research on a cellular level of endometriosis-

Dr Vonda Wright 1:12:19 Mm-hmm.

Dr Natalie Crawford 1:12:19 ... trying to look at the endometrium itself, what cell markers are similar in endometrial implants, can you diagnose this

Dr Natalie Crawford 1:12:27 on an endometrial biopsy in somebody?

Dr Vonda Wright 1:12:29 Mm-hmm.

Dr Natalie Crawford 1:12:30 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.

Dr Vonda Wright 1:12:40 Mm-hmm.

Dr Natalie Crawford 1:12:41 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.

Steven Bartlett 1:13:43 26 years old, the advice given to her by the NHS was to go back on the pill.

1:13:48 ... to solve for the, the pains that she was getting?

Dr Natalie Crawford 1:13:52 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.

Dr Stacy Sims 1:14:50 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.

Steven Bartlett 1:15:05 Mm-hmm.

Dr Stacy Sims 1:15:06 And it's pretty devastating.

Dr Natalie Crawford 1:15:08 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-

Dr Stacy Sims 1:15:20 Mm-hmm.

Dr Natalie Crawford 1:15:21 ... that

Dr Natalie Crawford 1:15:22 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?

Dr Stacy Sims 1:15:34 How does that work?

Dr Natalie Crawford 1:15:35 So if we're thinking about the responses to cold exposure-

Dr Stacy Sims 1:15:39 Mm-hmm.

Dr Natalie Crawford 1:15:40 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.

Dr Stacy Sims 1:15:54 Mm-hmm.

Dr Natalie Crawford 1:15:54 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.

Dr Stacy Sims 1:16:22 Mm-hmm.

Dr Natalie Crawford 1:16:22 So I mean, the cold water exposure's available there, so that's how we started the pilot study. Um, trying-

Dr Stacy Sims 1:16:28 Cold. Like if someone wanted to do this at home?

Dr Natalie Crawford 1:16:30 10 degrees Celsius. So what is that? About f-

Dr Stacy Sims 1:16:33 Thir-, 44?

Dr Natalie Crawford 1:16:34 ... 44? Feels cold. Yeah, it feels cold.

Dr Stacy Sims 1:16:36 (laughs) Really cold.

Steven Bartlett 1:16:36 But not an ice bath.

Dr Natalie Crawford 1:16:37 Not an ice bath.

Dr Stacy Sims 1:16:38 Right.

Dr Natalie Crawford 1:16:38 Because ice is-

Steven Bartlett 1:16:39 Ice is not good for women.

Dr Stacy Sims 1:16:40 Can you get that in the shower?

Dr Natalie Crawford 1:16:42 You, you need to submerge. This is, like, cold submergence.

Steven Bartlett 1:16:44 Yes, yeah.

Dr Stacy Sims 1:16:45 Can you do that at a home tub, just with-

Dr Natalie Crawford 1:16:46 Yeah.

Dr Stacy Sims 1:16:46 ... turning on the spigot?

Dr Natalie Crawford 1:16:48 Y- you could.

Dr Stacy Sims 1:16:48 You could get that cold?

Dr Natalie Crawford 1:16:48 If you get really cold, yeah, you might wanna add a little bit of ice and let it melt.

Dr Stacy Sims 1:16:52 Okay.

Dr Natalie Crawford 1:16:52 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.

Dr Stacy Sims 1:17:07 Okay.

Dr Natalie Crawford 1:17:07 Like Stacy said, decreasing inflammation in an inflammatory disease is key to controlling the factors you can. And much like we talked about inflammation in PCOS-

Dr Stacy Sims 1:17:16 Mm-hmm.

Dr Natalie Crawford 1:17:17 ... we heard the same word right here with endometriosis.

Dr Stacy Sims 1:17:19 Mm-hmm.

Dr Natalie Crawford 1:17:20 Chronic inflammatory diseases are the number one thing that we see across the board impacting the population, but especially women.

Dr Stacy Sims 1:17:27 Mm-hmm.

Dr Natalie Crawford 1:17:27 And so these same strategies to work on decreasing your own inflammation-

Dr Stacy Sims 1:17:33 Mm-hmm.

Dr Natalie Crawford 1:17:33 ... uh, is, for endo, it's a little different because you can target it for w- when you expect to have that high inflammatory burden. But that's really an important part that we don't talk about. I don't see that the NHS talked about an anti-inflammatory diet or getting more sleep or cold exposure. (paper rustling)

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