OTs In Pelvic Health
Welcome to the OTs In Pelvic Health Podcast! This show is for occupational therapists who want to become, thrive and excel as pelvic health OTs. Learn from Lindsey Vestal, a Pelvic Health OT for over 10 years and founder the first NYC pelvic health OT practice - The Functional Pelvis. Inside each episode, Lindsey shares what it takes to succeed as a pelvic health OT. From lessons learned, to overcoming imposter syndrome, to continuing education, to treatment ideas, to different populations, to getting your first job, to opening your own practice, Lindsey brings you into the exciting world of OTs in Pelvic Health and the secrets to becoming one.
OTs In Pelvic Health
From Periods to Perimenopause: Dr. Lara Briden’s Essential Insights
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Learn more about my guest
Facebook: https://www.facebook.com/LaraBriden
Youtube: https://www.youtube.com/@LaraBriden
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Inside Pelvic OTPs United you'll find:
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- Highly curated forums. The worst is when you post a question on FB just to have it drowned out with 10 other questions that follow it. So, she's got dedicated forums on different populations, different diagnosis, different topics (including business). Hop it, post your specific question, and get the expert advice you need.
More info here. Lindsey would love support you in this quiet corner off social media!
Lindsey Vestal:
New and seasoned OTs are finding their calling in pelvic health. After all, what's more ADL than sex, peeing, and poop? But here's the question. What does it take to become a successful, fulfilled, and thriving OT in pelvic health? How do you go from beginner to seasoned and everything in between? Those are the questions, and this podcast will give you the answers.
We are inspired OTs. We are out-of-the-box OTs. We are Pelvic Health OTs.
I'm your host, Lindsay Vestal, and welcome to the OTs in Pelvic Health podcast. My guest today is Laura Bryden. She's a naturopathic doctor and the bestselling author of the Period Repair Manual, the Hormone Repair Manual, and the T Metabolism Repair for Women.
She currently has consulting rooms in Christchurch, New Zealand, where she treats women with PCOS, PMS, endometriosis, perimenopause, and many other hormone- and period-related health problems. Dr. Bryden has been my go-to for years. When I had my private practice in New York City, I would scour her Period Repair Manual, learn as much as I possibly could, use the work in my sessions with clients, and so often recommended this book to my clients as an indispensable, ground-breaking resource. I cannot wait for you to hear our conversation today. I have to admit, Dr. Bryden, I am having a star-struck moment as I'm sitting across from you recording this podcast. You were an absolute essential resource when I had my private practice in New York City. You know, I served pre- and postnatal people during that time, and I think there wasn't a client who didn't hear me rave about you or recommend one of your books to. You also have been a source of such inspiration for me as I guide my journey throughout my career, so I just want to start off with the most sincere gratitude that I can give you for the work you're putting out in the world and how many lives you have impacted. It is innumerable.
Lara Biden:
That is so sweet. Thank you for that feedback. Yeah, I'm very glad that it's been helpful. That's great.
Lindsey Vestal:
And it continues to be, so I'm so eager to get started with you in today's conversation, and I would love to kick it off with kind of like a myth-busting question, if you will, which would be what are some hormonal health myths that you hear the most common from clients?
Lara Biden:
From clients? I mean, yes, there's going to be a few of them. I think the one I want to start with, though, is this has been a very strong narrative or myth is the idea that the pill can regulate the cycle. I mean, that's a good entry point because this brings us straight to Body Literacy 101. I mean, the menstrual cycle is created by ovulation. So ovulation is essentially how we make hormones. We make estrogen on the way to ovulation, and then after ovulation, we make progesterone. And that's really the only way as women we can make hormones apart from during pregnancy. The placenta makes a lot. So your pregnancy has its own thing going on. But we women are cyclic beings. So to talk about menstruation without talking about ovulation is just missing the whole thing, really. I call ovulation the engine of the menstrual cycle. And so knowing if and when you ovulate is called body literacy. It's a term I really love. And so a lot of my patients, some of them know about this. Some don't. But most of them are interested to figure out what's happening for them if they're ovulated. And as I say in my period repair manual, not all, but a lot of the questions come back to, okay, well, are you ovulating? Because it is possible. This is a myth then. A lot of women don't realize that it is possible to have a bleed without having ovulated. So a menstrual bleed showing up is not a guarantee that ovulation happened two weeks earlier. And what are called anovulatory cycles are relatively common, affecting about 30% of actual cycles. And even in a healthy woman, but of course some women are having mostly cycles where they don't ovulate. And that's not great because they're missing out on hormone number two, which is progesterone.
Lindsey Vestal:
That already, we've hit the ground running.
Lara Biden:
Yeah.
Lindsey Vestal:
I'd love to actually ask one more question as it relates to, to the pill specifically higher, these higher doses hormone pills that are coming out now. I'd love to hear some of your thoughts on that.
Lara Biden:
Yeah, well, actually it's been trending to lower dose estrogen. But I mean, any time, almost any type of hormonal birth control through my lens is not friendly to hormonal health in the sense that they all pretty much with the exception of the hormonal IUD, all types of hormonal birth control, mostly shut down ovulation and therefore deplete the body of its own hormones, estradiol and progesterone and replace back the medication hormones, which are kind of similar to estradiol and progesterone, but not really. And that's why, for example, women on the pill, especially the higher estrogen dose pills will, can develop symptoms of like vaginal atrophy and low estrogen symptoms, essentially like similar to you get in menopause. And so it's not uncommon that women on higher dose pills are put on vaginal estrogen just to try to mitigate that effect. And I know, yeah, it's young women, you know, women in their reproductive years should not be requiring vaginal estrogen. So that to me is kind of a red flag that is not doing anything good. Yeah. I mean, there's other, other impacts from that too, sort of depleting potentially the way hormonal birth control shuts down ovarian function and depletes those, well not depletes, but, you know, switches off those two main hormones can also affect bone density. It can affect brain health and yeah, long in the short term and the long term. How do you think pelvic health professionals can bridge the gap between so many myths that are out there? So much misunderstanding, so much lack of body literacy, how, how can we help? Well, I think, I think just promoting body literacy and just bringing ovulation into the conversation is a great first step because a lot of, at least with my patients, they are happy to learn that's how the female body works, that, you know, regular ovulation is both an expression of general health. That's the monthly report card. I talk about it in my first book. It's also a regular ovulation is called a barometer of health. So regular ovulation is both an expression of health and a creator of good health, because it's how we make the hormones that we need to be healthy, both in, again, as I said, in the short term and the longterm, it's interesting actually, because we're in this era right now the last couple of years, you've probably seen it on social media where there's a lot of talk about the benefits of estrogen and in the estrogen, but a little bit about progesterone for perimenopausal women and how everyone must supplement estrogen. You know, I don't, although I think estrogen supplementation can be helpful in menopause, I don't think everyone necessarily should do it. But one thing, one part of that conversation that I can't stop noticing, I can't help but notice is that, you know, all suddenly, you know, why is estradiol suddenly our main estrogen important for women over 45 when for young women, the attitude has been, well, they don't need it. We can just switch it off with hormonal birth control. It just seems like a very jarring, weird, inconsistency that hormones are only important when you're over 45 for some reason. So, yes. So I'm a cheerleader for female hormones. I think, as you know, estradiol, our main estrogen is amazing for pelvic health. Generally it promotes good, you know, tone. It helps with maintaining a healthy vaginal microbiome because the microbiome is a big part of vaginal microbiome is a big part of pelvic health for women as well.
Lindsey Vestal:
Yeah. Yeah. Actually speaking, speaking of microbiome, what, what insights or thoughts do you have Dr. Briden around that connection between hormones and cognitive health especially regarding focus, memory, even like nervous system emotional resilience?
Lara Biden:
Right. So, you know, throughout the lifespan is that, yeah. So, I mean, both estradiol, our main estrogen and progesterone and androgens or testosterone all affect the brain. They all support the nervous system in different ways. So we do know certainly that a woman needs, will benefit from having the 30 to 40 years of exposure to those hormones can help to reduce the long-term risk of cognitive decline. Of course, bearing in mind, there are only one part of the story. I mean, brain health is affected by lots of different aspects, lots of different things, including you mentioned microbiome. So, I mean, that's, yes, that's, that's also important for the brain. Good metabolic health is important for brain health long term and not just cognition, but mood. Right. So we do know that both, obviously both estradiol and progesterone affect mood. I would argue they're both good for mood, although progesterone tends to get sort of a bad reputation that it doesn't deserve. I would point out in most cases, I think. And yeah, and actually that's another just to sort of not to keep coming back to the pill, but it's hard to have a conversation about female hormones without talking about the medication that switches them off. So there is some evidence that the pill affects mood. I think women have known this intuitively for probably 60 years, but it's really only in the last 10 that we started getting some bit more solid research about that coming out, that sort of increased risk of depression and anxiety on hormonal birth control and not just while you're on it, but potentially, especially if teenagers are given hormonal birth control that can, even after they've stopped taking it, that can increase their risk of anxiety and depression later in life. Potentially that's just a correlation study. So yeah. And it's funny because you'll see quotes from scientists saying, Oh my goodness, why didn't we think about the fact that these hormones affect the brain? It's like, yeah, it's like hormones affect the brain. We intuitively kind of know that I think for men and testosterone, like of course, you know, testosterone affects, affects the brain and they need it. And you know, we also need estrogen and progesterone and testosterone. I'll point out, women have, we also have, you know, a reasonable amount of testosterone as well that we benefit from.
Lindsey Vestal:
Absolutely. Absolutely. And I, I do find that, you know, the ratio between progesterone, testosterone, and estrogen, you know, really needs to be looked at uniquely for each, each woman, because I think immediately we think, Oh, you know, I need to go on estrogen, but I think it's about the ratios between all three, isn't it?
Lara Biden:
It's about a lot of things. So if we're talking now about sort of estrogen for perimenopausal and beyond, and that's, yeah, it's not just about levels, right? I just, I actually just this morning came out of another interview where we were talking about a big factor, I think for how women feel on estrogen, whether they want to take it, but it's actually how well they metabolize and respond to estrogen. So estrogen behaves very differently in different women, and that's not going to just be about the levels. So just getting a like a blood or a urine or any kind of just test of hormone levels is really not telling you very much because so much depends on how all the hormone receptors are responding to it. And some women are just much more sensitive to estrogen than others. Those would be the women who even the synthetic estrogen in the pill, you know, potentially sort of made them feel weird or like that might be an indication that they're maybe not going to do as well on estrogen therapy, but that said there is a place for estrogen therapy. So I don't want, I know estrogen therapy is very popular right now. So I don't want people to sort of tune out thinking I'm against it or so. I mean, I'm definitely, you know, I, you know, recommend it to my patients very often. So there's a place for it, especially, and I'll just do this, because this is a podcast about pelvic health. I'll just point out vaginal estrogen is amazing. So, I mean, I think that's certainly going forward into, you know, menopause and beyond that can be an important part of treatment.
Lindsey Vestal:
If looking at the levels isn't, isn't the best way, which totally makes sense to me. What are some ways that we can find out a little bit more information about, about how our hormones are functioning?
Lara Biden:
Yeah, it comes back to body literacy. It's good. It's a perfectly timed question because we've started talking about knowing if and when you ovulate and that can be done. The best way to do that is with temperature tracking. And there's a lot of new devices that will kind of just do that for you. Like there's the old school way, way of just putting a thermometer under your tongue in the morning and then writing it down on a piece of paper. And because with ovulation, basal body temperature will increase by 0.3 degrees Celsius or 0.5 degrees Fahrenheit. So it's not subtle. I mean, you can, you can definitely see that when you're charting it. And so yes, if women, especially if women already have that knowledge or body literacy and they can carry that forward into perimenopause, they can start to see, for example, that their luteal phase or their progesterone promoting higher temperature phase shortens during perimenopause. That's pretty typical. That means they're not making as much progesterone. They can see that from the chart. The other things to sort of have as an awareness, I'll just point out that symptoms of exposure to high estrogen include things like breast pain and heavy flow. So if women in their forties are having breast pain and heavy flow, then they have had high estrogen in that cycle, regardless of what they managed to pick up with a urine or blood test. I mean, just by definition, that's what's been going on. So that can sort of help with the understanding. The other piece of body literacy, I think I've mentioned, I've referred to it already, but this may be circling back to your question about what are some things that some of my patients don't understand. I think a lot of my patients, maybe if they haven't looked into it too much, they'd sort of have this idea that we're on this kind of steady state through our reproductive years that, you know, estrogen and progesterone should be at a certain level, but they're not. Like they are changing quite dramatically throughout the cycle. So in the early, during the bleed, that's the early days of the cycle because you start counting a cycle on day one of the bleed. Estradiol, our main estrogen, is at menopausal levels. And in younger women, it's even lower than in older women. So that's, if you were to, I mean, that'd be quite frightening if you were to test your estradiol at that point, you'd be like, Oh my goodness, I'm in the menopausal range, but that's normal at that part in the cycle. And then it goes up by about four times. Progesterone goes up by about 14 times. So we actually make way more progesterone than we make estrogen, but yeah. So depending on where in the cycle you are, when you measure those hormones, you're going to get different levels. So that's why I feel like it's actually in many ways more meaningful to track based on symptoms and potentially temperatures and just have a zoomed out look of what is happening in the cycle as a whole.
Lindsey Vestal:
And I just think that is promoting, as you say so beautifully, body literacy because we're not turning our power over to a report or to a practitioner. We're going internal. We're kind of going, what's my barometer? What patterns am I seeing? And with that information, I am my own best expert, right? So now we're kind of putting the power back into our own hands and sure we can get levels and turn to people like you to get more information. But I really love this idea of introspection and also interoception. So to lean on our own body's wisdom for this information.
Lara Biden:
So the tracking your cycle with temperatures is called fertility awareness method or fertility awareness based methods. The people who, the women who do it are very enthusiastic about it. And yeah, it's like, as you just described, it's like, okay, this is so empowering. You can actually understand, see what's going on. And another expert future, if you want to bring her on, is a colleague, Lisa Henderson-Jack. She has a podcast called Fertility Friday and she probably knows, lots of people know lots about temperature charting, but she's definitely been doing that for a long time. And I'm sure some of your listeners are temperature tracking, so they can tune into that one as well.
Lindsey Vestal:
That's amazing. I'm also curious, you know, because in my, when I was in New York city and I had my private practice, I worked with a lot of people who had unconventional lifestyles, shift workers, doulas, frequent travelers. I'm curious to your thoughts on where circadian rhythms are often disrupted and, and, you know, how we could tailor some of our hormonal advice for these individuals.
Lara Biden:
Yeah, well, it's, it flows in the direction of a disrupted circadian rhythm will potentially very much impact in a negative way, the female hormonal cycles. So yeah, it's, it's tricky. I guess I have sections in a couple of my books, I think about trying to mitigate the, I mean, the impacts of shift work or travel, obviously sometimes if that's your job, that's what you have to do. But I think then it's about, you know, trying to just get a couple of examples of how to sort of mitigate shift work. So one way it would be, so we have two main signals to our circadian rhythm. We have multiple signals, but the two big ones are light and dark. Well, that's one, the light, dark ratio or timing. And then the second one is the timing of protein in the diet. So you, you can potentially, even though the reality is you might have to work an overnight shift. What you want to do is actually try not to eat too much during the overnight, even though I mean, eat enough to kind of get through, but time your protein to actually daytime hours, because we're nocturnal creatures. So we should never be trying to flip our schedule. So it can help to still kind of keep your protein timing the same as if you were awake during the day. And also you can use, for example, melatonin on your, like not to flip your cycle, but like when you get back onto the normal cycle, take it at night to try to solidify that normal diurnal rhythm, circadian rhythm. Yeah. It's a big one. Actually the researchers into circadian rhythm, I think whatever people, whatever scientists are looking at, they always think that's the thing, you know, that's the thing that affects everything. But if you read the papers by the circadian rhythm researchers, they're just convinced it affects every single thing, you know, obviously fertility, female hormones, metabolic health, the body clock matters quite a lot. Yeah.
Lindsey Vestal:
Yeah. I, when you're thinking, talking about the, you know, devices to, to check ovulation and things like that, which I did just get my, my preteen, one of those and, and she's, she's really enjoying it. It got me thinking a little bit more about technology overall, you know, such as the wearable devices, such as AI. Do you think that they are going to be playing a bigger role in helping us to track and manage hormonal health in the future?
Lara Biden:
I mean, I think, yes, it's hard to predict because some women, you know, don't resonate with them or at least not what's out there so far, but certainly I mentioned is it can make the wearables can make temperature tracking a lot easier. Just go straight to your phone. Basically all you have to do is wear the device, tell it when you get your bleed and it can, you know, generate the chart of like knowing for sure that you ovulated, which is quite handy. I think some of those, I mean, we have some algorithms now using that technology for avoiding pregnant pregnancy. There's this one FDA approved algorithm. I think they're going to be more to come was that's using fertility run as method to avoid your fertile window. Yeah. Other than that, it's hard to, yeah, it's hard to predict. What are your thoughts? Are you aware of other sort of fem tech that, you know, is you think is going to be important? Yeah.
Lindsey Vestal:
When I think about this question, I think a lot about like the Kegel devices, where you, you know, insert into, into your pelvic floor. And I, you know, I have a challenging relationship with them. And I, for two reasons, number one, you know, just like you not being a huge fan of watching the numbers and the levels for hormones, when we sort of lean on a device or even a screen to, to get, Oh, you know, my pressure wasn't as great this week.Right. What happened versus going, being able to say, you know what? I didn't sleep too great this week. You know, we traveled. And so I understand why I'm not able to actually connect my pelvic floor muscles this week. And, and I also think that some of that data depends on where the device is inside our pelvic floor. So, you know, if we're going to see variations and variances based on, you know, the where it's inserted inside us, we're not, we're not getting reliable data. So we're now basing sort of our progress, our trajectory on data. That's not even necessarily accurate. And again, I think it, it creates some distance and reliability on something other than ourself to be able to give us a report. So I have mixed feelings on that. And I also think that, you know, there's a big myth that we all need to do key goals for pelvic health. And that's the, that's, that's it. That's the grand gesture that fixes everything. And, you know, we know that sort of the, it's more about coordination and relaxation. And I find that even if I were to use one of these devices, even though the word relax may come up or, you know, it's, it's slowed down tempo I'm sitting there anticipating, cause I'm a little, I'm a little ambitious. I'm a little type a and I want to make sure I squeeze it at just the right time. And so I'm already in that tense state. So I have, I have mixed feelings about it as it relates to the pelvic floor.
Lara Biden:
That's really interesting feedback. So I've wrote a section on tracking for my latest book about metabolic health. And I sort of acknowledged at the outset, I think there are people who track, there are people who like to track and there are people who don't. And so I'm apart from checking my temperatures, which I've been talking about like tracking my ovulations through my reproductive years, I never tracked anything. I was, you know, a bit maybe cause there weren't a lot of tracking devices available back then when I was younger, but I would never, I don't track my sleep now or anything like that because for me and for some of my patients and I share a patient story in my book, it creates anxiety because to me it just feels like it's one more way to fail. I'm going to get a bad reading.And it's, and also the part of the at least for certain things like sleep trackers, blood glucose tracking, they're not super accurate. I mean, so there's going to be a margin of error anyway. And if you're, as you say, if you're like a type A personality, you're likely to experience that as anxiety. And that just feels like it's another source of something you can fail at. I mean, I just, I, for me, cause my sleep is quite, I mean, I share this in all my books. I have historically not been a great sleeper cause I'm just a really active nervous system type. And I think there's always like two, you know, I think if you're going to be a very sensitive type, then the flip side of that is sleep is going to be a little more challenging. And I would like trying to track my sleep would be a disaster because I would just feel like micromanaging. Yeah. So I'm not a fan of micromanaging things, although I do understand that certain types of tracking can be empowering for people. So I think I've just worked, I'm sure you're the same. I mean, like if you just work with enough different individuals over the years, and I've worked with thousands of patients, you just see this lots of different personalities out there, lots of different needs and requirements. So if people like tracking, that's fine then. Yeah.
Lindsey Vestal:
And I guess the question would be for us as people that support those clients or even the client themselves to, to be a little bit inquisitive and curious is this supporting me, right? Is this data giving me information that, you know, gives me actionable things to work on or am I kind of perseverating on it? Is it adding to anxiety? And I very much picked up on that myself because I was thinking when we had our first who's now 12 years old about getting a baby monitor. Right. And I just intuitively knew that I would not stop staring at that thing and I wouldn't rest. And so, you know, it's sort of this sense of how do you feel when you even think about that, you know, and, and getting that report and getting that data, does it serve you? And, and so anyone listening to this, I would encourage them to lean more deeply on that and to not necessarily get addicted to, to that data, but more asking, is this, is this translating into things that are helping me or am I kind of, you know, helping me spin out in a way? Yeah. I'm curious as to your thoughts, Dr. Brydon on sort of the biggest, some of the biggest drivers were irregular periods and potentially even early periods in modern day society.
Lara Biden:
Oh, you mean girls getting their period younger? Well, let's circle back to that part, but let's start with the irregular periods in, yes. So as we, at the outset, we talked about ovulation or irregular ovulation is an expression of health. So if ovulation is not occurring somewhat regularly, then that is a sign that something is wrong. And I'll just point out, a cycle does not have to happen every 28, 29 days. It does not have to look like that. So that's another way that women don't have to feel like they're failing, right? Like any, it's considered normal. If it's an ovulatory cycle, as in you've ovulated, your temperatures have gone up. If your period's arriving anywhere between kind of 21 days, every 21 days to every 35 days, that's normal for an adult up to every 45 days for a teenager, because younger women just have longer cycles.That's normal for them. And of course it's normal in the first couple of years after a girl gets her period for it to be somewhat irregular. The first few cycles of a girl's life are not ovulatory. So it's just the body, the ovaries waking up, making some estrogen, getting a bit of a sort of just breakthrough bleed from that, from that estrogen is not, it's not really a menstrual cycle yet probably for a few months. And then, but then if, if periods don't come at all by like 16, if they come and then go away, as I say in my book, you know, step one is, well, it's okay for it to go away for a couple months. That's probably normal after stress or something. But if it's been at least three months or longer, then the first step, the first stop should be the doctor to assess for, because that can be all different explanations, right? So they have to rule out pregnancy is the obvious one, but there's some less common things like hyperlactin would be an example of something that you can't pick up on your own. Like you would need a blood test to detect that. So hopefully thyroid problems or anything like that can affect period. So hopefully the doctor's kind of working through all those possibilities and then, but I, it does often boil down to a couple of possible diagnoses. So I'll just talk about them quickly because yeah, your listeners will be, if you're working with patients or clients have been seeing this a lot. So at the end of the day, after the other things have been ruled out, it's very often either hypothalamic amenorrhea. We'll talk about what that is or polycystic ovary syndrome, PCOS. And those are kind of the two most common explanations for irregular periods or lack of periods. There's also the possibility of early menopause that can happen. So the, but the doctor will rule that out. A lot of my young women patients, that's what they're panicked about. They're like, does this mean I'm in early menopause? It's most of the time.No, that's only about one in a hundred women and women under 30, but it needs to be ruled out. So then yeah. So hypothalamic amenorrhea, you probably see that a lot in your practice because it's a, it's a very low estrogen state. So this is losing your period to usually under eating, under eating carbohydrates in some cases, stress illness. Yeah. Eating disorder. I mean, this is so the, the, it's not a, it's interesting. Cause it's not a, it's not a disorder per se. It's the body's perfectly normal reaction to the problem. So there's a problem. I mean, under eating is a problem. It's not healthy for lots of reasons and the brain will respond by saying, let's, you know, shut it, shut it all down. Not, not, not try to make a baby when this is happening. So the, obviously the solution for, in most cases of hypothalamic amenorrhea is to eat way, to eat way more. And it can take six months to get a period back from that state. But hypothalamic amenorrhea is a very low estrogen state. So women would start to experience vaginal dryness potentially with that. Yeah. And it can be, sometimes it's hard to differentiate it from polycystic ovary syndrome. And a lot of, unfortunately, a lot of young women with hypothalamic amenorrhea who have lost their period to under eating are being mistakenly told they have PCOS based on an ultrasound. So I'll just point that out that the finding of polycystic ovaries doesn't mean anything. It really doesn't. It just means there was no ovulation. There was no dominant follicle that cycle. Younger women tend to have a lot more follicles as well. So it's not diagnostic of PCOS. I don't even like to consider it as one of the criteria, actually, although I know depending on which criteria sort of diagnostic criteria for PCOS you're looking at it, it might be allowed as, you know, it might be considered one of the criteria. But there are, which is not to say that ultrasound is not helpful for other things. It certainly is. It can diagnose ovarian cysts, which are totally different from polycystic ovaries. I'll just, I always try to make that point because the word cyst is in both. So it sounds like they must be the same, but ovarian cysts are abnormal, you know, large abnormal structures. There's many different kinds, whereas polycystic just means there's lots of little follicles or eggs, which is always going to be, and there's just no one big dominant ovulating follicle. So, and the other thing for clinicians listening, the thing that an ultrasound can help differentiate between hypothalamic amenorrhea and PCOS is typically with hypothalamic amenorrhea, there would be a very thin uterine lining. There's very little estrogen around. Whereas with PCOS, they can, over time, tend to a thickened uterine lining because they're making estrogen, but no progesterone to thin the lining and potentially not that many bleeds to shed the lining. So that can be a place for ultrasound in terms of, yes, assessing the lining. Yeah. And then obviously treatments will depend on what, you know, what the proper diagnosis is and sort of what might be driving that. Yeah.Should we talk about that?
Lindsey Vestal:
That's incredibly helpful. That's excellent. Yeah.I think that really hits home with our listeners. So thank you for sharing that about irregular periods. What are your thoughts on early periods?
Lara Biden:
Yeah. Well, this is a big controversy and I've tried to share it a couple of times on my social media and got some interesting feedback. So look, I don't know if you've talked about this. So, okay. Periods are coming earlier on average. And it's an average, right? So it's a bell curve. So you're still going to have, there were always girls getting their period, you know, at nine or 10. I'm not, I mean, I think that's not unheard of. And then there were some girls who were like more like 14 or 15. So the bell curve has shifted. I'm forgetting by, I don't want to misquote the science. So I won't attempt a number, but it's some number of, you know, months earlier. So that does suggest that something's going on. And then of course, associated with that, there'd always be just how the certain number of cases where, because of the normal age is anywhere from sort of nine or 10 to 15. There's always going to be that. Yes. Then there's going to be some cases of girls that are completely below that. And that would be like an early puberty, which totally must be assessed by a doctor, you know, treatment considered for that. But as to what the explanations are, I mean, I think most researchers think it's a, it's something in the environment. So it's a combination of exposure to environmental toxins, potentially the modern food supply to some extent, which is driving metabolic dysfunction, which is actually going to translate that kind of trend to metabolic dysfunction in the pop, in everyone, in children will, for girls will translate to earlier periods. So I think there's something going on with that. It's, it's not anything, you know, the girls have done wrong or their parents have done wrong or anything like this. It does seem to be quite a lot of emotion around it, which I do understand. Yeah. It's stressful, especially when they're still kids and they're trying to deal with the period. So I know some other practitioners, I haven't put out any sort of treatment ideas for how to manage early puberty. If you have other resources, you can maybe point to that in the show notes, but it's, it's a tricky one. I mean, this, I don't, to my knowledge, there's not, you know, a simple natural solution for that apart from just, you know, trying to have it, you know, prevention and have a healthy diet and as much as possible for kids.
Lindsey Vestal:
Yeah. Right. I completely appreciate that. We're, we still have so much to learn there. Yeah. Are there any kind of prevailing practices in hormonal health or women's health that you kind of like this wish were more openly debated or discussed?
Lara Biden:
Right. Yeah. And I hear what you're saying. Cause you're sensing like, yeah, there's been, yeah, there's been sort of some hesitancy around discussing yeah. The early puberty, I think, I mean, I guess there's two, two areas that come to mind. I mean, one is metabolic health, which is the topic of my third book. I mean, it is not, I mean, it is being debated, but I, I'm trying to move the needle a bit. I do feel like a lot of the kind of calorie counting narrative around weight and metabolic health has been actively harmful to women. And I think, you know, drives shame. And so I'm, I am trying to through my scientist lens, cause I think I might've mentioned earlier today, I was an evolutionary biologist before I became a naturopathic doctor. So I see everything through that lens. And there is again, coming from the environment, there's some, some individuals, some people are being very much affected by things in the environment, things outside of their control that have affected their I don't want to say damaged their metabolism, because that sounds like it's not fixable, but you know, have calibrated their metabolism in a way that makes it can make it very challenging to maintain a healthy body weight. And so there are always things you can do, but yeah.So that's one area where I'd like to see a kind of a more open debate. It does get quite polarized as you know, different camps, different people have different opinions about insulin resistance and those sorts of things. And the other area, I guess, which I feel maybe needs a bit more debate, well, there's hormonal birth control, which we've already talked about. So obviously that, and I'll just say I've been doing this a long time and 20 years ago, it was not okay to critique hormonal birth control. Like that was definitely considered a very radical subversive thing to do 10 years ago, it was still hard. You know, I just know from on Twitter, 10 years ago, if you mentioned anything about depression from the pill, that would be an immediate slap down. Now, it's changed, hasn't it? Like now a lot of if you when you say something, and you mentioned some of the research around negative effects on mood, and the most doctors and scientists would be like, yeah, you know, that's I've seen that data. And that's something we need to talk about. So there is, that's an example of an area that was taboo, opening up, and more people talking about it, which is great. So that's an example of how things can change. I would say I guess the third area I would mention, and this is kind of more into your territory now, but are all around pelvic pain and endometriosis. So I think, yeah, I mentioned another expert, I'm dropping a couple names in here. But there's another, she's a gynecologist in Brisbane, Australia named PETA, P-E-T-A, right? Like W-R-I-G-H-T, she's got a book on pelvic pain. And she's really opening up the conversation around it. Because as you know, there's been a lot of kind of rigid thinking around endometriosis and this narrative that the lesions cause it, they must be cut out, you know, that the lesions cause. So and I just feel like that's an area that is ready for hopefully some gentle, you know, rethinking in some senses, you know, back to the drawing board. I'll just, I'll let you know, if you do bring PETA on as a guest, she can, I'm sure say it much better than I can. But I would just point out that, like, there's lots of causes of pelvic pain, as you know, including a lot of pelvic floor and spasm and microbiome issues, and like this, and gut issues affecting inflammation in the pelvis generally. And that all those drivers, don't miss, I mean, the endometriosis lesions per se may be present, or they may be not, you know, it's, it's, there's a bit of a disconnect between, you know, what role does endometriosis lesions are actually playing in all of it. So does that resonate with your experience or?
Lindsey Vestal:
Absolutely, absolutely spot on. And I agree with you.I'm excited to connect with PETA and kind of dive into that a little bit more. And also incredibly interesting just to kind of hear you reflecting on, you know, Twitter experience 20 years ago to 10 years ago to now. And it's so rewarding, I imagine, in your career to kind of see those shifts and then to go what's next in the next 10 years and the 20 years, because I do feel like this idea and honestly, very much to your credit, Dr. Brydon, like this idea of body literacy is, despite the fact that there, there's more knowledge out there with technology, and not to say that body literacy isn't tied to technology, but I think people are asking more questions, they want to know more, they're not immediately thinking that someone with a white coat is, is the end all be all, they're remaining curious. And I think this is so incredibly positive, because I think that it will come back to an interest in body literacy growing and consumers demanding more from the information that they're being told and expected to kind of blindly follow.
Lara Biden:
So there has been broadly, and of course, there's always there all along, there were amazing doctors. And, you know, so it's, this is not a comment on, you know, individual doctors, but there has been broadly, I think, well, I'm curious to see if you agree, kind of a paternalistic attitude to women, that it's like, don't give them too much information. Because so 20 years ago, the problem with critiquing the pill, it's like, Oh, well, if you, if you scare women, they're just gonna get pregnant, like, they're just gonna like, just, you can't trust them, like, you have to just give them simple information. And I started thinking, well, that didn't, that didn't connect with the patients I was talking to, they weren't, they, if they heard some information about the pill, and especially if it kind of resonated with their experience, they didn't like just immediately stop it and just become pregnant, willy nilly, like, they're like, most of the time, they're like, Okay, I'm just taking in information, I'm going to make make another plan, I'm going to get an IUD or condoms or something else, you know, that because women are women are grownups, like, they can take in information. And so I think that has changed a bit. Yeah. So I think that another example would have started at the outset, the, I guess, one of the most prevailing weird narrative myths out there is that the pill can regulate the cycle when it actually just shuts down the cycle, like switches off the cycle. And that oversimplified narrative is like, well, it's going to regulate your period. I mean, that was just that started. The origin of that, actually, the origin story for that was back before hormonal birth control was legal, which is very sad to think about the days when women couldn't even access it. So of course, I am, I do defend women's right to have hormonal birth control and access it. Like, but the origin story back then was like, well, they didn't, it wasn't legal to give this medication to prevent pregnancy. So they gave it to quote, unquote, you know, wink, wink, regulate the cycle, which back in the day, they knew it didn't, that wasn't what it was doing. I mean, and but somehow that this became this weird, it just became this weird story to the point that fast forward 50 years, and one in three women who take the pill are taking it to regulate the period. And it can't do that. So I mean, just to clarify, in case of people who are still kind of puzzled to hear me say that, obviously, the pill, the combined pill can induce regular bleeds. So it can do that. But I'm talking about it as a menstrual cycle as an ovulatory cycle, or ovulation is the main event, it can't regulate that. And to be clear, there can be a time when inducing a bleed is important, especially if there's been a buildup of the uterine lining. So but I guess one way to frame that would be, there's no medical reason to bleed monthly on the pill. So you know, if you're taking the pill, and you want an occasional withdrawal bleed from it, it doesn't have to be monthly, like to mimic a monthly cycle is meaningless. It's really just that, you know, that old story from the 1950s, I guess 1960s to sort of, it was apparently it was, I mean, I don't quote me on this, but I think it was like the Catholic Church was against it. And they said, if they said it was to regulate the cycle that it was, have you heard that story before? Yeah.
Lindsey Vestal:
Yeah. But isn't it crazy, these things that, you know, especially now with information so readily available, and at our everyone's fingertips, what stays, and what goes, it's always so fascinating to me what kind of like, human psychology fascination with sound bites plays out to the point where, as you said, one in three women are taking it to regulate their period.
Lara Biden:
Yeah. And I'll tell you what, when they find out it can't do that, they're really, some of them are really mad. And so that I mean, we don't want we don't want that either. We don't want wigs. And we don't want women getting, you know, sort of so miffed about this, you know, one lie that was told to them that they're not going to necessarily believe other things. Yeah.
Lindsey Vestal:
So we just give accurate information.
Lara Biden:
Yeah, just, just when we can handle it, just give accurate information. I do want to talk a little bit about the hormonal ID. I think I mentioned it earlier, it's the one type of hormonal birth control that doesn't necessarily switch off ovulation. I mean, any progestin only method technically can allow ovulation, they work primarily by drying up the cervical fluid and changing the uterine lining. So they, it is possible, weirdly, so with the hormonal ID, which releases a small amount of progestin, it's not progesterone, into the uterine, into the uterus, and some of it does go systemically as well, because for what it's worth that hormonal IDs can also affect the brain and the breasts, but it's a lower dose than you'd get in the pill. And it does, especially in older women, or especially a little bit later into the ID, when the dose has gone down, naturally reduced, then women can ovulate. So the analogy I sometimes use is, with the pill, as in with combined pill, women bleed, but don't cycle, as in bleed, but don't ovulate, which makes no sense. With hormonal ID, interestingly, women can cycle as in ovulate regularly and make hormones, but not bleed, if it's suppressing uterine lining enough to suppress bleeding. So they're kind of opposites in some ways. And the other thing I guess to say about the hormonal about well, IUDs generally, not just the hormonal one, but copper, or hormonal IUDs, they do affect the vaginal microbiome. So the research around that is a little troubling. Of course, when they were, especially when the copper IUD was invented, no one knew about the microbiome or really thought about the vaginal or uterine microbiome, it actually changes potentially the uterine microbiome as well, because there's a string that goes, you know, connects the two, you know, microbiomes potentially. So I think, I'm curious to see a bit more research come out around that. I'm not anti-IUD though, I'll just, for what it's worth, a lot of naturopathic doctors, so my profession would choose the copper IUD as their preferred method, because it allows, doesn't affect, doesn't shut down ovulation to any extent and doesn't introduce any synthetic hormonal medications into the body. So yeah, there's a place for that.
Lindsey Vestal:
Did you say that both hormonal and copper IUDs impact the vaginal microbiome?
Lara Biden:
Yeah. Yeah. Yeah. And I guess the mechanism is still being worked out. I mean, I think that's my understanding is they do. I mean, I think the copper one, so I've written a few pieces about this over the years, I think one sort of theory around, so for example, the copper IUD can increase the risk of bacterial vaginosis or BV. And it doesn't mean that everyone who uses a copper IUD will get that, but it just increases the risk by some amount, which I don't have the statistics on. I try to not quote like guesstimated statistics because it decreases the risk. And I think some of the mechanism might be just heavier flow can potentially worsen. I'd have to look at sort of the updated mechanisms as to why they think that's happening. And my understanding is I think there's something similar for the hormonal IUD. Certainly I've had patients report changes to their vaginal microbiome on IUDs. So, and that's fixable. I mean, it's not like, that doesn't mean it's a deal breaker. It's just something to the microbiome. You must have had, do you have other episodes about the vaginal microbiome?
Lindsey Vestal:
I don't, but I need to.
Lara Biden:
Can I drop a third name? I feel like I'm just like sharing.
Lindsey Vestal:
Please, I love this.
Lara Biden:
So there's, her name's, she's Australian as well because I'm down in New Zealand, Australia. So Moira, I'm just forgetting. She's in my book. So I'm doing why I've forgotten her last name, but her website is called Intimate Ecology, which is a nice name. So she's,
Lindsey Vestal:
Oh i love that
Lara Biden:
yeah, you'll find it.
Lindsey Vestal:
And I've got your book. I've got all your books.
Lara Biden:
So she's in my second book. She gave me some quotes about perimenopause, menopause, and the vaginal microbiome was one of the big changes actually with menopause, well, not multiple changes, but in terms of pelvic floor, the drop to the lower levels of estradiol can dramatically change the vaginal microbiome. It also changes the gut microbiome, but as your listeners may know, it's a good, this is a good sort of compare and contrast. So your listeners may have heard that the gut microbiome is when it's healthy, it'll have more diversity, like more variety of species. It's the opposite for the vaginal microbiome. So a healthy vaginal microbiome should be mostly lactobacillus of a couple of strains and just dominating. And that's what keeps the vagina slightly acidic and it's, you know, beating off other pathogens. And so a healthy vaginal microbiome has a very particular sort of composition and with, yeah, with hormone, with drop in estrogen, that will change. So in different directions, more to kind of the bacterial vaginosis or potentially to, depending on what's going on, it can obviously change to thrush or candida or yeast infections. Yeah. So there's a lot more nuance to vaginal microbiome than I realized. I mean, the research around that area has been galloping over the past decade or so.
Lindsey Vestal:
Fantastic. Yeah. Yeah.
Lara Biden:
Yeah. And potentially it affects fertility as well. So the vaginal microbiome does feed into the uterine microbiome potentially. And yeah, and then actually that can affect the pelvic microbiome. This kind of goes back to pelvic pain. So there is some suggestion now that women with pelvic pain, potentially women with endometriosis, depending on how relevant the lesions are themselves, but have higher levels of certain types of bacteria in the pelvis, in the pelvic microbiome. There wouldn't be a lot of bacteria in the pelvis, but there's some, it's like, like we know now there's like a brain microbiome and like, it's just, we just went from, and this also spans my career. So when I was started practicing almost 30 years ago, like that was back in the time, that was like in the mid nineties. So I was working in a small town in Canada and I remember the local doctors there were like, good bacteria. Like what a weird, like back then it was like, even just the idea that of good bacteria in the gut was considered radical. And of course now that's well understood. I mean, it's still lots we don't know, but yes, a lot of things have changed.
Lindsey Vestal:
Just hearing you reflect a little bit about 30 years ago when you were interested in good gut bacteria, I'm curious as to, you know, I feel like you've always been on the forefront before these things take off. What do you credit that to? You know, sort of thinking about your own trajectory.
Lara Biden:
It's because I was going to use the phrase ahead of the curve. So naturopathic doctors typically are ahead of the curve and there's good and bad things to being ahead of the curve. So being ahead of the curve means you could be wrong about some things. So does that, I mean, I remember one of my instructors back in naturopathic college saying, well, if you wait for the full consensus, the full evidence, you'll be waiting 30 years. So that's certainly the case in terms of some of the microbiome stuff. Like if I waited, so I was prescribing stuff for my patient's microbiome well before there was really the body of scientific literature to back that up. So there's pros and cons to that. I'll answer your question about what I attribute that to, but let's tell one more story. I remember back at the time I was dating a doctor at the time. And I was like, you know what? I've heard that polycystic ovary syndrome is to do with blood sugar. I was like, you know, I think it's to do with like insulin, you know, insulin level and blood sugar problems. And he's like, what? At that time, I was just completely, he thought that was really left field. So, I mean, that's another example where, yeah, I was a little ahead of the curve in a good way. I don't know. I think I attribute that. I don't know. I think I've just, well, I think curiosity is the main, there's a combination of biology backgrounds. I was a research biologist at first. So I'm just curious about how, so how biology works. And then of course, you know, being part of the net by the community, being ahead of the curve anyway. But I think I always put, try to put things through the lens of what will, what makes sense biologically, like, is that biologically plausible putting it through that lens rather than, you know, what is the established paradigm? So certainly around hormonal birth control, I'm like, that can't be right. Like, we're not supposed to like shut down women's hormonal systems routinely. Like that just never, ever made sense to me. And it would be like, and the analogy I've given sometimes is it would be like, like the routine use of hormonal birth control for the last 70 years, kind of era of hormonal birth control would be like saying to men, like, look, you don't need your testicular function or your testosterone until you're ready to make a baby. So we're just going to like shut that down and switch it back on when you're ready. It's just, in the meantime, we're going to give you this, we're going to shut off your own testosterone and replace it with this medication. That's kind of like testosterone, but a little bit, actually more like estrogen and actually not like either of them. And that will probably affect your brain and your bones and muscles, but you know, that's just what we do now. That's how we roll. That's what, you know, we give women these medications. I mean, not to be too casual about it. I mean, I do, I understand that obviously the hormonal birth control has a place and some of my patients still take it. So it's not like I have a blanket statement that no one should take it. It's just, there has to be some space for women understanding what it's, you know, what it's doing, considering the pros and cons and yeah. Yeah.
Lindsey Vestal:
I have one last question for you. Although I could talk to you for weeks and weeks and weeks. If you could recommend one small underrated daily habit to really support hormonal health, what would that be?
Lara Biden:
Yeah. It's support circadian rhythm. So this ties back to, you mentioned about, you know, people doing shift work and where for them, it's a lot more challenging, but for the rest of us, it's, it actually has a huge effect on menstrual cycle, on the perimenopause experience, transition, just getting some morning light, timing protein during the day, trying to get some, a good dose of protein by 10 AM, obviously dimming the lights in the evening, sending your body clock, grounding your body clock in reality. So it kind of knows, knows where it's at and that can really pay off. Certainly I talk about it quite a lot in my new book on metabolic health, because it's a great first step, even before people try to make a whole new set of food rules or anything like that, like just feel, you know, start to feel better with things like that. So, yeah.
Lindsey Vestal:
I love that. I think that's something we can, we can all take action on. Dr. Bryden, I am so thankful and so grateful for your time today. And again, just for all of the work you continue to do to champion body literacy and hormonal health, you're such a gift. And again, can't thank you enough for your time with me today.
Lara Biden:
Thank you.
Lindsey Vestal:
Thanks for listening to another episode of OTs and Pelvic Health. If you haven't already hop onto Facebook and join my group, OTs for Pelvic Health, where we have thousands of OTs at all stages of their pelvic health career journey. This is such an incredibly supportive community where I go live each and every week. If you love this episode, please take a screenshot of this episode on your phone and post it to IG, Facebook, wherever you post your stuff, and be sure to tag me and let me know why you like this episode.This will help me to create in the future, what you want to hear more of. Thanks again for listening to the OTs and Pelvic Health podcast.
