©2019 by Drs. Kara Dionisio & David Miller, ND.

EPISODE 6

Mean Flow with Dr. Kara Dionisio, ND

INTRO/OUTRO

That Naturopathic Podcast TNP. Hello there.

 

00:00:05

Dr. Kara Dionisio ND

Hi and thanks for joining us. I'm Dr. Kara Dionisio.

 

00:00:08

Dr. David Miller ND

I'm Dr. David Miller. And we hear your frustrations. This show is for you.

 

00:00:12

Dr. Kara Dionisio ND

This show is for you if you're feeling like your current health care strategy is not getting to the root cause or the underlying reasons for your health.

 

00:00:20

Dr. David Miller ND

This show is for you if you've been told that you're fine but you definitely don't feel very well.

 

00:00:24

Dr. Kara Dionisio ND

This show is for you if you're walking out of your doctor's office with one, two, three, four, or even five medications without any mention of diet, lifestyle, or a long term game plan.

 

00:00:34

Dr. David Miller ND

This show is for you if you've got several specialists taking care of you but no one is really putting it all together.

 

00:00:40

Dr. Kara Dionisio ND

This show is for you. If you believe that health should be part of health care. These problems have solutions.

 

00:00:47

Dr. David Miller ND

We know it.

 

00:00:47

Dr. Kara Dionisio ND

Our patients know it.

 

00:00:49

Dr. David Miller ND

And we want you to know it.

 

00:00:50

Dr. Kara Dionisio ND

Naturopathic medicine is the solution that you need to know about.

 

00:00:54

Dr. David Miller ND

Ok. And welcome to another episode of that naturopathic podcast. I'm Dr. David Miller.

00:01:00

Dr. Kara Dionisio ND

And I'm Dr. Kara Dionisio.

00:01:01

Dr. David Miller ND

And you are being interviewed today.

00:01:03

Dr. Kara Dionisio ND

I am host and guest today.

00:01:05

Dr. David Miller ND

She's host and guest ... it's a very exciting day because normally we interview other awesome naturopaths and other awesome doctors and health care practitioners but today we just have to accept that Kara is a bit of an expert in women's health ... broadly?

00:01:21

Dr. Kara Dionisio ND

Yeah.

00:01:22

Dr. David Miller ND

That true? Yeah. And it's really important I think that we talk about heavy periods and that's the topic for today.

00:01:30

Dr. Kara Dionisio ND

Yeah I'm nervous. Our other guests have set such a high bar.

00:01:34

Dr. David Miller ND

They have.

00:01:35

Dr. Kara Dionisio ND

Yeah.

00:01:36

Dr. David Miller ND

It might be a little ... it might be a little bit of fun. This is a little different than usual. We'll have a lot of fun with it.

00:01:40

Dr. Kara Dionisio ND

We're good at jamming.

00:01:41

Dr. David Miller ND

OK. Tell us a little ... Well we know about you because you're obviously co-host of this awesome podcast and you're a great clinician and you run your own clinic and all that. So we won't bother people too much with the intro that way but.

00:01:58

Dr. Kara Dionisio ND

Yeah.

00:01:58

Dr. David Miller ND

Maybe ... so tell people why when I said Hey Kara how about I interview you for something with women's health, why did you pick this topic?

00:02:07

Dr. Kara Dionisio ND

Yeah it's pretty quick wasn't it.

00:02:08

Dr. David Miller ND

It was.

00:02:09

Dr. Kara Dionisio ND

Yeah. So heavy periods. I think there's probably two reasons why I chose this. One is more apparent as I see lots of women who come into my practice and a good majority of the women who are coming in for specifically menstrual health issues. There's a high percentage who are really really struggling with heavy periods to the point where they're sitting in the chair that you're sitting in right now and are really actually quite distressed really upset there. They're ... they can't find answers or they're not happy with the answers that have been provided, but they're really struggling like every month or even more. It's affecting their quality of life it feels out of control. And it's a really -- it's a really impactful thing to a woman's life when heavy periods are kind of ruling one week of the month.

00:03:07

Dr. David Miller ND

How many ... like how many people or what proportion of women would you say are having problems with heavy periods.

00:03:14

Dr. Kara Dionisio ND

Yeah. So there's actually some good stats on this. And I would say I agree from what I'm seeing in my my practice. I think it's one of the top three reasons women go to their gynecologist. About 20 percent of teenagers. That's a pretty big population of women who have heavy periods, and then also getting closer to menopause and those menopause years. The hormone changes that occur around that time are another pretty big time for heavy periods. So about 50 percent of people --of women -- age 40 to 59 have heavy periods. So that's a pretty significant part -- you know, population of women who, you know and it's not just you know heavy periods is the acute thing ... you know where they're really uncomfortable -- they might not be able to leave their house -- it's that heavy. They're losing a lot of blood so they're getting very tired and iron deficient. And you know women need their iron is as we talked about in Episode 2 to do all the awesome things they're doing. And so that's a pretty big like direct effect of heavy periods. And then yeah it's also -- there's ... it brings up a whole bunch of other things just about menstrual cycles in general and kind of, we can keep going wider and wider out on the more society and historical effects of how women are are viewing their periods or experiencing the periods.

00:04:39

Dr. David Miller ND

Yeah. So what's -- what you think is like the main troublesome ... Obviously like a heavy period in itself is troublesome but like what are the ways in which in day to day life of a woman heavy periods are most mind-numbing crazy-making? Like obviously we know as health care practitioners we know that there's all these other health effects of it or that are leading to it. But from the person who's just like -- like you said you can't really avoid the symptom. Right it's like Oh my God -- that's a really heavy period. I can't do X Y Z I'm limited in these ways ... what are those ways that women may see day to day that it limits them?

00:05:21

Dr. Kara Dionisio ND

I think you know a lot of women it's heavy enough that it's changing what they're doing in their day. You know they might be avoiding certain situations or you know can't get through a meeting or can't get through... you know ... maybe at work they only have certain breaks but they can't make it that long. So just from a practical standpoint you know when you're worried about leaving your house that you know all your backup and backup pads and systems and cups that you know maybe they're doubling up or tripling up you know that that's a problem. I think it also speaks to the inherent problem of menstrual cycles and we can we can get to that as well. You know the modern woman's experience of menstrual cycles -- I think we might need to shift some thoughts on that as well.

00:06:15

Dr. David Miller ND

Versus the Red Tent days.

00:06:16

Dr. Kara Dionisio ND

Yeah exactly. Yeah. It's supposed to be a time where you know historically women have always you know honored the time of their menstrual cycle as a time to rest. You know a time to go inward. A time to replenish. And you know often ...

00:06:34

Dr. David Miller ND

And communion is there ... was there communion?

00:06:36

Dr. Kara Dionisio ND

Yeah for sure. Yeah. You know.

00:06:39

Dr. David Miller ND

Like communion amongst women. Yeah. Woman to woman communion.

00:06:43

Dr. Kara Dionisio ND

For sure. Yeah. And kind of sharing in that. I really do think it in historically and spiritually and even in many religions traditionally you know periods have been a very sacred and spiritual time. And you know when you all of a sudden become a modern woman and we're trying to hide it you know -- we're you know trying to go on with our regular life with all of the things that we're adding to that all the things the kids the jobs all of that. And you know it's something that just becomes a nuisance.

00:07:22

Dr. David Miller ND

At least a nuisance it sounds like -- at least a nuisance. Cos you still got to keep being supermom. You're still going to work. You still probably the head of the house in terms of decision making about health and -- traditionally -- like there's outliers always. But like your job as a woman and your job as a woman with a job.

00:07:42

Dr. Kara Dionisio ND

Yeah.

00:07:42

Dr. David Miller ND

Doesn't really say Okay take a week off.

00:07:47

Dr. Kara Dionisio ND

No it doesn't say that and I'm not suggesting that we can. I do think we can build it in because there's a big problem when you are trying to hide or suppress or not acknowledge a really important part of what makes you a woman. Right. The menstrual cycle is what gives life. Right. And so just to pass it off and try to continue as normal and ... or even ... you know a lot of the women I talk to hate their menstrual cycles -- they hate their periods. They want nothing to do with it. They want it to go away. The amount of women I hear whether I'm talking in groups or with my patients one on one that say I hate my period I just can't wait for menopause to come home.

00:08:35

Dr. David Miller ND

Doesn't seem -- there's something about that that seems -- again I'm just coming from the perspective of a male who's never had a period. But it's just something about that as a believer in like you know natural laws and nature phenomena it just seems like something not entirely healthy about hating your period.

00:08:56

Dr. Kara Dionisio ND

It makes me so sad. Right. It's it's ... And I'm not saying it's this wonderful magical thing and we can frolic in the woods during our period and you know under the under the new moon. You know I realized you know that's not going to be everyone's experience. But when you when you repress a really inherent part of yourself -- whether it's you know your sexuality or your gender or you know your role in society -- whatever it is, anything you're suppressing that's not a good thing and it's going to come out somewhere. And then it makes me sad too because that means there's a lot of women out there really struggling with their periods, struggling with heavy periods and not finding help.

00:09:43

Dr. David Miller ND

What are the other ... So if someone has heavy periods what are the other things you're expecting to see them also like suffering with?

00:09:55

Dr. Kara Dionisio ND

Well acutely the heavy period. But that's just a symptom. Right. So the heavy period is a symptom of the rest of the cycle. Right it's a symptom of you know -- we wonder are you ovulating in that cycle? Which is a key component to healthy periods.

00:10:11

Dr. David Miller ND

What does ovulating mean to some people who ....

00:10:13

Dr. Kara Dionisio ND

Ovulating. So releasing an egg. So that egg that releases mid cycle is you know there to create life if it should happen to intercept with a sperm but if not it still has a really important function in health in women's health. It's actually I would say -- if there's one thing that we can do as women to protect health it's to have lots of ovulatory cycles in our lifetime. And that egg releases progesterone -- that progesterone balances off that kind of sexier hormone estrogen who can get a little bit high on her throne. So we need that progesterone produced from the egg. We need ovulation for protecting heart disease, for protecting our bone health long term. And it's a really awesome thing to ovulate. There's great things about just how you can feel at ovulation too. And so from a medical standpoint ovulation is kind of a keystone of the whole menstrual cycle.

00:11:19

Dr. David Miller ND

It almost sounds like like a like a linear prerequisite for a healthy period. Right so then if we don't have ovulation ... you know this is just male ... again just a male talking but ...

00:11:34

Dr. Kara Dionisio ND

Educated male.

00:11:34

Dr. David Miller ND

Yeah. But it's like OK so if I don't if I don't ovulate properly then all the things that depend ovulation don't happen properly. So you know how I believe in like hierarchies and you know like yeah things have to be sort of done in an order whether you like it or not.

00:11:50

Dr. Kara Dionisio ND

For sure.

00:11:51

Dr. David Miller ND

They do so how do we maybe -- maybe how do we encourage -- I mean maybe that's a bit of a big topic but how do we encourage healthy ovulation?

00:12:00

Dr. Kara Dionisio ND

So yeah it's a -- it's -- you can keep going back and back. Right. Because healthy periods require healthy ovulation and healthy ovulation, I think if you want to take it back pretty big picture, your body is not going to ovulate if it doesn't think it's safe to make a baby.

00:12:21

Dr. David Miller ND

Mm hmm.

00:12:22

Dr. Kara Dionisio ND

Right so that's the big picture. There are a lot of things that will influence that. So the first half of the cycle then has to be healthy in order to have you know the hormonal cascade. You know the brain signal FSH you know leads to the signal in the ovary making estrogen, developing follicles, and then triggering another hormone to release the egg. So there's a huge cascade of events that have to happen there. And so if we're not getting -- if the health of any part of those is compromised then we have compromised ovulation. We know that things like even just in general health. So high blood sugar levels, insulin resistance, oxidative stress -- the ovary is very very susceptible to you know blood sugar, inflammation, oxidative stress. So you know going back to our root principles you know NMRX -- nourishing moving relaxing.

00:13:22

Dr. David Miller ND

And give a shit. That's what X is.

00:13:25

Dr. Kara Dionisio ND

Yeah. And give a shit. Yeah ... Are really important for that keystone thing in the cycle which is ovulation. And that's why we see heavier periods and other types of menstrual cycle issues more in teenagers and also leading up to menopause because those are two times for different reasons that ovulation might not be happening every single month.

00:13:52

Dr. David Miller ND

Okay. One thing you taught me this morning which thought was really cool is that. At menarche -- Yeah like how old are kids having -- how old are young girls having their periods? Pretty young it seems it seems really young. Yeah. They gave a couple of patients around that age and just look like little ... such little humans. Yeah and they're having a period. But what was really cool is that those young little humans are actually sometimes not ovulating when they have their period first. Can you explain a little bit about that.

00:14:21

Dr. Kara Dionisio ND

Yeah. That ...So in teenagers as they're starting their period their bodies just you know it's just getting in the rhythm so that ... there's a you know an HPO axis so an axis between the brain and the ovaries and this cascade of events that has to happen to lead to a regular menstrual cycle and lead to ovulation. That axis is a little immature in adolescents. It's maybe just not got the hang of or got the rhythm yet. And so some of those cycles end up being anovulatory or that they don't actually ovulate or release an egg. And so when you do -- when you don't have the ovulation -- we'll talk a bit more about estrogen progesterone later -- it can lead to heavier or more irregular periods. And that's a really common problem in teenagers. It's probably one of the reasons why female teenagers end up at their doctor's office. And fortunately unfortunately the solution to that is often the birth control pill and ...

00:15:23

Dr. David Miller ND

Which we didn't really know exactly ... I think you looked into it more extensively to see how it works because that was sort of interesting like I thought it was going to be like a hormonal feedback effect.

00:15:34

Dr. Kara Dionisio ND

I did too. Yeah.

00:15:35

Dr. David Miller ND

Yeah. Do you want to do want to tell us all how the birth control pill works in heavy periods.

00:15:41

Dr. Kara Dionisio ND

Well I was ... yeah I was confused too because I'm like well you don't actually ovulate then when you're put on the birth control pill. And so I'm like How does that work to to lighten periods? It would make sense that it makes it more regular. And the periods you get on birth control are actually not menstrual periods they're actually called withdrawal bleeds because you need ovulation to have a period. And but what it's looking like is the estrogen that's in the birth control pill increases blood clotting. And so it kind of stops the heavy flow.

00:16:19

Dr. David Miller ND

That was so weird to learn. But it goes along with the fact that there are increased risk of stroke with use of oral contraceptive.

00:16:26

Dr. Kara Dionisio ND

Sure. Right. And you know I mean teen pregnancy is a huge deal right and if that's the best choice for teenagers then that's OK. But if the birth control pill is prescribed solely for heavy periods then we have a problem right. Because all of a sudden we have a teenager, a young teenager, whose body is just getting the hang of ovulating -- maybe has only had a few ovulatory cycles, is put on the birth control pill and then maybe stays on it through university or through late teens and then all of a sudden you know as Mary wants to have children -- and not that the studies show that it does impact fertility -- but I do think it's a problem that that woman has not really had an ovulation which as I was talking about the key health benefits of ovulating. She hasn't had ovulation for basically her whole life. When you know she's possibly could have had 15 years of ovulation.

00:17:21

Dr. David Miller ND

Does she have more eggs then?

00:17:23

Dr. Kara Dionisio ND

I mean it's kind of a drop in the bucket when you're talking about like billions to 40000 to -- I can't remember the numbers actually but yeah.

00:17:35

Dr. David Miller ND

Ok. So they're just sort of learning how -- the body's just sort of learning how to react to other things going on. So is it possible then to say that probably young girls having their first periods are going to be heavier -- like just because they don't have the ovulation happening. Are they generally heavier?

00:17:55

Dr. Kara Dionisio ND

Yeah. I mean that's that's my experience and experience of the teens I see. They are also quite painful that would be the other issue which is a whole other podcast.

00:18:05

Dr. David Miller ND

Mm hmm.

00:18:06

Dr. Kara Dionisio ND

Yeah.

00:18:06

Dr. David Miller ND

What would you tell like a mom who was talking to her daughter about that time of life where you know these things start to happen what would you say would be a good thing to know. Because I'm learning already from you that there's some things we should probably know to talk to young girls about. What would you say is a good thing to tell them?

00:18:21

Dr. Kara Dionisio ND

Yeah I would tell them -- you know even just explaining this is why it's happening -- It's going to get better. You know -- it could take you know six months a year or even two years -- but her body is designed to get into that rhythm and it knows what to do. And so you know it's not -- it's not a pathology right. It's not a medical problem. It's a process, a natural process that just need--takes time to develop. And so in the short time we talk about you know some ways to alleviate the flow or alleviate the pain and maybe we'll wait on getting to those treatments in a little bit.

00:19:03

Dr. David Miller ND

Okay. Well we could we could go to that now. We could sort of separate things into like a short term versus a long term approach.

00:19:10

Dr. Kara Dionisio ND

I think maybe before we go there we should probably maybe just quickly define what heavy periods are.

00:19:15

Dr. David Miller ND

Sure

00:19:18

Dr. Kara Dionisio ND

Which is very difficult. And there's lots of different varying ideas even in research of how to define heavy menstrual periods. And it's also very subjective. Right. So when I'm sitting here and I ask a woman how heavy are your periods. She has nothing to compare that to, right. She is heavy for her, and she subjectively may feel like that's heavy. But then when I ask her OK well how long on your heaviest day during the day -- how often do you have to change your pad? And she might say Oh just once at lunchtime. Right. And so I wouldn't consider that a heavy period. And then other women might say oh they're not bad. You know just every hour or so. So it's a very subjective thing. In research the standard that we've been following for about 50 years is menstrual blood loss over 80 milliliters through the whole period.

00:20:12

Dr. David Miller ND

How do I know 80 milliliters.

00:20:15

Dr. Kara Dionisio ND

Yes. How do we know 80 milliliters. So ... it depends on what menstrual product you're using. And now they're getting better and better so I don't even know if this is true anymore. But a standard ...

00:20:32

Dr. David Miller ND

because the research you have is older right? Is that correct?

00:20:35

Dr. Kara Dionisio ND

Yes. So that that 80 millimeters came from like studies in Sweden and the UK about 50 years ago. And that was not even based on -- they didn't measure volume, they measured the amount of haematin -- this marker of blood loss. And so -- but it's funny because it's been universally accepted in every research paper I've seen since the definition is 80 milliliters. And I mean to some women that seems like a lot -- to me that sounds like nothing. And so again there's that subjectivity. I would say you know from a broad view heavy menstrual cycles are ones that are impacting your quality of life, that you are soaking through a pad maybe more than every hour, or you're needing to double up pads, or you can't get through the night, or it's restricting your activities. I would go on more of a patient reported this is how I'm experiencing it point of view based versus "let's measure over a period"....

00:21:35

Dr. David Miller ND

Yeah exactly.

00:21:36

Dr. Kara Dionisio ND

... Volume". Now the volume is important though right. Because they did find that blood loss over 80 milliliters would in most women cause iron deficiency and that's a huge problem. Right.

00:21:51

Dr. David Miller ND

Yep. Unless you have hemochromatosis.

00:21:54

Dr. Kara Dionisio ND

Yeah. And so just to try to get to that 80 mils the newer menstrual cups -- which I highly recommend by the way -- they hold up to 30 mils.

00:22:04

Dr. David Miller ND

Is this the Diva Cup?

00:22:06

Dr. Kara Dionisio ND

the Diva Cup is one but there's like probably 50 different cups. I use one called Femi cycle you can ask me about that. It's pretty fantastic; when you dump it upside down nothing falls out. It's got a cup inside a cup so -- the cup holds -- and that's actually probably the easiest way to measure volume. You know you can say I used you know "today I used 2 cups". And so and then.

00:22:36

Dr. David Miller ND

But not everyone's going to do that.

00:22:38

Dr. Kara Dionisio ND

Not everyone's going to ...

00:22:40

Dr. David Miller ND

You would recommend it but not everyone is going to do that. So is there a way of like with number of pads or tampons for our more conventional people to ...

00:22:50

Dr. Kara Dionisio ND

Sure! A fully soaked super pad is 10 ml. So like one of the heavier duty pads is 10 mils. A super tampon I think is about 12 to 15 mls. And so you can -- you can judge it based on that. And I mean clinically ... like in practice I just ask you know how frequently, what what product you use, and how frequently are you changing it, and can you get through the night? And that seems to be the easiest way to get an idea of heavy flow.

00:23:19

Dr. David Miller ND

Yeah impact on their life.

00:23:20

Dr. Kara Dionisio ND

Yeah. And also running iron panels and ferritin level ...

00:23:23

Dr. David Miller ND

What a great idea!

00:23:24

Dr. Kara Dionisio ND

And a hematocrit and you know seeing you know what the downstream -- like immediate downstream effects -- might be.

00:23:32

Dr. David Miller ND

Mm hmm.

00:23:33

Dr. Kara Dionisio ND

And I've talked about this too that that's a pretty vicious cycle that heavy periods, iron loss iron deficiency thinner blood heavier periods.

00:23:41

Dr. David Miller ND

Ok repeat! Repeat -- it's so worth repeating.

00:23:46

Dr. Kara Dionisio ND

Ok.

00:23:47

Dr. David Miller ND

Because a lot of these things that the body does are really like very intelligent and you know a smart system -- like if you're low in this it increases the absorption of that or whatever. What happens Kara, when someone has heavy periods -- to their iron? What happens? And then explain that ridiculous cycle.

00:24:05

Dr. Kara Dionisio ND

So it's a cycle that doesn't make sense because it actually is a downward spiral. And to be honest when I look in research to find this link it's very skim -- skim? Skip? Scant.

00:24:22

Dr. David Miller ND

Scant, skimp.

00:24:23

Dr. Kara Dionisio ND

It's literally scant it's not heavy, but it's there and it makes sense physiologically. And also I directly personally experienced this and my patients have reported back that it does make a difference that -- so the cycle is -- for one reason or another you have iron deficiency or you have a heavy period, so you have a heavy period, you're losing a lot of blood, so you're losing a lot of iron, and then that iron deficiency will drop your hematocrit level so the blood becomes more thin and it predisposes you to having heavier periods.

00:25:03

Dr. David Miller ND

Continue. Continue. Continue.

00:25:04

Dr. Kara Dionisio ND

Repeat and repeat. So you're losing blood. You're losing iron. You're becoming anemic. How tired do you think you're gonna feel?

00:25:16

Dr. David Miller ND

Yeah. yeah that's crazy ... you know ... because we've been talking about iron for quite a bit now ... since talking to Dr. Justin Gallant, it's affected my practice and helped ... I think I've been able help a lot of women in my practice by getting smart about iron and I can't believe that there's this big of a problem with iron and this is ... I'll just tie this ... I'm not -- I don't want to hijack your show, this is your jam.

00:25:43

Dr. Kara Dionisio ND

No.

00:25:43

Dr. David Miller ND

Jelly? Jelly? This is your jelly. But like it's interesting how some people in the past -- so I'd have had like a similar idea of this and I was talking to my mom about iron and women and how I think 90 percent of women are anemic to some degree.

00:26:01

Dr. Kara Dionisio ND

Yeah.

00:26:01

Dr. David Miller ND

And she said a surgeon that she knew -- like a friend's dad -- said years and years ago like in the 70s or whatever -- he thought -- he had such an understanding of the importance of iron in women that he thought that women shouldn't donate blood. Which I thought was a really really interesting thing to hear for a surgeon from the 70s coming to not the same conclusion, but like ...

00:26:26

Dr. Kara Dionisio ND

Yeah.

00:26:26

Dr. David Miller ND

Let's be careful about iron and our most important demographic of our population arguably which is women of reproductive age -- or you know from -- there they're the most -- they're so important. And so I think we really need to take care of them and so I think us guys should be giving blood more than women for sure. And those women should be fully assessed with a full comprehensive iron panel.

00:26:54

Dr. Kara Dionisio ND

Yeah. And that's just honoring the foundations of what makes life.

00:26:59

Dr. David Miller ND

Yup ... it's pretty important.

00:27:01

Dr. Kara Dionisio ND

Layering healthy menstrual cycles on that is a natural evolution. And whether you start with you know that vicious cycle you just need to start breaking it somewhere. Whether you aggressively get iron up and you also do things that reduce menstrual blood loss. And then if you want add in another vicious cycle that is kind of fun from a geeky point of view is adding in the thyroid connection to that.

00:27:31

Dr. David Miller ND

Ok. Tell us tell us thyroid, iron, heavy menstrual ...

00:27:35

Dr. Kara Dionisio ND

Yeah. So all of those will -- one of those -- so low thyroid function, low iron, or heavy periods will all worsen each other. So for example iron is really important -- sorry -- the thyroid hormones are really important to help iron and get incorporated into erythrocytes or red blood cells. Iron is really important in converting T4 which is one of the thyroid hormones into the more active thyroid hormone T3. And so those two really play off on each other. And if they're both low you're gonna also feel like shit -- you're gonna feel really tired. And then we can add in hormones to that. So estrogen or higher estrogen levels which are often implicated in heavier periods increase something called thyroxine binding globulin. So it's gonna bind up all your free thyroid hormone so it can't do it's job whereas progesterone which is produced from ovulation -- that key key part of the cycle -- it actually decreases erection binding globulin. So you actually have more thyroid hormone hormone to do its job like helping iron. So it's just.

00:28:50

Dr. David Miller ND

It's like the stool analogy right. If one of the legs of the stool is then you're falling over.

00:28:57

Dr. Kara Dionisio ND

Yeah. And so women those three stools are iron thyroid and menstrual cycles.

00:29:03

Dr. David Miller ND

Mm hmm. Mm hmm. What other what other sort of things will we see with regards to possible hormone imbalances and heavy periods. Is it as easy as that. Remember I'm just a guy -- is as easy as that? Is there something we can say like OK if you have heavy periods and your hormones are likely doing this or that. Is there any correlation like that?

00:29:25

Dr. Kara Dionisio ND

Often. So sometimes no. Sometimes hormones are ... look like they're doing ... you know ... the job ... you know it looks like a perfect hormone chart, of the rise and the fall in the levels and the ratios, and in those patients ... you know ... we're going to look outside to other issues. So things that are often missed especially in teens are any blood clotting issue. So any genetic issue something like that is often missed. And so that might need to be worked out. We're also not talking about ... Well I guess we can talk about it ... but there are also some more medical issues that will cause heavy heavy periods, either dependent or independent of hormone levels. So things like uterine fibroids, adenomyosis.

00:30:20

Dr. David Miller ND

Speak English Dr Kara.

00:30:22

Dr. David Miller ND

Yeah.

00:30:23

Dr. David Miller ND

A DINO myosis.

00:30:25

Dr. Kara Dionisio ND

How about just like so like growths in the uterus.

00:30:29

Dr. David Miller ND

Mm hmm.

00:30:29

Dr. Kara Dionisio ND

Which often have hormonal and underpinnings.

00:30:33

Dr. David Miller ND

Mm hmm.

00:30:34

Dr. Kara Dionisio ND

But at that point you know for the purpose of this podcast we could do other podcasts on those things.

00:30:41

Dr. David Miller ND

We could I think you were gonna say like the purpose of this podcast is not really to talk about severe pathological considerations. Maybe you know we're not going to talk about it but what would be the things that would make you go -- a little more red/orange flag versus this. Or is it sort of as simple as like how we often follow. Yeah there is like red flags but you really just do the basics first and see the dust settle a little bit like, what would be something someone ... cos people normalize their symptoms a lot right.

00:31:13

Dr. Kara Dionisio ND

Yeah.

00:31:13

Dr. David Miller ND

They're like ... That's just ... you know like when I'll talk about guts and they're like "I'm regular. I go every week" and it's like....

00:31:21

Dr. Kara Dionisio ND

It is regular.

00:31:21

Dr. David Miller ND

I guess.

00:31:22

Dr. Kara Dionisio ND

Weekly is regular.

00:31:24

Dr. David Miller ND

That ain't right though. You know that's not optimal so you know people may normalize their symptoms. What for those people that may think that their condition is not "medically necessary". What would you -- what would you say are some of the things that make you think OK. Really get checked out sort of urgently, like red orange flags.

00:31:44

Dr. Kara Dionisio ND

I would say those things are going to be part of the initial workup when heavy menstrual bleeding is quite extreme. Or if they're also experiencing pain or if they're also experiencing a lot of you know spotting or irregularity in the cycle. Now those might not be a fibroid -- like that might be fully hormonal issues but it's worth at that point checking out with a transvaginal ultrasound just to see what's going on. And it actually probably doesn't change treatment options by too much but it's important to know you know what's going on in there. The one absolute red flag is when I have -- when there's a woman who is after menopause -- so she's not had a period for a year and all of a sudden starts bleeding that warrants investigation just to see what's going on with the lining of the uterus. That's an absolute red flag. Yeah. The other absolute red flag here is I guess it's more not in assessment but in management. So if we have a woman who -- I actually have women say I didn't know if I should be going to the hospital for this like and I hear that weekly you know that's how heavy their periods are.

00:33:06

Dr. David Miller ND

That's the ones I'm talking about, the ones that sort of normalize a maybe serious condition.

00:33:09

Dr. Kara Dionisio ND

Yeah sure. And and what the kind of guidelines on that is and this is what I follow is if you're soaking a pad every 20 to 30 minutes or actually two pads -- that's a pretty strong indicator. And the other indicator is if you are showing signs of being hypovolemic.

00:33:29

Dr. Kara Dionisio ND

So you've actually lost enough blood to lose blood volume.

00:33:36

Dr. David Miller ND

And what would be symptoms of that maybe like low blood pressure.

00:33:38

Dr. Kara Dionisio ND

So low blood pressure getting dizzy, faint, tachycardia so your heart rate -- your heart is racing -- being clammy or confused. You know those signs of shock that can happen in extreme -- I would say it's not uncommon. And so the E.R. will have measures to help in those situations.

00:34:03

Dr. David Miller ND

And it gets a little reminder I always like to play this in this because there's a lot of this has the context of like how healthy are you day to day in your diet and lifestyle your whole life. Because if if you're doing all the basic things pretty you know astutely or whatever you're eating whole foods diet and you sleep well and then things start to get real sideways that's maybe different than the person who has sort of been like that all the time and eats you know not the most healthy whole foods -- can can you tie that in at all -- does that affect how you perceive someone's problem like their standard of health when they come to see you?

00:34:41

Dr. Kara Dionisio ND

Yes and no. I would say I think of the menstrual sign -- the menstrual cycle -- as -- it's funny I had described it to you as a vital sign and you aptly renamed it a "vitality sign" which I really love. So your menstrual cycle is a really awesome place to pay attention to what's going on in your health. It's literally a mon -- every month, it's a rebirth. So every month you start over and your body can tell you something else in that cycle. So understanding what's going on at each phase and paying attention to it can give us some pretty awesome clues to the overall -- your overall health. So yes you know what you do in your life, your healthy foundations, are certainly going to impact and benefit your menstrual cycle but not always. Right. So I actually suffer sometimes from heavy menstrual cycles. I know when it's -- when I'm pushing and not resting and doing too much and being a wife and a mom and a business owner and a doctor and you know building a house and all that and I'm pushing and pushing and pushing that's when I'm more prone to having heavier periods and it's interesting; the egg that you release for this cycle took about three months to mature. So it's a really good three month window into how well you've been taking care of yourself.

00:36:13

Dr. David Miller ND

Interesting. I didn't know that.

00:36:15

Dr. Kara Dionisio ND

Yeah.

00:36:16

Dr. David Miller ND

Getting Schooled here.

00:36:18

Dr. Kara Dionisio ND

Yeah. Which, you know is, when I say to my patients they're like oh well I've been writing this exam or "you know I've never had a heavy period but I've been writing this exam I'm doing this and that". And OK. Yeah me self care has gone out the window. I can see why I have a painful period or a heavy period. At the same time I've always found -- you know where -- maybe why I'm passionate about this topic is you know I do have a history of having miscarriage. I had a D and C and actually since that time I've had -- been more prone to having heavier periods and I've always been like what's going on? I do take care -- you know -- I do eat well, I do exercise. You know I'm busy like every other mom out there, you know is that it? And so it's not always... you know ... foundations health/ nutrition will always impact, but sometimes there's other things going on. And for one woman I think it could be completely mental emotional spiritual issues. For another it could be you know hormonal issues. It could be a genetic hormonal issue. It could be a toxin exposure. It could be -- you know -- your thyroid? Or maybe you are only having a bowel movement every week and you know the guts are where we excrete are our extra estrogen. If not if it's sitting in there it actually you reabsorb estrogen from your poo.

00:37:56

Dr. David Miller ND

Entero-hepatic recirculation.

00:37:58

Dr. Kara Dionisio ND

There you go.

00:38:00

Dr. Kara Dionisio ND

So you know there's a lot of things to think about and that's why I said there's no simple solution. And me with heavy periods is gonna be very different from a teen or someone leading up to menopause or someone with a blood sugar issue or thyroid issue. There's a lot of underlying root causes that need to be looked at.

00:38:20

Dr. David Miller ND

Who else do you get on board with when you're managing a patient who's got ... sort of like a tough case ... like who's number are you dialing when you feel like you've got a tough case?

00:38:33

Dr. Kara Dionisio ND

So I find this is -- these patients are ones that are already in the care of their gynecologist. So it's been enough you know ... and that's what I would say please come in when at the first sign of heavy periods. That's when your body is more resilient and there's more possibilities of finding -- you know -- it's not as acute that maybe we have the time. This work takes time; it takes at least a month, 2, 3 cycles to get going. So it's really the time when you first get the hint of a heavy cycle or things going off that should be addressed; don't just suppress it and say "oh this sucks this is my period". But usually the women that come in to me are unfortunately ones that have really they're like OK this is getting -- I can't do this anymore. They've gone to their gynecologist and that's when maybe they've had solutions presented to them that they're either going ahead with or are not happy with. So maybe we should go over some of the conventional approaches.

00:39:39

Dr. David Miller ND

Yeah go into that -- maybe the short term acute stuff that you see used and maybe there's some research for.

00:39:48

Dr. Kara Dionisio ND

Yeah for sure. And I do think it's -- there are some viable approaches that go from simple to final. And so the the early ones I see ... the first one I see usually more recommended from the family doctor's office, and in fact I use this approach too, is prescribing just an over-the-counter anti inflammatory. So like an Advil -- there's one specific for heavy menstrual periods. It's called mefenamic acid which specifically targets certain parts of inflammation that's implicated in either painful or heavy periods. So giving....

00:40:32

Dr. David Miller ND

How does giving an anti-inflammatory help with heavy periods. Like we discussed it earlier, it was like "What can you spell that out to me?"

00:40:42

Dr. Kara Dionisio ND

Sure yeah. I'm confused. I think I'm getting clear but I've always been confused about this and I've also been confused on my observation that women who have heavy periods -- they don't tend to be painful at all. And women who have very painful periods, sometimes they're heavy but often that's not the symptom that's bringing them in. It's the pain. So I'm not saying absolutely but the pattern I see is you have painful periods or you have heavy periods. And so inflammation is a part of the natural process of actually triggering menstruation or triggering getting your period. But in one of those kind of inflammatory molecules is called PGE2 (prostaglandin E2) and so that one though, what it does is it actually vasodilates. And so when your vasodilating something.

00:41:44

Dr. David Miller ND

Vasodilate means?

00:41:46

Dr. Kara Dionisio ND

The blood vessels kind of not constricted its dilated. I don't know -- help me out.

00:41:51

Dr. David Miller ND

They open up. They open up.

00:41:52

Dr. Kara Dionisio ND

They open up. And so yeah. So by using Advil or an anti inflammatory you're cutting down on those inflammation things that might lead to kind of vasodilation. And I think that's how it works. The research, again, I don't think it's super clear on the mechanisms of all of this. But yeah it's been shown if you take Advil or an ibuprofen or an anti inflammatory during your period, but I actually find, and the studies support this, that if you take it two to three days before the period is expected it can reduce flow by 30 to 50 percent which is quite significant. And so no not ideal to have Advil every month for two to three days but it's not the worst thing either.

00:42:42

Dr. David Miller ND

No for sure and we like to be practical, right? That's our style, is to be practical and most of us have something like that at home, it's fairly accessible and if that's what I have to do in the short term, but at the same time you have to have a long term plan.

00:42:54

Dr. Kara Dionisio ND

It's the short term plan while you have to figure out the long term. Yeah.

00:42:59

Dr. David Miller ND

So it's practical accessible and I'd say it has, you know, for most people a low risk high benefit ratio when used like that.

00:43:08

Dr. Kara Dionisio ND

Yeah 30 to 50 percent is huge. And so I will ... I'll recommend that often the natural partner to that is ginger. There's only one or two studies on it. Ginger reducing heavy periods and in that study they actually combined it with an anti inflammatory like an ibuprofen or something like that.

00:43:34

Dr. David Miller ND

And you take it all the time, the ginger? Or is it something you only take like prior to your period?

00:43:37

Dr. Kara Dionisio ND

Prior to and during the days of heavy flow.

00:43:40

Dr. David Miller ND

We talking about like a gram or two or like a pretty heavy dose?

00:43:43

Dr. Kara Dionisio ND

Yeah we're talking about 250 milligrams three times a day. Yeah. And so, and often we need both. Like I'll do you know Advil and ginger for a couple days before the period and that does really seem to help. Not every woman but some some women that's quite helpful. So that's usually what I see coming from the the doctor's office and then the other options, the next medication approach, is something called Tranexamic Acid. OK.

00:44:16

Dr. David Miller ND

You were struggling with that one before.

00:44:18

Dr. Kara Dionisio ND

I still can't say it. Trans exam ic acid. t r a n e x a m i c. The other name for it is called Cyklokapron. So we're gonna go with that. And so Cyklokapron actually inhibits blood clotting. And so -- sorry it does NOT inhibit blood clotting.

00:44:40

Dr. David Miller ND

I was gonna say that wouldn't help too much, would it?

00:44:41

Dr. Kara Dionisio ND

No. It does not help! It's a plansminogen inhibitor technically but it actually promotes blood clotting and prevents the breakdown of blood clots. So just like a wound you're going to clot up to stop the bleeding. That's how this seems to be helpful. And it is helpful. It does reduce blood flow again by up to 50 percent. It's not the greatest long term solution. Anytime we're promoting clotting it could be dangerous especially perhaps in a woman who is you know leading up to menopause where there might be heart risk or risk of developing blood clots. That's not necessarily a great scenario but if it stops excessive bleeding in the short term it is a very effective medication. And then from there there's also birth control pill which we kind of talked about already that I do see offered often and then we go into more -- sorry before surgical -- the Mirena IUD or a progesterone based IUD is probably the most effective outside of surgical approaches and it can reduce blood flow by up to like 80 or 90 or 95 percent.

00:46:00

Dr. David Miller ND

Sorry I'm coming from ... again the space of not know much ... how do we do an IUD when we have, like, is there any problems like inserting an IUD while all this is going on or?

00:46:12

Dr. Kara Dionisio ND

It seems to be very effective.

00:46:16

Dr. David Miller ND

Just sounds like ... if things are sort of like in trouble in the uterine -- cervical uterine health, inserting an idea at that time is that what they do?

00:46:26

Dr. Kara Dionisio ND

Yep.

00:46:26

Dr. David Miller ND

OK.

00:46:26

Dr. Kara Dionisio ND

It is and it's and now it's interesting because the non-.

00:46:31

Dr. David Miller ND

You understand where I was coming from ...

00:46:32

Dr. Kara Dionisio ND

I do know where you're coming from. And I think there are some serious questions about it. But again if it -- when we have IUD that are not progesterone based they actually are a significant cause of heavy menstrual bleeding. So maybe that leads to inflammation and other issues there but when you use the progesterone based IUD that progesterone is directly local to the uterus and prevents -- it offsets the estrogen, reduces the thickness of the lining of the uterus, and reduces in heavy periods.

00:47:10

Dr. David Miller ND

You said progesterone helps resolution of clots. Is that -- did I hear that right when when we were chatting before like it helps you....

00:47:19

Dr. Kara Dionisio ND

Let me get there and just look when we go to hormones. Ok. And then the final things which are kind of often offered would be an endometrial ablation where they actually kind of take out the lining of the uterus. I'm not sure what they're using to do that. It's a little different than a D and C and then the last resort but it is a resort -- about one in three women is a hysterectomy.

00:47:47

Dr. David Miller ND

And this is all the conventional route. This is -- they did not see doctor Kara. Probably.

00:47:55

Dr. Kara Dionisio ND

Yes.

00:47:56

Dr. David Miller ND

Right.

00:47:56

Dr. Kara Dionisio ND

And unfortunately there's a lot of women who get to the point where I say ... they're at the point where they say Kara I don't know what to do. But I feel like I don't have any other choices. And at that point sometimes that is the best choice right? And that's ok we manage it other ways, you know there's other issues too to talk about, but that's how serious heavy periods can get. And once they get to that point it can be more difficult to manage it.

00:48:26

Dr. David Miller ND

Mm Hmm. So what about some more like naturopathic approaches. I'm gonna say naturopathic because then the transcription is easier. What do you what do you think from the more naturopathic perspective?

00:48:46

Dr. Kara Dionisio ND

So treat the root cause.

00:48:49

Dr. David Miller ND

What a crazy idea?

00:48:50

Dr. Kara Dionisio ND

Isn't that a crazy idea!

00:48:52

Dr. David Miller ND

Do a proper assessment.

00:48:54

Dr. Kara Dionisio ND

Yeah.

00:48:55

Dr. Kara Dionisio ND

So you know I'm going to look at thyroid, blood sugar levels, blood regulation, iron levels, you know all of that stuff to set -- and general lifestyle -- to set the background of healthy hormones. But when it comes to heavy menstrual bleeding and a natural approach, I'm doing everything I can to improve ovulation and to increase progesterone in the second half of the cycle. And we didn't really talk about that but really briefly; in the first half of the cycle estrogen is kind of building house, like it's building a nice nest in the uterus for the eventual or perhaps expected maybe baby. Right. So it's building a nice house. It's kind of like just doing it like you know throwing up a house right? It's like here's like a nice little nest to build.

00:49:49

Dr. David Miller ND

It's framing -- its framing it.

00:49:50

Dr. Kara Dionisio ND

Yeah. Yeah.

00:49:51

Dr. David Miller ND

Put the framing in, the foundation is ready.

00:49:54

Dr. Kara Dionisio ND

For sure.

00:49:54

Dr. David Miller ND

Ok.

00:49:54

Dr. Kara Dionisio ND

If estrogen is going crazy it's going to build a giant house like she's a bit of a queen. She might want a big house so a big lining in the uterus. And then you have ovulation hopefully which is going to produce progesterone and the product progesterone actually reorganizes matures. Makes that house pretty and organized maybe a bit thinner and also produces a lot of clotting factors and so by the end of the cycle when you start to get your period those clotting factors produced by progesterone help what you want in menstruation is a slow organized bleed. We don't want like crazy wildfire. We just want something that's organized and slow and contained and managed and so that's why the progesterone is key there. So I'm first of all asking is ovulation happening? And supporting progesterone whether that's with herbs you know Vitex is a pretty big one there or actually using progesterone as well. And so it's a hard question to answer from my approach because it's gonna be very different for every woman. There are certainly some acute things -- like I've talked about Ginger. There's a really good herb called Capsella that can really slow acute bleeding but really--

00:51:20

Dr. David Miller ND

What's capsella called, common name?

00:51:22

Dr. Kara Dionisio ND

Shepherd's Purse. Yeah. Yeah but my long term game plan is, in a nutshell, healthy ovulation. And trying to make every stage of the cycle healthy which is going to make the period healthy.

00:51:42

Dr. David Miller ND

It really sounds like if there's like a conceptual take home it's that a healthy, not heavy, period is quite dependent on healthy ovulation.

00:51:55

Dr. Kara Dionisio ND

Yes.

00:51:56

Dr. David Miller ND

That's what I'm taking from this very informative talk.

00:52:01

Dr. Kara Dionisio ND

Good.

00:52:02

Dr. David Miller ND

Yeah. You know you learned me well. Yeah I feel like -- I feel like that's been super helpful for my understanding of heavy bleeding and just the period in general. That has helped me immensely. I feel like I've learned from these episodes as much as everyone does I hope.

00:52:21

Dr. Kara Dionisio ND

That's awesome. Yeah. And you can see that you know in conditions or stages of life where ovulation is less reliable -- young teens leading up to menopause or in a condition called PCOS where ovulation isn't happening. Those times when you are more prone to getting a heavier period.

00:52:44

Dr. David Miller ND

Yeah less steady in a way with the ovulation.

00:52:48

Dr. Kara Dionisio ND

I think ovulation is a woman's right. It's a beautiful awesome thing.

00:52:56

Dr. David Miller ND

Yeah. We didn't talk too much about that but that's when you really -- you really shine.

00:53:01

Dr. Kara Dionisio ND

Yeah. It's time to be like your best, awesome self.

00:53:04

Dr. David Miller ND

You relying a lot on ovulation right now.

00:53:07

Dr. Kara Dionisio ND

I am.

00:53:08

Dr. David Miller ND

Yeah.

00:53:08

Dr. Kara Dionisio ND

I had said when you ovulate your face is actually more symmetrical. And I said to Dave I said that nature is making my face more pretty right now. And ...

00:53:19

Dr. David Miller ND

Which you can't see on a podcast but ...

00:53:23

Dr. Kara Dionisio ND

yeah. It's also improving my linguistic communication and language centers of my brain so hopefully that has come across today.

00:53:33

Dr. David Miller ND

Well you said you shouldn't be as on as you are today because it was something worth celebrating last night.

00:53:37

Dr. Kara Dionisio ND

Yes.

00:53:38

Dr. David Miller ND

And I said I can't even tell because you know -- so you're riding on you try riding on that progesterone pretty good. Or that balance maybe more precisely but --

00:53:50

Dr. Kara Dionisio ND

Right now it's probably more estrogen and testosterone.

00:53:52

Dr. David Miller ND

Yeah. Yeah but then it's going to make its progesterone. Yeah. But it sort of depends on today. I'm getting -- so much depends on today. Ovulation.

00:54:02

Dr. Kara Dionisio ND

And there's lots of things we can do to promote ovulation and a lot of studies come out of IVF where there's a lot of stakes. You know it's very important for women struggling -- they want to make a baby and it's also expensive. So there's actually a lot of research into developing really good eggs. So that's maybe time for another day.

00:54:24

Dr. David Miller ND

Yeah we can talk about that so should we wrap it up? Is there anything else you want to teach me and the people.

00:54:32

Dr. Kara Dionisio ND

I think we did well.

00:54:32

Dr. David Miller ND

Yeah I think the ovulation is really really key. That's that's my take home and healthy ovulation means healthy periods. And of course of course there's details to that.

00:54:46

Dr. Kara Dionisio ND

Yeah. I think my take home -- I've just been getting so sad lately of the stories I hear of women who just hate their cycle and it really you know it sounds a bit utopic but it is a magical awesome thing and it can be such a great teacher. And so, if you're listening and you are in that space, then start learning to work with someone who understands your cycle and can help you. It's an important thing -- it's 400 times in your lifetime you will do this cycle so you might as well get it. You might as well understand what it means to you.

00:55:26

Dr. David Miller ND

Yeah not hating it seems like -- we'll wrap it up with the sort of tying into the beginning when we talked about that -- it just seems like from some perspectives, a rather inconvenient thing to have to go through, but from other perspectives -- like wow, what a thing! Like the most important thing in a way.

00:55:44

Dr. Kara Dionisio ND

Yeah.

00:55:45

Dr. David Miller ND

And you know there must be some signals from your mind and your thoughts to your cells when you say that you hate your period; you hate your femininity. It's like the most feminine way -- thing in a way. Right. So. Yeah a little deep stuff to end.

00:56:01

Dr. Kara Dionisio ND

Couldn't have said it better. There's a great book -- if people want to learn about that aspect of it more -- there's a really great book called Wild Power.

00:56:07

Dr. David Miller ND

Who's that by?

00:56:08

Dr. Kara Dionisio ND

Elizabeth somebody.

00:56:12

Dr. David Miller ND

OK.

00:56:13

Dr. Kara Dionisio ND

Yeah just google Wild Power menstrual cycles -- you'll you'll bring it up or we'll put a link to the show notes.

00:56:18

Dr. David Miller ND

Cool. OK.

00:56:19

Dr. Kara Dionisio ND

Alright Dr. Dave.

00:56:20

Dr. David Miller ND

Thank you so much for teaching me ...

00:56:21

Dr. Kara Dionisio ND

Thanks for having me on That Naturopathic Podcast today. It was a pleasure.

00:56:24

Dr. David Miller ND

Yeah it was fun. OK. Take care everyone. Thanks so much for listening.

00:56:28

INTRO/OUTRO

That Naturopathic Podcast. TNP. Hello there.

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