030 The Case of Horrible PMS w/ Dr. Anu Arasu

The Case:

• Amelia is 39 and dealing with heavy periods.
• She was also experiencing extreme PMS including headaches, bloating, and uncomfortable breast tenderness.
• It got so bad, she started to plan meetings, social gatherings and vacations around her cycle.
• The only solutions doctors offered was to take the birth control pill but a previous blood clot made that a risky proposition.

The Investigation

Every menstruating woman experiences her period differently but it was hard to hear about what Amelia was going through. I completely understood her predicament and resistance to start taking the pill again after having suffered a blood clot the last time she was on it. I knew there was still hope and that there had to be something else going on that we could address that would help make her periods more bearable. My first hunch was to look more closely at her hormones.

Joining me to discuss this case is Dr. Anu Arasu. She’s the founder of London Bioidentical Hormones clinic and was one of the first doctors in the UK to train in functional medicine.

What’s Actually Happening with Hormones During the Menstrual Cycle?

Having your period is the result of cyclical release of hormones. In the first day of your period, both estrogen and progesterone will be low. At the end of the period (about 7 days later), the estrogen begins to rise. In an ideal world, we would then get a LH (luteinizing hormone) surge. This triggers ovulation (and the peak of our estrogen cycle). If ovulation does not result in a pregnancy, then the corpus luteum breaks down and produces progesterone. Soon, both estrogen and progesterone levels drop triggering a bleed.

What is a Heavy Period?

It’s tricky to quantify what is a heavy menstrual flow and what is “normal” and a lot of women don’t know where they fall on the spectrum. It is difficult because we often only have ourselves to compare it to. Dr. Arasu says that if your menstrual flow is affecting your quality of life then it might be outside of ‘normal’. For example, if it stops you from doing things, going to work, socializing - or in Amelia’s case be able to go on vacation. Or, if there has been a dramatic change, then it is worth speaking to someone to find out what’s going on and what can be done about it.

Potential Causes of Painful Periods or Heavy Menstrual Flow

There are a variety of things that can affect the menstrual cycle. Heavy periods could be caused by endometriosis or fibroids. Heavy periods can also be the result of not having a regular menstrual cycle (which could be caused by hormone changes or Polycystic ovary syndrome (PCOS). Hormone imbalance can also result in heavier periods. And, some women are just naturally prone to heavy periods.

Testing for Hormone Imbalance

If pathologies like endometriosis, PCOS, and fibroids have been ruled out, a hormone test might provide a clearer picture of what’s going on. Dr. Arasu suggests doing both a urine test and a blood test to get the full picture of what’s going on. The DUTCH test (a type of urine test) is recommended because in addition to showing hormone levels, it also gauges metabolization efficiencies. However, this test will not reveal the follicle stimulating hormone levels which can indicate if someone is premenopausal. She also uses daily saliva tests to track what is going on over a period of time with regards to your progesterone and estrogen levels throughout the month.

Estrogen Dominance

Estrogen dominance happens when estrogen and progesterone are not balanced. This can be determined through the DUTCH test which looks at all of the potent estrogens. Specifically, experts will be looking at estradiol, estriol, and estrone - the total estrogenicity.

Estrogen Clearance

Metabolization of hormones is another important piece of the puzzle. If these dominant estrogens are not being metabolized, this can cause issues with the gut (which lead to other issues). A gut test will confirm this, particularly if there are anomalies with levels of beta-glucuronidase (which converts and clears estrogen).

The Gut Estrogen Connection

Dr. Arasu explains the new research into the gut microbiome that has identified genes involved in the production of estrogen. This emerging research (and one we’ll be watching) that looks at estrobolome (a type of gut microbes) and the role it plays in estrogen clearance. The more we understand about this relationship, the better will be able to control estrogen imbalance (like estrogen dominance) through diet.

Diet to Reduce Heavy Periods

If the heavy periods are being caused by estrogen dominance, then dietary and lifestyle adjustments may help to reduce the severity of these menstrual cycles. Here are a few shifts that will aid in estrogen clearance (and support hormonal balance):

• Eat more dark green leafy vegetables and cruciferous vegetables
• Eat lots of vegetables or follow a vegetarian diet
• Get adequate fiber (constipation may cause the circulation of partially metabolized oestrogen)
• Avoid using plastics or cosmetics that may contain xenoestrogens
• Minimize or cut out alcohol
• Get sufficient exercise
• Reduce Stress

Hormone Support from Bioidentical Hormones

Bioidentical hormone treatment may not be the first place to start in treating estrogen dominance. She starts with the above, as well as looking at the gut and supporting estrogen clearance with supplements like calcium gluconate and DIM. If the suggested lifestyle and diet changes don’t work, Dr. Arasu says bioidentical can do a great job in rebalancing the hormonal system.

The Difference Between Bioidentical Hormones and Synthetic Hormones

Hormone replacement therapy has raised questions of safety, so it’s important to point out the difference between synthetic hormones and bioidentical hormones. Synthetic hormones are not identical to the body's own hormone structure as well they may bind to the wrong hormone receptors. Synthetic hormones may also cause side effects like irritability, acne and insomnia. It’s also important to note that synthetic progesterone (which is often what is prescribed to counter estrogen dominance) has been found to increase the risk of breast cancer. On the other hand, bioidentical hormones are identical in structure to the body’s own and therefore will bind with the correct hormone receptors and act exactly as the natural hormone does. However, bioidentical hormone therapy is not without risk, as we explain in this episode of the podcast.

Mystery Solved

One of the first things we did in attempting to solve Amelia’s health mystery was to do a DUTCH test on the 21st day of her cycle. Her results showed that she had elevated estrone and estradiol while her progesterone was low. Her levels of 4 hydroxy (the bad hydroxy) levels were way off too meaning she wasn’t metabolizing estrogen properly.

The clues were adding up.

We also noted that Amelia had been on the birth control pill for many years when she was younger, and also reported that she is often constipated (two more contributing factor to estrogen dominance).

The final clue was found in the gut. I ran a GI Map stool test where I found some dysbiosis (overgrowth of bacteria and yeast) and as I wa...