Ep. 353 Uterine Bleeding, HRT, Cravings and More with Cynthia Thurlow, NP

Today, I am thrilled to bring you our seventh AMA episode.

I am super excited to connect with all of you today to share valuable insights and answer your questions about dysfunctional uterine bleeding, hormone replacement therapy, perimenopause, and menopause. I will also be addressing queries on blood loss thresholds and dysfunctional uterine bleeding and offering strategies for managing endometriosis and cravings. 

Join me as I answer many questions from listeners, shedding light on all these critical concerns and several more. I love doing the AMA episodes, and I know you love listening to them, so keep your questions coming!

“Progesterone decreases hot flashes and night sweats and improves sleep. There is good evidence that progesterone also increases bone formation.”

– Cynthia Thurlow, NP

IN THIS EPISODE YOU WILL LEARN

• How an estrogen and progesterone imbalance could cause persistent bleeding 
• How much blood loss should there be in a menstrual cycle?
• Why some women crave sweet and salty foods at night during perimenopause and menopause
• Strategies for managing cravings during perimenopause and menopause
• How endometriosis often links to autoimmunity and digestive issues
• Why would someone experience unusual symptoms like itchy ears, crankiness, and bloating in menopause?
• Various hormone replacement therapy options for perimenopause
• Why you should implement lifestyle changes before considering HRT
• The benefits of oral progesterone for sleep and bone health

Connect with Cynthia Thurlow

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• Check out Cynthia’s website
• Submit your questions to support@cynthiathurlow.com

Transcript

Cynthia Thurlow: [00:00:02] Welcome to Everyday Wellness podcast. I’m your host Nurse Practitioner, Cynthia Thurlow. This podcast is designed to educate, empower, and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives.

[00:00:10] Today, is AMA #7. I am super excited to connect with you all answering your questions about dysfunctional uterine bleeding, hormone replacement therapy, perimenopause, menopause, how much blood loss is too much? How do we address some of these dysfunctional uterine bleeding issues, endometriosis, cravings, and more? 

[00:00:55] This is AMA #7. I have been a little bit remiss. I actually love doing these AMA episodes, and I know that you love hearing them. Keep your questions coming. I am endeavoring to do a minimum of at least one to two per month. And most recently, you guys have been really generous with your questions. So, thank you so much. Today, we’re going to talk about periods, dysfunctional uterine bleeding, HRT, perimenopause, and menopause and more. And as I mentioned, I’m trying hard to curate questions. This AMA is really dedicated to a woman in the free Facebook group. It’s called Intermittent Fasting Lifestyle/Cynthia Thurlow. And this is a woman who was asking about why she was having persistent bleeding despite appropriately following up with her GYN. She is on HRT. She’s also on anticoagulant because she has an arrhythmia called atrial fibrillation. And she was trying to figure out and determine why she was still having bleeding and had a very extensive workup. So, she had done all the right things. 

[00:02:03] And ultimately, I said, “It’s very likely. It sounds like you probably have an imbalance of estrogen to progesterone.” That’s probably what’s driving some of this, given everything else that you’ve shared, because the bleeding started prior to utilizing the blood thinner. Having said that, if you’re not already part of Intermittent Fasting Lifestyle/Cynthia Thurllow is a free Facebook group. I do personally answer questions several days a week. I do not give medical advice, but there are some really thoughtfully worded questions, so keep the questions coming. You can also send questions to my admin team at support@cynthiathurlow.com. 

[00:02:40] Let’s dive right in. So, dysfunctional uterine bleeding. What is it? How do we define it? I went down a total rabbit hole today so that I could give you some sense of what is normal and what is not normal. And for any woman that’s navigated perimenopause, you have probably experienced some significant dysfunctional uterine bleeding. So normally we should have about a third of a cup of blood loss per menstrual cycle. And that’s about 80 mL. For those of you that are healthcare providers used to the metric system, 80 mL per cycle or a third of a cup. And to give you some idea, one tampon or pad holds about 5 mL or one teaspoon of blood, and a super tampon holds 10 mL or a bit more in terms of two teaspoons. So, over the course of a menstrual cycle, 80 mL is equated to 16 fully soaked tampons or eight fully soaked super tampons.

[00:03:38] And when we get to the stage of what is considered to be flooding, and I jokingly call it the crime scene periods, I experienced this in the probably earlier-ish stages of perimenopause, you can have as much as 500 mL or two cups of blood loss. Now, I know that a third of a cup doesn’t sound like a lot, but the difference between a third of a cup versus two cups, those of you in the states are 80 mL versus 500 mL is quite significant. The concern is always when you’re having really heavy menstrual cycles, is that not only do you have a lot of blood loss, but you can also have lowered iron levels. And so typically, I will say, especially for women in perimenopause the heavier cycles are an indication of an imbalance. And I think for most of us, it’s really an imbalance of progesterone. And so, you have these anovulatory, these cycles where you are not ovulating. You may not even know that, but you just know that your cycles are heavier. But those heavier periods can also be indicative of other things like polyps, fibroids, or even adenomyosis. And obviously those are structural things that are going on in the uterus that have to be evaluated. But just to kind of give everyone some context. 

[00:04:50] So, first question is from Cassie, “How much is too much blood loss and how can I get this to end?” So, Cassie is in perimenopause and I kind of give everyone some sense of what is normal versus what is abnormal. Cassie has not identified how heavy those cycles are, but I would imagine she’s probably closer to that flooding, two cups loss during each menstrual cycle. And my first thing is always the same, go see your GYN, your primary care provider, whoever provides you, Well Women’s care, so that you can create a strategy, they’ll probably do some lab work. I think it’s important to also check thyroid. We know that thyroid in and of itself, if we have an underactive thyroid or hypothyroidism, it can impair ovulation and can impair the secretion of progesterone. We also know that it lowers sex hormone binding globulin, which can in and of itself increase circulating estradiol levels or the predominant form of estrogen. 

[00:05:46] So depending on your conversation, your evaluation by your healthcare provider, they may add progesterone. And for some women, this may initially just be utilized during your luteal phase, which is when progesterone predominates versus throughout cycle. Sometimes healthcare providers will suggest that you take some anti-inflammatory agents like Aleve or Motrin that are not utilized to be taken forever, but just taken to help reduce the blood loss. And then also something that’s interesting when you think about nutritional therapy that can be helpful. For a lot of people, they are sensitive to A1 casein, which is a protein found in conventional dairy. And sometimes a dairy-free diet can be very helpful because that particular A1 casein protein can stimulate the release of mast cells and mast cells are an inflammatory response in the body and a lot of women in perimenopause and menopause start having issues with this.

So, just something to consider on a more conventional note, things like the Mirena IUD, which is a progestin, so synthetic progesterone can reduce the amount of bleeding up to 90%. So if you’re on a Mirena IUD, no judgment. I mean, it is a very effective way of addressing the bleeding, but a lot of healthcare providers may then talk about if it continues and persists, things like ablations and even a hysterectomy. So, Cassie, lots to consider. Getting labs and having an evaluation by your healthcare team and professional, I think is a first step. 

[00:07:16] Next question is from Andrea. She said, “I’ve been diagnosed with endometriosis. Help.” Okay, so we probably haven’t talked about endometriosis on the podcast much at all. It is an inflammatory immune-mediated condition where endometrial tissue actually grows outside the uterus and it’s driven by estrogen. And it’s typically diagnosed with laparoscopic surgery. And according to one of my favorite GYNs, Dr. Lara Briden and Dr. Jeff Braverman, who’s a US reproductive immunologist, most women with endometriosis have a genotype linked to autoimmunity. That doesn’t mean that they themselves, because they have endometriosis, that they have an autoimmune condition. But there’re some similarities and we’ll commonly see endometriosis with women that also have irritable bowel syndrome. And this can be related to visceral hypersensitivity. So, if you’re someone that has a lot of, like, diarrhea or a lot of constipation, and you’ve kind of narrowed it down to specific foods, you may also have this concurrent diagnosis. It can also be linked with lipopolysaccharides, which are an endotoxin and also leaky gut. 

[00:08:25] So definitely something worth addressing. If you suspect this is an issue for you. And it can also be very painful, significantly painful. And I’ve had many girlfriends that have had endometriosis, and it can impact fertility, it can be quite significant. Again, if you want to think about more lifestyle-mediated things in conjunction with working with your GYN or your primary care provider. Gluten free, dairy free diets have been shown to be helpful watching histamine rich foods. So, a lot of healthy foods are high in histamine. So, I always think about kombucha. I think about some of these charcuterie meats, some of the fermented foods which are healthy for you, but if you are already susceptible, that can exacerbate it. And then we want to think about promoting healthy estrogen metabolism. So, making sure you’re getting lots of cruciferous vegetables, make sure you’re pooping every day. I mean, things that are pretty basic. And then ultimately considering potentially pelvic floor therapy dependent on how extensive the endometriosis is. And obviously, again, this is not my area of expertise. I did a little bit of due diligence to make sure that I could speak to this from a place of helpfulness. 

[00:09:34] Next question is from Maria, “Why am I craving sweet and salty foods at night? I try to maintain a healthy protein-centric diet during the day, but it all ends at nighttime.” Maria, I wish I could tell you that this isn’t the norm for a lot of people. I think that we really have to speak first to what is going on physiologically in our bodies as we’re navigating perimenopause into menopause. And there’s this concept of a protein leverage hypothesis. And what this means is if we are not eating sufficient amounts of protein, and I’ll identify that in a second, in the setting of high follicular stimulating hormone and low estradiol. So high FSH is what we typically will start seeing as we’re navigating the tail end of perimenopause into menopause, because our brains are screaming to our ovaries to release an egg, and our ovaries are saying, “We’re done, we’re ready to pack up, we’re going on vacation permanently, and then we have less circulating estrogen.” So in that setting, this protein leverage hypothesis becomes important. We need more protein as we’re aging and not less. So that’s number one. Number two is we need enough protein with our meals, no less than 30 to 40 g per meal, because we need that amount of protein to leverage muscle protein synthesis. This leucine threshold, this is information that Dr. Gabrielle Lyon, who’s a dear friend, talks about pretty extensively. And we’ll make sure that we link up that podcast with this AMA.

[00:11:00] So, understanding that if you are in a position where you’re not eating enough protein, and then you get home at night and your body is looking to leverage and ensuring that you have consumed enough food during the day, it will drive those cravings. So, no less than 30 to 40 g of protein with each meal, I would make sure you’re not over fasting. I think a lot of women that listen to this podcast or fasting aficionados and people that embrace fasting, even if it’s an intermittent fast or they’re doing it consistently, day to day, helping them understand that if you’re over fasting and your body just is undernourished, that can also drive cravings. 

[00:11:38] So, really looking honestly at your habits, if it’s easier to track macros to get a sense for whether or not you are consuming enough food, I think that’s reasonable, even if you do it just for a week. Sometimes my husband and I will track our macros for a week just to make sure we’re on track. And so, apps like Cronometer, which I have zero affiliation with, I just think it’s a very easy, gives you macros and micros and micronutrients can also be important. And I think when you’re tracking, it can allow you to see are you deficient in potassium? Are you deficient in trace minerals? And that in and of itself is driving some of these cravings. So, I think it can be many things. I would also say it’s important to manage your stress. I know when I’m stressed, I don’t crave healthy food. If I’m not sleeping well, I don’t crave healthy food. I think that’s very, very important. And then if you’re still getting a menstrual cycle, if you’re still in perimenopause, like understanding where you are in your cycle can sometimes explain some of those cravings that you’re experiencing. 

[00:12:40] And so, I think it really goes back to lifestyle, being honest with yourself. I find most women, if they have 30, 40, 50, 60 g of protein in that first meal, and if you’re listening to this and saying, “I can’t make it to 40, that’s okay, it may take time. My first meal typically is 50 to 60 g of protein. And that sets me up for the whole day.” But we know we are more insulin sensitive earlier in the day. We know that first meal is so important for setting up blood sugar regulation and starving off things like hyperphagia, which is that craving sensation many of us get if we don’t eat the right food. So, sitting down and having a bowl of cornflakes versus sitting down and having leftovers from dinner, or having eggs and bacon and avocado, you’re going to get a very different blood sugar response. You’re very likely going to stay satiated much longer than that carbohydrate heavy meal. And I get a lot of questions about oatmeal. And I would say I’m not picking on oatmeal. I’m just going to pick on the super processed stuff that I know, a Pop-Tart, thinking about just having toast in the morning. I mean, those things are not going to set you up for good blood sugar regulation. 

[00:13:52] And the other thing to consider is, when we’re thinking about macros, protein is very important, I would argue is the most important macro. But secondarily to that, I think it’s important to be cognizant of portions of carbohydrates. I’m not anti carb, but I do think that our portions of carbohydrates can be problematic. And by that, I mean you go on vacation, you have all the things, you have the pancakes one morning, you’ve got toast the next morning. You’re wondering why you’re craving everything and anything that is very different than having a little bit of sweet potato or like a root vegetable with your breakfast, or having low-glycemic berries or some citrus fruits, which they’ve got a bit more fiber, they’re going to have less of a net impact on your blood sugar and they’re probably going to help with some degree of satiety. So just something to consider, Maria. Certainly, keep me posted on how that works for you.

[00:14:46] Next question is from Suzanne, “I have so many weird symptoms in menopause, my ears itch. I’m super cranky and I’m always bloated. I’m not yet on hormone replacement therapy, but I’m guessing these are just less common symptoms.” It’s funny, I do think both Dr. Felice Gersh and Dr. Mary Claire have talked about the loss of estrogen and how it can impact itchiness all over the body. But ear canals being one of them, I myself have experienced that. Thankfully, it appears to have kind of like leveled off now that I’m on HRT. But yes, low estrogen can drive those symptoms. Just being cranky, I mean, that could be a lot of things like what’s your sleep like, what are your macros like? Are you managing your stress? I think all those things can be contributory. And then bloating, I find bloating in many ways can be digestive mediated obviously, but might you need digestive enzymes? Maybe you need to have some stool testing. Maybe you need to eat within a compressed feeding window. Because I find for a lot of people, they’re so used to eating all day long, just kind of like snacking and eating all day long, they’re never really giving their body an opportunity to digest, break down their food properly. 

[00:15:58] And so there’s many things to consider, but I would say at a minimum, the itchy ears definitely can be related to low estrogen. In fact, I can’t remember which GYN said this, but I think she actually told some of her patients, sometimes a little bit of compounded estrogen or even estrogen that you can utilize in other parts of your body. Even a little bit of that sometimes can help reduce itching. So something to consider, the crankiness. I’ve already mentioned what I think that’s probably related to. But bloating, as long as it’s not like significant bloating, if it’s just after a meal, if it’s persistent and bothersome, get it checked out. It probably is something that’s fairly benign. But I think bloating is one of those ambiguous symptoms that necessitates getting it evaluated if it’s persistent. So, I hope that that helps. 

[00:16:48] Next question is from anonymous, “I’ve heard you talk about oral forms of bioidentical hormones like progesterone and estradiol, but what about other routes? As I’m in perimenopause, should I use oral or another form?” Well, anonymous, I think so much of it’s dependent on where are you in your perimenopause journey? What are your symptoms? How is your sleep? How are you managing your stress? I think in many situations, I think oral progesterone, even if it’s used just during your luteal phase of your menstrual cycle, can be a really very effective way of helping support sleep, anxiety, depression, etc. Now, obviously, there are women that benefit from starting even estradiol therapy or an estrogen patch during perimenopause. And I’ve heard Dr. Peter Attia mention more than once that he actually likes to start women on HRT in perimenopause and not wait till they’re in menopause, which I think is completely reasonable. So, I think it’s dependent on your hormones, your symptoms. I do not like oral estrogen. I do not recommend anyone take oral estrogen. It gets a very large first pass effect. It magnifies all the side effects. I think that starting with oral compounded or generic progesterone, obviously, the generic progesterone is the least expensive option, super inexpensive, like $6 to $9. I recall when I was filling my very inexpensive. If that doesn’t work effectively, you can move on to a compounded option, which usually has sustained and immediate release and some people need that. 

[00:18:22] And then thinking about estrogen, I think about estrogen patches, very inexpensive. It’s usually E2 or estradiol, which is the predominant form of estrogen. And then sometimes providers like to use a combination of estradiol and estriol, which is E3, that can be breast protective. Sometimes you’ll hear that described as biased. But I do think that there are very inexpensive options that are available that you can fill at your local pharmacy without a compounding pharmacy, and if they work well for you, awesome. Like, awesome. Now, testosterone, it’s important to talk about testosterone. Testosterone there’s no FDA approved form of testosterone for women, which is criminal. So, some providers will give women a tenth of the dose of a male dose. So, a men have these AndroGel packets and they’re not very big. I think trying to give someone a tenth of a dose is really hard. You probably get too much one day and not enough another. So more often than not, what you see is compounded testosterone for women either in perimenopause or menopause. Now, not every woman navigating that transitional period needs testosterone. About 25% of women still make enough testosterone on their own. And I actually listened to a lecture by Dr. Pam Smith and she was saying, “I’m one of those people. I actually have very healthy, robust testosterone levels.”

[00:19:43] I am not one of those people. So, I actually really benefit from testosterone compounded testosterone, because for me, it’s a big differentiator for– I know everyone always focuses on libido, but I think about motivation, a desire to go to the gym, muscle building, which for me is the predominant reason why I take it, because I think it makes a big difference for me. I will never be super ripped. I’m never going to be one of those women, like those kind of mesomorph bodies where they’re super ripped. That’s just not my body phenotype. I’m just kind of thin and lean. So for me, it’s about allowing me to have the opportunity to build that. So, getting back to anonymous’ question, a lot of it depends on symptoms and testing. I think this is a really good indication for working with someone that is savvy with being able to support women at the stage of life you’re in. Sometimes people will also make recommendations about DHEA, sometimes pregnenolone. Pregnenolone is known as this memory hormone. Those things are over the counter, but I don’t generally recommend them unless you are low or deficient. And then obviously, looking at other hormones I think can be helpful. Full thyroid panel, looking at cortisol, looking at all those things can be helpful for providing a total clinical picture. 

[00:20:57] Okay. Next question is from Erica, “A friend of mine just started taking pellets and recommended them to our friend group that others should start them to. We are all in our late 30s, early 40s. I don’t agree with this because I’ve heard mostly negative things about pellets, but wanted to hear your thoughts.” Erica, it has been my experience clinically, I have never received pellet therapy. So, I want to be totally upfront about that. I think there are some very well-meaning people that are using pellets and have had good results. I think they’re pretty conservative. But what I’ve also seen is a lot of anti-aging clinics and pill mills is usually what some of us will call them, where everyone’s getting pellets and people feel really good initially, and then it’s just not consistent. And there are probably listeners to this podcast that have had great experiences, and if you are one of them, that is great. I typically see the people who have had a negative pellet experience, and in talking to colleagues of mine, many of whom have been guests on the podcast, we almost always have conversations around this topic, I think judiciously in the hands of a very competent, capable, conscientious provider. I’m sure there is some efficacy for pellets, but again, I usually see the people who felt great when they first got pellets, and then they feel terrible. 

[00:22:16] I’ve had women come to me in programs that have said, “I know my testosterone is low, I have no energy.” And then we look at testing, and their testosterone is actually in a very healthy range, and that’s not the issue for why they’re tired. So, I think on a lot of different levels, we have to think about, like, “Why in a younger woman?” So, if you’re not menopausal, if your testosterone is low, is it because you’re insulin resistant? Is it because of estrogen mimicking chemicals? Is it because of chronic stress? I think those things are important to look at before consideration of hormonal replacement therapy in an otherwise healthy individual. And then I think it’s. If it’s something you’re not comfortable with, Erica, I think it’s not the right decision for you. And there’s so many other options. I do think that there is a place for HRT used judiciously and appropriately, but I think we have a whole generation of individuals that are just not sleeping, they’re not managing their stress, they don’t eat a healthy diet, they over exercise or don’t exercise at all. They’re over fasting or eating constantly. And so, I think the lifestyle piece has to be kind of dialed in before we start doling out medications. 

[00:23:24] If it’s something that would otherwise be fixed with lifestyle, so hopefully that helps. But I would say trust how you feel intrinsically. If you feel that pellets are not the right answer for you, that is totally okay. And for everyone listening, we do have a free guide that we will make sure we link up that if people want to get access to a list of vetted professionals. When I say vetted, these are people that I know socially. I have not per se gone and seen every one of them as a clinician or as a patient, but individuals, both physicians, nurse practitioners, midwives, PAs that are in the United States that offer hormone replacement therapy. Probably different modalities, but we’ll give you some other options. 

[00:24:06] Okay. Next question is from Heather, “I have had a complete hysterectomy when I was 54 years old, and I’m now 62. So Heather is eight years into menopause. I was placed on Estradiol 18 months ago, which has greatly reduced my hot flashes. Is there any benefit at all to also taking progesterone?” So, Heather has had a total hysterectomy. They took her ovaries and her uterus and her cervix, and she’s asking if there’s benefit from taking progesterone. And my answer is always, “Yes.” I think that there is so much benefit from progesterone. And I recently stumbled upon a researcher for anyone that wants to go down and read more about this. Her name is Dr. Jerilynn Prior. She oversees the center for Menstrual Cycle and Ovulation Research, or called CeMCOR. And she’s on the forefront of progesterone research and talks about that progesterone decreases hot flashes and night sweats and improves sleep. And there’s good evidence that progesterone also increases bone formation. So, it’s not just estrogen that can be helpful, for the sleep. I always say progesterone is great for inducing sleep. Estrogen’s oftentimes great for keeping us asleep. Same thing with bones. It’s not just about estrogen. We also know we have progesterone receptors and testosterone receptors diffusely across the body. We know that progesterone can be taken by itself. And kind of the conventional wisdom for a long time has been, if you are without a uterus, you don’t need progesterone. And I always say the same thing. We have progesterone receptors diffusely across our body. 

[00:25:40] And so, for that reason, and especially for the sleep support, for a lot of people who still feel like, a little anxious, maybe they’re feeling like their sleep isn’t as good. They struggle to fall asleep. There are a lot of women that express these things. I think that can be very beneficial. So we know, based on some of the research that I was looking at, that she has conducted that oral progesterone at a dose of 300 mg, this is a little bit higher than what I typically see. I typically see a range of 100 to 200 mg at night increases deep sleep by 15%. Now, that’s quite significant, because deep sleep is something that starts to become more challenging as we’re getting older, deep sleep is when we consolidate memories. It’s when the glymphatic system, which is this brain detoxification system, that’s when that is activated. And so as we get older, it is very common to see deep sleep erode. So very, very significant. I think the research that she was doing was looking at 300 mg, which, again, is a little bit more than what I typically see. But at that dose, a 15% increase in deep sleep. I think that’s quite significant. 

[00:26:46] And we also know that it helps stimulate and form new bone. So definitely things to be considering. I would encourage you, Heather, to go back to your GYN or your internist, whoever’s prescribing your HRT, and have that conversation. I always say, when you’re wanting to have a conversation with your healthcare provider, just coming from a place of curiosity and just saying, like, “I would like to learn more about this. Would you consider prescribing me progesterone? Because I know there are benefits that extend beyond just the uterus.” I think coming at it is a sense of curiosity. Even for myself, my own primary care provider, I’m super respectful. We don’t always agree 100%. We generally agree most of the time. But sometimes I will ask, like, “Help me understand why we are doing things this way.” And I think if you come about things in a deferential way, you will definitely get a whole lot farther. And really, ultimately, we want to be in partnership with our healthcare team. Well, I loved this AMA. Keep your questions coming. 

[00:27:45] Again, you can send questions to support@cynthiathurlow.com. There’s also a free Facebook group called Intermittent Fasting Lifestyle/Cynthia Thurlow, where you can join. There’s no gimmick, there’s no drama. It’s a really great group of men and women that are actually in there, and I do personally answer the questions. I am very involved in that group because it allows me to get a sense for what people are curious about. Thank you. 

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