Episode #94: PCOS and Menstrual Irregularities

One of the biggest problems with PCOS is our menstrual cycle. Irregular periods, heavy periods, some people talk about painful periods. I want to go through today and just talk about PCOS and your menstrual cycle, the irregularities that we see, what they mean, what to do about them, where to get started, and to help you navigate what’s what’s going on there. So with that, let’s dive into PCOS and your cycle.

You’re listening to the PCOS Repair podcast, where we explore the ins and outs of PCOS and how to repair the imbalances in your hormones naturally with a little medical help sprinkled in. Hi, I’m Ashlene Korcek, and with many years of medical and personal experience with polycystic ovarian syndrome, it is my joy to watch women reverse PCOS as they learn to nourish their bodies in a whole new way. With the power of our beliefs, our mindset, and our environment, and the understanding of our genetics, we can heal at the root cause.

Welcome back to the PCOS Repair podcast, where today we’re going to be talking about all things PCOS and your menstrual cycle. In order to fully understand the abnormalities of a cycle when you have PCOS, we need to start with what is actually going on in a normal cycle. Typically, we think of there being four main aspects or phases, parts of the cycle. We, first of all, start with day one, which is where we have our first bleed. The first day that we notice any bleeding, that’s day one of your cycle, and we would call that the menstrual phase or the period. That typically lasts for anyone somewhere between three and seven days. Should be fairly consistent flow with maybe a peak in the middle, so it starts maybe a little slow, gets a little heavier, and then tapers off. It’s fairly normal. The amount of flow is such a difficult question for people to know, but for the most part, you should be needing to change out a medium to heavy pad or tampon every couple hours at your heaviest flow. There’s been times where I would feel a super plus tampon in 30 minutes, that is extremely heavy flow. That would be what we would consider abnormal heavy but when you have a normal that’s heavy, sometimes it doesn’t feel extra heavy. I would say somewhere in the ballpark of if you’re having to be aware of your pad or tampon and you’re using an appropriately heavy, as in probably heavy, maybe not heavy plus, but just heavy, if you’re having to be aware of needing to change that before 2 hours.

If you feel like you can’t leave the house and go 2 hours without needing to change that, you’re probably having a heavy period. Now, if you have that for half a day on your heaviest day, and it’s borderline what I’m talking about there, that’s probably borderline normal, especially if that’s been normal for you since the very beginning. If you feel like your period has changed in heaviness, that’s something to pay attention to as well. Has it gotten lighter over time, heavier over time, longer in days, things like that are worth noting. They’re not always important as far as being significant, but they are worth at least paying attention to. Okay, so first part, we have the bleeding part. As that is happening, we have a rise in FSH. As our FSH rises, our follicular stimulating hormone, it is basically telling our follicles on our ovaries to start developing. We’ll have several follicles begin to develop, and the one that begins to take the lead will then become the dominant one. The other ones will reabsorb, and that will become the egg that will be ovulated that month. Then we have the follicular phase. We had a period, it leads into the follicular phase.

The follicular phase goes all the way up until we have an LH surge about mid-cycle. That LH surge signals our ovary to release that matured ready follicle as an egg, and that egg then goes and hopefully joins with some sperm and becomes an embryo and will implant in the uterine lining. Then it will, hopefully through enough progesterone, that it will also be contributing to. Our progesterone should be rising at this point. As that progesterone rises, if we did have conception, so we created an embryo, if the embryo implants and there’s enough progesterone, then pregnancy will occur. Pregnancy will be sustained until the embryo creates its own placenta and so forth, and then will become its own entity, and the progesterone levels become a little bit less important. That would be if you got pregnant. Now, if you did not get pregnant, so the LH surges, the egg is released, and you did not get pregnant that month, maybe you weren’t trying to get pregnant that month, you were trying not to get pregnant that month, then what’s going to happen is your progesterone, hopefully is still high enough to maintain a substantial luteal phase, should be about the second half of your cycle.

Ideally, give a 28-day cycle, ovulation should be happening right around 14 days, and then you should have another 14 days from ovulation until that progesterone and estrogen drops signaling the lining of the uterus to shed. That uterus lining is called the endometrium. As the estrogen and the progesterone are rising throughout your cycle, that lining gets nice and thick and cushy and ready for an implanted embryo to keep it nice and secure and housed. So it gets nice and thick. Then when there is no viable embryo, then when the estrogen and progesterone drop, your body will shed that lining and start fresh the next month. That’s a normal cycle.

What is going on in an abnormal cycle? First of all, let’s talk about what are some of the symptoms that we would have of an irregular menstrual cycle, and then we can go through what’s happening with each of those. First of all, what about irregular? Irregular could be anything that’s less than 21 days, more than 35 days, or completely absent, never having started, or you don’t have a period unless you take some medication. Those are all different ways that women will present with irregular periods but essentially, if you’re having cycles that are coming too frequently or are taking too long to come, we consider it too long at about 36 days, but that could even be months in between cycles. What is happening there? Oftentimes here, what’s happening is that we don’t have enough change in our LH surge. We’re not having a follicle develop, we’re not getting a good enough LH surge to ovulate and then we’re not getting the rise in the progesterone and estrogen, so we’re also not getting the drop in progesterone and estrogen that signals our body to shed that uterine lining. If we have something that is keeping our uterine lining really small like an IUD. Even the copper or the Mirena IUD sometimes will keep our lining of our uterus small enough that we won’t have a cycle, specifically when it has the hormone with it. The Mirena or the Skyla or any of the progesterone-based IUDs tend to keep that uterine lining nice and thin, when that happens, we tend to not have the shedding or the period. So birth control can cause that, but also just a lack of ovulation can cause it to go longer because your body is essentially waiting.

We didn’t progress to the next stage. Say we had a period, so maybe you’re having periods every three months. So say we have a period, the FSH hormone may be elevating, but we’re not getting a good dominant follicle, we’re not getting an LH surge, maybe our LH is already elevated because of root cause hormones, our body is not detecting that like, all right, LH went up. Let’s release that egg. What we get is we get these several mature follicles that just keep maturing on the ovary, and we get this polycystic ovarian look on ultrasound, but we’re not seeing ovulation. If we don’t see an ovulation, our body is just waiting. It’s like, Okay, I’m waiting, waiting, still waiting. Then at some point, our uterine lining may get heavy enough that it just sheds on its own, or it may spot a little bit to shed, or you may not have any spotting or period at all for months because if you’re estrogen and progesterone low, you’re not getting that thickened endometrial lining, so it’s just a stalemate.

Other reasons that we can have irregular periods is because maybe we have really high estrogen, and so our endometrial lining is getting very, very thick, but we’re not actually ovulating, but we’re having an overflow bleed but that’s not going to come on a routine through a cycle. It’s going to be like it builds up enough and then it spills over. It’s going to come at a more variable timing. The other thing that can happen is that if we are having really light or really heavy periods, that can be an indication, again, of that endometrial lining being that we’re going too thick or too thin, or that we’re going too long in between. We may have heavier periods if we’re having longer cycles. You can see where all of that would be happening.

When it comes to pain with our menstrual cycles, typically this is not specifically PCOS-related. We hear them in combination so much that we tend to think that they are. There can be some hormonal effects that make us be more crampy, but a lot of times it has to do with some degree of endometriosis going on as well. If you’re having pain with your periods, it may definitely be worth having your doctor explore that a little further to see if something in addition is going on. The cysts of PCOS are really not painful, they don’t rupture the same way as an ovarian cyst can. A true ovarian cyst is a single cyst, and it’s very different than PCOS. That can happen to people who have PCOS, it can happen to people that don’t have PCOS. It’s a separate problem. That’s worth noting as well.

What’s going on in our bodies that is creating these symptoms? First of all, if we are having high LH, this can be a cause of testosterone being high. It can create an up our LH ratio with our FSH. When that ratio isn’t correct, our body doesn’t get that difference between FSH, stimulating a follicle, and then LH, telling it when it’s time to release it and finish maturing one, that conversation isn’t happening correctly because the levels are off. That can occur due to high testosterone. It can occur due to androgens released from the ovaries. What can happen is different things in our body, such as stress, such as food, such as our environment, can stimulate things that tell our ovaries to produce more androgens in the form of testosterone, primarily. This can come from various forms of our body not processing stress well, not processing inflammation well, not providing our body with foods that keep our insulin low. That doesn’t have anything to do with insulin resistance. It just has to do with the presence of a lot of insulin, which has to do with the foods that we’re eating, that stimulates our ovaries to produce androgens, when that happens, it can throw off our LH balance and we can really mess up our ovulation, so when we mess up our ovulation, over time, our progesterone goes lower and lower, stress levels lower, our progesterone, lower and lower, perceived stress on our body because of nutrition issues, because of exercise, sleep deprivation, our busy schedules, all of these things can really have an effect on those hormones and at each point in the cycle, if the next thing doesn’t happen, it’s almost like… I use this analogy, I think, in week’s episode, I mean this in a very different way but if you line up a bunch of dominoes and it’s like the symphony requires one domino to push the other one over so that the next thing can happen and the next thing can happen in a cycle, it’s almost like you put the dominoes too far apart and they couldn’t hit each other, so the next one didn’t go. You have this stall out and we don’t complete the process, and that leads to these symptoms.

How do we navigate fixing that? Well, the problem, I think, in a lot of therapies is that we go about diagnosing, do you have irregular periods? Very rarely does anyone look further into that beyond maybe ordering labs that include that top of pyramid labs that we just talked about, the FSH, the LH, the progesterone and the estrogen, maybe some testosterone and we may look at those to see if they’re out of balance but the problem is that when we see whether or not those are out of balance, the problem goes deeper. If we’re not looking at those deeper root cause hormones or we’re not looking at the symptoms that those deeper root cause hormones would create, such as different cravings, such as different energy levels, such as looking at maybe our levels of stress or what our body may be perceiving as stress because of the way that we’re eating or exercising or sleeping or working or whatever it is that we’re doing. We don’t have a very clear view as to why those hormones are out of balance.

We can see that our cycle is not working correctly, we can see that maybe we have low progesterone or we have a high LH-FSH Ratio. We don’t, in medicine, do a very good job at diving into the why. Then if we didn’t dive into the diagnostic and the root cause medicine of it very well to get a very holistic picture of what’s going wrong here, then when we jump to our treatment methods, we’re going to jump to things like, provera, let’s induce a period, or let’s put you on the pill so you have regular periods, or let’s say we did go far enough to diagnose you with PCOS, let’s give you some metformin to reduce your risk of type 2 diabetes and maybe reduce your insulin response. These are all things that they may give you, but at the same time, it’s not that they’re wrong or that they’re not helpful, but they’re addressing the top of a pyramid problem without going deeper into what’s going on on a holistic level in our bodies, in our environment, with our cycles, with our metabolic hormones, our endocrine hormones that are deeper, that are all affecting what’s going on in these top of pyramid, symptom-inducing suppressing hormones.

I want to also, as we talk about treatment, include in this conversation that there are some things we want to keep in mind. One of the reasons why your doctor may recommend including something like Provera in your health regimen, is that if you go long, long, long periods of time without shedding your endometrial lining, so without having a bleed and without changing out the lining of the uterus, that endometrial lining, those cells can get old, they don’t refresh themselves, they’re not rejuvenating themselves, and they become at higher risk of developing cancer. This is not something that is going to happen if you don’t have a period every single month. It is well-researched that you do not need to have a period every month for safety but this is something where it’s like if you’re never having a period and you are going years without having a period, you should probably think about having some provera every couple of months. My approach with this with clients is that while we need to keep that in the back of of our mind, as long as it hasn’t been six years since you’ve had a period, if it is, then maybe we should have some provera and then start the healing process but for the most part, when I’m working with clients, if they’re talking about provera with me, they’ve been on it off and on, and their doctor has them on about, usually every three months. That’s what I typically see in women is that they’re being recommended Provera every three months if they’re not having a period, and they’re not otherwise on birth control.

What I recommend with that is that go to your doctor and you see how long you can go without it with the idea that you are actively adjusting your lifestyle to try and induce a period naturally, and you would like to have as much time as possible between Provera to induce a period as possible. Typically, what I’ve seen back from doctors when clients talk to their doctor about this is that they’re like, Oh, that’s fine. You can go like six months or so, but we just don’t want you to go indefinitely, and so we have you on a regimen, that way, it gives us enough time. Typically, we can start inducing natural periods as long as they have even one natural period every couple of months, which happens relatively quickly in a healing journey to start getting some periods back.

Even if they’re not as regular and ovulatory as we want them to be, they’re at least returning. When that happens, we’re able to start not doing Provera at all because just like you would have had Provera every three months, now at least you’re having a natural period every three months, and we can get rid of that altogether. That’s something, though, that I do want to bring up. There’s a reason your doctor is doing that. I’m not suggesting that you don’t do it, but there are ways of talking to them about it and getting a timeline of what their comfort is with how long you go between it when you’re trying to induce a period naturally, your lifestyle changes. With that, being able to advocate for yourself when it comes to medical treatments for irregular periods and period problems is really important and understanding how your cycle should work and what your options are, are just the start of that. And then knowing how to bring up these conversations and If you need help with that, that’s something when I work with my clients, we talk very much about, I am not a replacement for their physician. I am working with them on lifestyle changes, working with them to help also talk to their doctors and ask questions so that their health is being addressed, along with their natural holistic approach to their PCOS wellness as well.

In conclusion today, I think it’s really important to understand that the point of this episode is that when we have a healthy normal cycle, our hormones are fluctuating throughout. If we have one area that gets a hang up, then all of a sudden we start to see these symptoms come up but those symptoms can be the same, and there can be many different things going on underneath. We can try to just gloss it over with something like birth control. We can try to dig a little deeper and diagnose someone with PCOS but even then, we need to dig deeper into what’s going on in those metabolic hormones, what’s going on in our lifestyle that’s leading us to struggle so much so that we can take a holistic approach, a well-rounded approach to our entire lifestyle, our mindset, our stress management, our nutrition, our sleep, our exercise, and all the things that are going to help us to let our body rebalance those hormones, repair our cycle.

Then as we repair our cycle, ovulation will return as it feels like all of those things are coming into place. Ovulation is the last thing that tends to show back up, that’s something to keep in mind, too. If you’re feeling like, Okay, my period is coming back, but I’m still not getting pregnant, there can be a few more things that need to be tweaked, a little bit deeper healing that needs to happen because ovulation is something that is a lot more finicky and a lot less ready to return than just the bleeding each month.

With that, if you have any questions, you know where to find me. I’m over on Instagram @Nourishedtohealthy. I do have a resource for you about PCOS period repair, and I will include that in today’s show notes, it’s a nice PDF download that walks you through, gives you some visuals about how a normal cycle works and how to go about beginning to repair your PCOS cycle from a more natural standpoint. I will provide the link for that so you can go and grab a copy in the show notes. Until next time, bye for now.