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The Menstrual Cycle: Perfectly Imperfect


The human body is capable of incredible things. It is the most complex machine in existence, and if history if any guide, we are just starting to understand its secrets. That being said, it is not, however, a perfect thing. I actually find comfort in this, the idea that our bodies are fallible. It is a reminder that our job is not to be god-like, but to find our places in the little corner of the universe we inhabit. Anyway, that is a different conversation for a different time. The point I am trying to make now is that our bodies are irregular. And that’s the norm. Leave it alone. However, every once and a while, one of these irregularities causes headaches (real or figurative) in our daily lives that are not often sustainable over long periods of time. At that point, these slight differences in anatomy and/or physiology become a topic of bigger conversation. Today, I want to discuss one such common “flaw” in our physiology, one that affects a great many of us from time to time: the magic and the misery of menstrual hormones.


Before going any farther, I want to again reiterate the difference between an irregularity and a pathology, because when we talk about the menstrual cycle and the symptoms that come up, we are sometimes dealing with one, sometimes with the other, and sometimes both. No female body (or male body for that matter) is the same as the body next door. No menstrual cycle is going to look exactly the same as the one that came before, even if a woman has a perfectly even 28 days each time. This is partially because environmental factors affect hormones (and a bunch of other things affect hormones too), but it’s also because our bodies are imperfect. And the first and probably most important point I will make during this post is that that’s ok. Not everything needs to be treated or managed, not everything is pathology. More often than not, we just need to leave our bodies alone a little and accept that not everything about our menstrual hormones is going to fit into the textbook or the internet article we just read. However, as I mentioned already, sometimes these irregularities are detrimental to quality of life, which makes them worth understanding and approaching with help and support. And other times, there is indeed a bigger imbalance that needs to be addressed.


So let’s start at the beginning. In order to help ourselves and help others, it’s important to be empowered with a general idea of a few things: what the body is trying to accomplish during the menstrual cycle, which hormones it uses to meet those goals and which other factors determine how it all plays out.


1. What is the body trying to accomplish during the menstrual cycle?


Well, the easy answer to that is pregnancy of course. But we can break it down a little further than that. The menstrual cycle has two general parts, the follicular phase and the luteal phase, with ovulation being the midpoint between the two. During the follicular phase, the body chooses an egg for maturation, with the help of the hormones we will discuss next. That egg, or follicle is groomed, grown and eventually release from the ovary during ovulation, which tends to occur around day 14 of the cycle. But it can also be difficult to predict. After ovulation, the purpose of the cycle becomes readying that egg for fertilization and aiding it on it’s journey down the fallopian tubes. This all may sound simple enough, but the symphony of hormonal interactions that occur at all times during this cycle and change depending on the day, actually make it a bit complicated.


2. Which hormones help the body meet those goals?



It’s hard to find a proper “starting point” when it comes to hormonal feedback loops because they are, in fact, loops. It’s a real chicken or the egg sort of situation. So instead of going through every single cause and effect, we’re going to focus on both parts of the cycle and which hormones are at play at those times, as well as what’s going on during menstruation and ovulation. There are four major hormones on the table: follicle stimulating hormone (FSH), luteinizing hormone (LH), estrogen and progesterone.


During the follicular phase, FSH and LH (although in smaller amounts) stimulate the developing follicles in the ovaries to secrete estrogen. The increased estrogen then sends messages back to the hypothalamus that help keep FSH and LH relatively low, despite the fact that they are still active. As the follicle develops more and more and secretes more and more estrogen, eventually a threshold is reached at which point, instead of estrogen keeping LH levels low, actually spikes them way up, a part of the cycle called the “LH surge”. This is right before ovulation occurs, and estrogen levels are also at their peak here. FSH spikes a little too. The spikes help propel the mature follicle out of the ovary, for its journey down the fallopian tube.


At this point in the cycle, estrogen is the dominant ovarian hormone and FSH is a little more prominent than LH. The follicular phase roughly covers days 1-14 of the menstrual cycle, and day 1 is the first day of menses. Therefore, keep in mind that for the first several days of follicle development, the uterine lining is actively exiting the body from the last cycle. Women with post-menstrual syndrome often find themselves symptomatic during this time.


After ovulation, estrogen gets cut off pretty quick. The sudden drop in estrogen after ovulation is another thing to keep in mind when it comes to cyclical symptoms, especially certain types of migraines.


All of this is followed by the luteal phase. The follicle, now called the corpus luteum, starts secreting progesterone. Increasing progesterone levels then send messages back to the hypothalamus to start turning down LH and FSH, the same way rising estrogen levels did in the follicular phase. If pregnancy occurs, progesterone levels continue to rise. If not, the CL exits the body with the uterine lining and progesterone levels drop off, along with estrogen. At this point, menstruation occurs and the whole cycle starts again as low levels of both estrogen and progesterone re-stimulate the secretion of FSH and LH.


3. What determines how all of this plays out?


Well that’s where things get tricky, because the number of possible answers to that question is virtually limitless. For example, changes to how well hormones are broken down makes a difference in how long they exert their effects. Furthermore, if there is a hormonal imbalance elsewhere in the body, ovarian and pituitary hormones can be affected. This is not even to mention the effects of environmental factors like chronic stress. The list goes on and on. While learning the intricacies and details of all these possible pathways to a problematic cycle is certainly worthwhile, we cannot cover them all here and will instead have to wait for a proper class (stay tuned, Syracuse!). Today, we are going to cover a few common issues that come up in the menstrual cycle that might affect how satisfied we are with the whole experience.



INSULIN RESISTANCE


Insulin resistance occurs when the cells in our body have literally just had it with us and our crappy life choices, so instead of allowing insulin to help bring glucose inside, it locks the door to both the insulin and the sugar. This insulin resistance leads to a pile up of sugar in the blood instead, since it can’t get in the cell. The pancreas then reacts to the problem by producing more and more insulin to try to pry the door open, which works for a while, but not in the long term. Not only is this the starting point for Type 2 Diabetes, but it has implications for reproductive hormones also. High levels of insulin actually encourage the overproduction of testosterone, one of the defining features of PCOS, as well as the overproduction of estrogen, which can cause all sorts of symptoms if it is out of balance with progesterone during the luteal phase.


What sorts of symptoms might insulin resistance produce during the menstrual cycle?


Overproduction of testosterone can endanger the ovary’s ability to ovulate, and without ovulation, the ratio of estrogen to progesterone wavers in favor of estrogen. The premenstrual period can become quite uncomfortable in this scenario, since changes to that delicate balance have been linked to premenstrual anxiety and depression, weight gain, breast tenderness, mood swings and a plethora of other things. Because it affects testosterone levels too, it may be harder to become pregnant and/or stay pregnant as well – insulin resistance, then, can cause issues with fertility. High testosterone levels in women can also lead to facial hair growth and other symptoms of PCOS.


Furthermore, and perhaps more fun than anything else, it can be harder to lose weight when both your insulin is high and your estrogen is high, especially if you are already overweight.


How can we treat insulin resistance? The goal is to get the cells in your body to want sugar again and/or convince them to burn fat instead. The following, then, are important:


1. Keep your diet low in carbs, give intermittent fasting a try.


2. Get exercise, especially exercise that utilizes big muscle groups.


3. Lose weight – numbers 1 and 2 can help a lot of with this, but hormonal imbalance may need to be dealt with concurrently.


4. Herbs that can help include Holy Basil, rosemary, bilberry, schizandra, sumac and goldenseal.



CHRONIC STRESS


So little did you know (or maybe you did), your body can actually steal your progesterone to make cortisol if it finds itself in need of more stress hormones. This is a really simplified way to look at it but the outcome holds up. So you being totally strung out on stress day in and day out is not only creeping up your cortisol, but its depleting your progesterone stores and shifting the estrogen/progesterone balance in favor of estrogen again. Super fun.


So what might this look like in your cycle?


Well, a lot of the same stuff we already discussed because here again we are talking about a shift in the ratio of progesterone to estrogen during the luteal phase. But on top of that, you’ve got chronically stimulated cortisol which hey, won’t help you lose weight either. It also won’t let your body easily flip to “Rest and digest” mode, which is where we need to live most of the time if are to do things like detox our hormones properly (more on that in the next section).


The answer to this question is of course to treat stress. Do it through counseling, do it through support groups. Get yourself out of unsustainable living situations. Treat pain. Address trauma, or don’t if you’re not ready. Quit smoking, or don’t, if that’s the thing keeping you from sinking right now. Plants can help, and here’s a few:


1. Nervine herbs like skullcap, blue vervain, hops, milky oats


2. Gentle adaptogens like nettle, tulsi and Ashwaganda


3. Hypnotics to help with sleep like valerian, passionflower and California poppy


What about herbs for low progesterone though?


Yes. We can also use those, carefully and safely, knowing that if we don’t address stress this won’t really fix the problem. We can also use them for women with insulin resistance and/or PCOS, especially if they are having trouble losing the weight they need to lose to help correct the insulin resistance.


Some herbs to consider are Vitex, black cohosh, angelica, false unicorn root and wild yam.


DECREASED LIVER CLEARANCE



Another big topic, and decreased liver clearance of hormones can happen for a ton of different reasons. We often think of the liver as a “detox” organ for things we ingest, such as alcohol, food, medications, etc., and while this is true, most of what it does is actually to metabolize things already in our body, including hormones. If the liver isn’t working well, or its overwhelmed, estrogen won’t break down properly. It will keep circulating in the blood stream and exerting effects, which can cause increasingly unpleasant menstrual cycles.