00:00:00:04 - 00:00:18:20

Noah Reed

Welcome back to the DUTCH Podcast, where integrative medicine providers can expand their understanding of functional endocrinology and testing, and everyone (no matter who you are) can learn more about their bodies. most complex communication system. I'm Noah Reed, vice president of sales and marketing for the DUTCH Test.

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Noah Reed

Coming up on this week's episode, our very first, “Ask the Expert,” segment brings you Dr. Tara Scott, a nationally recognized authority on hormones and wellness. Dr. Scott will be answering the questions about the reproductive cycle that you've been wondering about for a long time.

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Noah Reed

Join us for an overview of the female reproductive system and the phases of the menstrual cycle. Plus, she'll answer the question: “what is a normal cycle?” Now let's dive in. Dr. Tara Scott first became involved with hormones and integrative medicine while practicing as an OB-GYN and soon became certified by the American Academy of Anti-Aging Medicine.

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Noah Reed

She founded her practice Revitalize with a devotion to evidence-based regenerative medicine and a focus on hormone-related issues. She is also the creator of the online Revitalize Academy, a course to help patients improve their hormone problems themselves.

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Noah Reed

Dr. Scott has been speaking and educating for over ten years and has taught doctors her approach in five continents. She has chosen to speak for TEDx, and she has been featured in the List Authority Magazine, Thrive Global, and on numerous podcasts.

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Noah Reed

And now onto the show.

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Mark Newman

Thanks, Noah. And I am super thrilled to have Dr. Tara Scott joining us today. So, thank you for being with us.

00:01:39:07 - 00:01:40:11

Tara Scott

Thank you for having me.

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Mark Newman

As both a man and a not a doctor and specifically not a female patient doctor. We really wanted to have someone on, too, to really take us through the ins and outs of that premenopausal phase of life so people can really get a good understanding of what happens with those hormones.

00:01:59:08 - 00:02:12:02

Mark Newman

So, I think let's just start at the beginning of that awakening. There happens to be someone in my house who's in that sort of process of that that awakening of the ovaries and that that cycle that we talk about a lot.

00:02:12:02 - 00:02:29:19

Mark Newman

So, can you take us back to like sort of in terms of hormones and physiology like right before that and then just kind of walk us through what those family of hormones and physiologically like what's happening as women enter that phase where they are officially premenopausal and cycling?

00:02:31:06 - 00:02:53:04

Tara Scott

Sure. So, as an infant, you have 1 to 2 million eggs that you're born with. And basically, as you age, a lot of those follicles just kind of die. We call that atresia. So, what happens first is the pituitary gland starts pulsing your gonadotropin releasing hormone and your FSH and LH.

00:02:53:13 - 00:03:13:17

Tara Scott

So, FSH is a hormone that the main jobs to stimulate the ovaries to grow a follicle while LH is the heart the hormone that is going to stimulate ovulation. So, first it's mostly FSH. So, in puberty, the average age in the United States is around 11 or 12.

00:03:14:08 - 00:03:30:15

Tara Scott

The first thing that happens is breast development. So, it's thelarche, andrenarche, growth spurt, then menarche. So, that's how that's the order that it goes in. So, the first thing that happens, FSH goes up, you start having first you out of your hypothalamus that does your pulses.

00:03:31:00 - 00:03:48:05

Tara Scott

FSH goes up and you start producing estrodial. So that happens even before ovulation and that can happen a while. So first you get the breast buds about a year and a half after that, we can expect potentially the period to start.

00:03:48:05 - 00:04:06:19

Tara Scott

It depends. This is just kind of on average. So, then you're going to get adrenarche, which is starting to get pubic hair, starting to get hair under your underarms. So that's the next thing. And that's generally, you know, promoted by the androgens, which are also produced in the ovary as well, and the adrenal gland.

00:04:07:14 - 00:04:28:00

Tara Scott

And then after the growth spurt, then you can expect that the first period happened anywhere around 11 to 12. It actually, I think is getting early in earlier, so much so that the American Academy of Pediatrics is like changing the definition of of early puberty, precocious puberty, which the definitions should stay the same.

00:04:28:09 - 00:04:30:21

Tara Scott

We should just realize that it's happening earlier and earlier.

00:04:31:21 - 00:04:51:12

Mark Newman

Yeah, I my kids have the unfortunate or fortunate experience of living in my house. So, I've been testing two girls and a boy since they were very young. And it's really interesting to see them starting at before adrenarche, having levels that are lower than, a post-menopausal woman.

00:04:51:12 - 00:05:04:09

Mark Newman

I mean, it's basically like zero. Like there's nothing there. There's just no substrate, there's just not a lot going on. And then watching them like being able to I can distinguish the difference. When my girls were nine and 11, I could tell the difference between the nine-year-old and the 11-year-old.

00:05:04:09 - 00:05:21:12

Mark Newman

And even now, as the second one is 11, she's a little bit higher than the other one in terms of of estrogen. And then and watching then that onset of menses happen and like life begins and all of that and I thought I'd be clever and test her the month after that to see if ovulation was happening

00:05:21:12 - 00:05:41:12

Mark Newman

which it seems like it wasn't. So, I'm curious when that first onset of menses happens like estrogen builds that that tissue, which then you lose a month monthly and that sort of thing. But like at the onset of menses, are you assuming and expecting at that point there is regular ovulation going on typically?

00:05:42:14 - 00:05:58:07

Tara Scott

It takes generally about 18 months from the first period to have a regular ovulatory period. So, some people I mean, some people, some girls will just have a monthly cycle, but it's not the most common thing. That's generally what our textbooks say.

00:05:58:11 - 00:06:15:19

Tara Scott

Of course, you and I both know that with plastics, with environment, with, you know, other endocrine disruptors, this is all changed since our textbooks. But that's what we were taught, is that it's about 18 months until you can count on having regular ovulatory cycles.

00:06:16:02 - 00:06:32:04

Mark Newman

Right. It is interesting the impact of like since the time you were smaller than a thimble, you know, you're being bombarded with estrogens that someone in 1847 would have been absent from their like in utero development when sexual differentiation is happening and all of that.

00:06:32:04 - 00:06:48:20

Mark Newman

And, and then seen that play out in terms of, you know, how people's cycles start. So as those start, can you describe for us if we move forward then to where regular cycling is happening in the stereotypically healthy female, like what's happening?

00:06:49:02 - 00:06:59:17

Mark Newman

What are those hormones doing? In which hormones are we concerned about that are dancing around throughout the month? What are those hormones and what are they doing throughout that that month of the menstrual cycle?

00:07:01:03 - 00:07:17:15

Tara Scott

So, we teach that day one is the first day of menstrual full flow. Like if you have a little bit of spotting before, that's generally not included in the period it's day one of full flow. So that can be difficult to discern when you're having anovulatory bleeding, especially around the time of puberty.

00:07:18:02 - 00:07:32:21

Tara Scott

But at that point, that FSH and LH and your pituitary gland is trying to drive for a follicle to develop. About day five of your cycle one follicle steps forward and says, hey, it's my turn, I'm going to be the dominant follicle.

00:07:33:10 - 00:07:50:10

Tara Scott

And you can expect that generally in your cycle that one follicle will produce 95% of your estradiol that cycle. Okay, so as it grows, it starts to produce estradiol, it sends a negative feedback back to the brain saying, hey, we have plenty of estrogen down here.

00:07:50:22 - 00:08:10:15

Tara Scott

And then you also have inhibin too. So, that is preventing humans from having a litter. So, once there's a dominant follicle, the stimulus will decrease then. So, no more follicles generally are recruited. That follicle will continue to grow and produce estradiol. In the middle of the cycle

00:08:10:15 - 00:08:26:13

Tara Scott

you have the LH surge and what that is signaling is the rupture of the follicle or ovulation. So, there's a surge that generally takes about 24 to 48 hours in the middle of the cycle we teach on a 28-day cycle.

00:08:26:13 - 00:08:42:12

Tara Scott

So, you would expect that to be day 14, the shot. I explain it as the shell of the egg, but really the cells I can remember how well it becomes the corpus lutein, but it's like graphene follicle.

00:08:42:12 - 00:08:49:21

Tara Scott

And there's something specifically that's called but of course I got my anatomy invaginates in collapses and becomes the corpus luteum.

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Mark Newman

Gotcha.

00:08:50:09 - 00:09:13:15

Tara Scott

And then the corpus luteum and then starts producing progesterone, which peaks around seven days after ovulation at about 25 milligrams production per day. So, at that point, the egg and sperm had already either met or not met. And if it if there's no conception, then the hormones start to fall, then inhibin will fall as well.

00:09:13:20 - 00:09:30:08

Tara Scott

And FSH will already be looking forward for the starting to get the next follicle to start growing as the estradiol and the progesterone that had been produced from the corpus luteum and then will fall. So, the whole point of this is reproduction.

00:09:30:16 - 00:09:49:14

Tara Scott

So, the progesterone that's produced from the corpus luteum as they're waiting to see if there's any implantation, is getting the lining of the uterus more stable. It's causing regulation, estrogen causes proliferation, and progesterone is causing regulation of that tissue.

00:09:50:16 - 00:10:14:17

Tara Scott

And then it's getting that lining lush and ready in case there is implantation. Conception generally occurs in the tubes and then the embryo will come down to the uterus and implant. And so, then you would have implantation. And if conception has occurred, then progesterone production will continue from that corpus luteum until about week 13, when the placenta

00:10:14:17 - 00:10:20:17

Tara Scott

takes over. If conception doesn't occur, then everything drops and the whole thing starts over again.

00:10:21:08 - 00:10:31:15

Mark Newman

Okay, back to the follicular phase of the cycle. So, let's so follicular, ovulatory, luteal. That's the way we can break down those three parts of the cycle?

00:10:32:04 - 00:10:32:14

Tara Scott

Right.

00:10:33:00 - 00:10:44:21

Mark Newman

So, if we go to the follicular phase normal for a woman, if we're talking about so for us we're trying to look at estrogen and progesterone and then, of course, the DUTCH is comprehensive. We're looking at lots of other things.

00:10:44:21 - 00:11:03:04

Mark Newman

But as it relates to those female reproductive hormones, we typically don't have people collect in the follicular phase where or or get to that when we do want them to collect. But what what is normal in that follicular phase for estrogen and progesterone maybe as it compares to a post-menopausal woman?

00:11:04:13 - 00:11:17:19

Tara Scott

So, normally it's interesting because when we're talking about hormone replacement, there's no agreement as to where what kind of value we shouldn't shoot for. But I was always taught that women feel the best in the follicular phase, not the luteal phase.

00:11:17:19 - 00:11:36:14

Tara Scott

I mean, they feel the best the second week of the cycle. So those are the values that we kind of shoot for. So, again, no one's ever studied that or look at what serum values are. But most of the time I test, though I've tested a lot of people over the last 15, 20 years and I generally

00:11:36:14 - 00:11:56:02

Tara Scott

I haven't done labs at that. At that time, serum labs, because of either fertility cycle, day three were generally thought to be able to assess what's called the ovarian reserve. It's an indirect measurement of how many follicles you have left if you're an advanced maternal age, which would be anything over 35.

00:11:56:16 - 00:12:14:10

Tara Scott

So, we see a variety of estrogen. And and certainly I'm always amazed that some people have their symptoms a lot right in this follicular phase because they're making a lot of estrogen. But you generally don't make much progesterone until maybe starting around ten, 11 a little bit.

00:12:14:15 - 00:12:18:14

Tara Scott

Most of it's coming from the corpus luteum, though, so you're not going to get it until ovulation.

00:12:19:07 - 00:12:32:20

Mark Newman

Right. So that the estrogen levels then should be in the early phase, should be north of what a post-menopausal woman would be, but not not as high as you'd see in luteal and not nearly as high as you'd see around ovulation?

00:12:33:02 - 00:12:54:02

Mark Newman

And then the progesterone levels is your expectation that the progesterone levels prior to ovulation so I'm premenopausal, I haven't ovulated which creates that really robust progesterone surge, Am I expecting similar progesterone levels in the follicular phase as a post-menopausal woman would see or they do they tend to be a little bit higher than what a post-menopausal woman

00:12:54:09 - 00:12:54:23

Mark Newman

would be?

00:12:55:16 - 00:13:09:01

Tara Scott

They're probably similar to post-menopausal ranges or anywhere from 0.1 to 0.3 is pretty low. It's pretty tight and post-menopausal ranges might be a little over one. So, and I don't ask me the units.

00:13:09:05 - 00:13:09:11

Mark Newman

Sure.

00:13:10:10 - 00:13:20:05

Tara Scott

You're the lab guy, not me. So, they're they're pretty similar to post-menopausal, right? Because there's just not a lot of progesterone production by definition.

00:13:20:05 - 00:13:37:22

Mark Newman

Right. So, there's different there's differentiation between estrogen deficient and estrogen normal at that phase, but there really isn't in progesterone, which is why we don't test there. So, if we move forward to unless we're in a cycle mapping situation, which we'll get to a little bit, so if we move forward to ovulation, so in ovulation, I've got

00:13:38:03 - 00:13:54:21

Mark Newman

an estrogen that's high and volatile. Would that be a good description? And then progesterone that's about to surge, right? So so hopefully it's obvious why if we're doing a one-point test, we wouldn't want to do it there because we're shooting at a moving target for estradiol, which doesn't tell us a whole lot.

00:13:55:03 - 00:14:15:08

Mark Newman

And then the progesterone is about ready to, or or maybe has started to surge, which again, you're shooting at two moving targets, not a good idea. So, then we move to the luteal phase and this is where we we tend to see people test that's where instructions point people towards so why why is that the ideal phase

00:14:15:14 - 00:14:22:05

Mark Newman

of a menstrual cycle? If you're going to test on one day why why are we shooting for those days and what days are those typically?

00:14:23:10 - 00:14:41:22

Tara Scott

Well, typically we say between day 19 to 21 and again, that's on a 28-day cycle. So, if you're pretty consistently at 28- to 35-day cycle, we think that you would ovulate around day 21. So we really want it to be seven, around 7 to 8 days after ovulation.

00:14:41:22 - 00:14:57:05

Tara Scott

So, if women know they're always a 35-day cycle, then it would definitely be a 28-day test for them. We're trying to catch that peak of progesterone for a couple of reasons. The symptoms are driven by that imbalance between estrogen and progesterone for the most part.

00:14:57:06 - 00:15:15:08

Tara Scott

Now, some of my patients, like I said, not as commonly will have specific symptoms in the follicular phase. That's when the cycle map is great. If they have a specific set of symptoms. So, most of our patients are symptomatic after ovulation, so mid-luteal, maybe even the last few days before the period starts.

00:15:15:19 - 00:15:16:12

Mark Newman

So, so then we’re.

00:15:16:12 - 00:15:22:08

Tara Scott

Trying to capture that balance between estrogen progesterone and that's why we test after after ovulation.

00:15:22:12 - 00:15:39:20

Mark Newman

Right. So, there's okay, so, we've got a plateau of sorts with both progesterone and estrogen, which makes them relatively stable and a pretty good target for us to shoot at. And if we do that, then what are you looking for in terms of when you're talking about the balance between the two?

00:15:40:00 - 00:15:48:18

Mark Newman

Like, what are you looking for there and what do you tend to see when that gets imbalanced? And in which direction do you typically see that and see it problematic?

00:15:50:00 - 00:16:10:21

Tara Scott

So, with the functional testing, like the DUTCH Test, you guys calculate a ratio for us or you're depicting it with the dials, which makes it I'm a visual person, so I love that part of the test. But when you're looking at serum labs, there is a different normal range for ovulation, follicular, ovulation, and then just luteal in

00:16:10:21 - 00:16:32:10

Tara Scott

general. Right. What I notice since I began doing this, like I said 20 years ago, is that the labs actually change the luteal range. So, the whole definition of ovulation is you're producing progesterone. So, it used to be 4 to 20 in a serum for normal range for progesterone and they've changed it to 1.8 probably because we're

00:16:32:10 - 00:16:51:05

Tara Scott

testing progesterone more and their normal database is seeing lower progesterone. So, their response is to change the normal range, which is the last thing you should do. Really, it's it should stay the same. And so that's one of the reasons why a lot of women, when they're seeing their practitioners, they're not knowing when to check.

00:16:51:16 - 00:17:08:04

Tara Scott

Even if we're talking about serum levels versus they're not knowing how to interpret it, they're being flagged as normal because clearly with the serum level, like we talked about, follicular 0.0 to 0.8 or whatever and then 1.8, there's not much of an increase with ovulation there.

00:17:08:04 - 00:17:20:17

Tara Scott

So, I don't know how that can be normal. So, what we're looking for, if you have those ratios calculated like it is in the DUTCH test, that makes us it makes it a little bit easier on us because we're looking for a match, right?

00:17:20:18 - 00:17:35:02

Tara Scott

So, estrogen causes growth and progesterone causes apoptosis. So, it's like I always explain to my patients that it is like estrogen is what you're charging on your credit card and progesterone is what you're paying off. You don't want there to be a balance, right?

00:17:35:02 - 00:17:40:02

Tara Scott

Because may not be a big deal for a few months, but over time, that's going to be a problem.

00:17:40:02 - 00:17:54:21

Mark Newman

Yeah, that's a good that's a good analogy. I like that. The way we've done our presentation of that on the DUTCH Test is, you know, we have those dials so that the ratio, if you will, is sort of a visual one of saying like, you can just stare at that, a sort of a tug-of-war, sort

00:17:54:21 - 00:18:13:13

Mark Newman

of thought of like wherever you are (low or high) is interesting. But then where you are relatively speaking, which is what like the ratio is, is more about is who's winning that sort of production more that if estrogens when in that production worn is sort of dialed higher than the progesterone, then the types of problems that you're

00:18:13:13 - 00:18:27:23

Mark Newman

talking about, you know, you're going to start to see in your patients. Let me move you back to the follicular phase, because I want to I wanted to go through just quickly the types, especially we think in terms of doing the cycle mapping where you get to see the whole the whole cycle.

00:18:27:23 - 00:18:40:09

Mark Newman

We focus a lot of energy and rightly so, on the luteal phase. But what are the types of dysfunction you see in the follicular phase? And you sort of alluded to those, but what are the what are the hormonal causes of that meaning?

00:18:40:09 - 00:18:49:09

Mark Newman

You're seeing the symptoms you're talking about because estrogen is too high, because can you speak a little bit about the types of issues you'd see in that early part of the cycle in a patient?

00:18:51:04 - 00:19:06:21

Tara Scott

One of the biggest things is migraines. And so migraine as we traditionally see in ovulation with that drop in estradiol. But then the second most common time would be right before the period starts because you've got the drop in estrogen and progesterone right before the period starts.

00:19:07:08 - 00:19:21:04

Tara Scott

But more commonly I see women who are on day three and five are getting migraines. And what that is from is when estrogen ramps up so quickly and your estrogen dominant even in the follicular phase because we don't expect you to have progesterone.

00:19:21:11 - 00:19:38:06

Tara Scott

So, if you're estrogen is way out and I'm sure you've seen these in your cycle map that you're seeing these really high follicular estrogens. Women can be symptomatic then too as well. And where that comes from is, again, I explain it to, you know, that happens in the perimenopause.

00:19:38:06 - 00:19:56:01

Tara Scott

So, I kind of explain to my patients this: picture your eggs as old man at the Y sitting on the bench waiting to swim a lap. Right. And so the lifeguards in this chair, the lifeguards are FSH and the lifeguard is sitting next and then a man is getting up, hopping on the black swimming lap, coming back.

00:19:56:12 - 00:20:15:00

Tara Scott

And then the lifeguard says next and the next guy hops up, swims his weapon, comes back, and the lifeguard says, Next. Nothing happens because they're old and they can't hear. So, what do you think happens next? The boy picks up his megaphone and screams next.

00:20:15:00 - 00:20:27:19

Tara Scott

And then what? What do the men do? They all stand up. Is he talking to me? Is my shirt. So they all stand up. So you've got all these eggs follicles growing from the increase in FSH for the poor-quality responding follicles.

00:20:28:06 - 00:20:40:12

Tara Scott

Then some of them will stand right around the block and be waiting. Sometimes what happens is one jumps in. He gets to the other side of the pool. Before he even comes back. Another one jumps in. That's where we get luteal out-of-phase sequencing that.

00:20:40:12 - 00:20:54:11

Tara Scott

You get these 15, every 15 day cycles because you have ovulation and then a few days later you have another ovulation. So, it always confused me. How could people have cycles every 15 days? And the NAMS is actually mean that as a luteal out of five days cycle.

00:20:54:18 - 00:21:05:00

Tara Scott

Well, that's what's happening. You got a one jumping in and he's not even waiting for the guy to get out. Now what happens? The other ones, they might just sit there and then might say, I don't really feel like swimming anyway, and they might leave.

00:21:05:00 - 00:21:16:02

Tara Scott

So, some of them will have atresia Some of them will make follicular cysts and continuing to produce estradiol but never actually hop on the block and swim. So, you just have chaos, right? That's what perimenopause is.

00:21:16:20 - 00:21:35:20

Tara Scott

But we often see that in that late reproductive stage where over 35, you know, where you're maybe not doing that, but you're getting a lot more FSH, you're getting a lot of estradiol in the follicular phase. I had one patient who was having a lot of nausea, a lot of nausea the second week of her cycle.

00:21:35:20 - 00:21:48:15

Tara Scott

And again, I did a cycle map on her because she wasn't having symptoms. Traditionally in the luteal phase, it was the second week of the follicular phase. And so that was because her her she had problems with estrogen dominance.

00:21:48:15 - 00:21:54:20

Tara Scott

She had problems with estrogen detoxification. And she was way ramping up for us for dial prior to ovulation.

00:21:55:13 - 00:22:14:16

Mark Newman

That's fascinating. A great example of what can drive a short cycle. Also, nice segway. So, short cycle. So, talk to me about. That's one example. One of the other sort of causal factors, because we think a lot of times we test women who have irregular cycles, but those come in different flavors.

00:22:14:22 - 00:22:25:22

Mark Newman

Right. So if we have not as much irregular but like short cycles, what other things can drive a woman to have? Or when do you see women with consistently short cycles?

00:22:26:19 - 00:22:43:13

Tara Scott

So, we teach that 28 days is a normal cycle and I would say probably anywhere from 26, 27 to 35 is probably within the range of normal ovulatory cycle. So short would be less than 26, 23, 24. There's two things that can cause that.

00:22:43:14 - 00:22:58:09

Tara Scott

One is what's called a luteal phase deficiency, which generally means the egg is old, it's not producing as much progesterone. So that guy is not swimming as fast as he would. Right. So, you're obviously adding, but not as much progesterone, right, as problem number one.

00:22:58:19 - 00:23:16:07

Tara Scott

Problem number two is an old egg is going to ovulate earlier. So instead of 14 days, they're going to be a lot of women may ovulate around day 10 because this increased FSH the follicle gets to about two millimeters before it ruptures.

00:23:16:12 - 00:23:30:09

Tara Scott

So, if it's growing fast from this FSA simulation, it's going to get to the right size quicker. Maybe day ten as you get older because of the forces that's going up, you have ovulation earlier and then you have a shorter cycle.

00:23:30:17 - 00:23:44:09

Tara Scott

We know that from the time of ovulation to period should be 14 days. So shorter than that would be luteal phase deficiency or older eggs would be earlier ovulation and then a shorter overall cycle.

00:23:44:21 - 00:23:57:05

Mark Newman

Yeah, I went I went through a bunch of our cycle mapping data just to see if it told that story to sort of prove to myself, you know, is that estrogen peak more consistent from the front or more consistent from the back?

00:23:57:05 - 00:24:07:17

Mark Newman

And it was really interesting that it was very consistent from the back of the cycle that when you go back to that 14, 15 days boom, there's your estrogen peak for short cycles, for long cycles like that was the most consistent data.

00:24:08:09 - 00:24:28:09

Mark Newman

Obviously, we're individuals and there are all sorts of different patterns. But the most consistent thing was that right at 14, 15 days from the end of the cycle is where where we see that estrogen peak. So, you're describing short cycles and you're describing people who are typically still ovulating but not making enough progesterone.

00:24:28:09 - 00:24:48:01

Mark Newman

So then if you're testing somewhere between. Four and ten days before the end of the cycle with something like a DUTCH Complete, then you should still be able to assess to what degree the progesterone is sort of struggling to be made in adequate quantities.

00:24:48:02 - 00:24:50:22

Mark Newman

Is that is that a good description of how you sort of think through that?

00:24:52:01 - 00:25:08:11

Tara Scott

Yeah. And of course, we never know what ten days before the cycle is because retrospectively you don't know when your period is going to be Women feel, you know, mittelschmerz or the pain of ovulation. Some can look at the spennebarcet or that's the mucus of ovulation and they know when they're obviously eating.

00:25:08:15 - 00:25:29:06

Tara Scott

Some women do LH predictor kits where they're doing urinary collection for LH surge and then their timing of elation and then they're collecting after that. So you'll hit most of it if you arbitrarily say between 19 or 21, if my patient tells me they're consistently a 34 day cycle, we'll adjust when we tell them to collect it.

00:25:30:02 - 00:25:49:18

Mark Newman

Yeah, we've had people for a long time now use those ovulation predictor kits and you know you've got to spend an extra 20 bucks, which is way less frustrating than collecting on Monday, start your bleeding on Tuesday, and you're like, Oh, so disappointing because then you can't adequately, you know, assess whether the progesterone was adequate or inadequate

00:25:49:18 - 00:26:00:00

Mark Newman

and sometimes whether it was just on the lower side. But your ovulating or anovulatory like those distinctions become hard to make if you don't get in that window.

00:26:00:16 - 00:26:11:16

Tara Scott

Well, the bigger problem is the patient I talked to today, she closed on day 21 and she had appeared on day 35. Now, what do you have, you have ovulation. And you have a huge high estrogen and progesterone.

00:26:11:17 - 00:26:14:03

Mark Newman

Which may be perfectly normal for that day.

00:26:15:02 - 00:26:27:13

Tara Scott

Right. That's what I'm saying. So, you know, so again, by the time we get the test back, they'll have had their period so we can tell them. But when she collects that, she doesn't know. She's told the 21, you know, and that's part of the issue.

00:26:27:13 - 00:26:35:16

Tara Scott

This is why I would love to have instead of a continuous glucose monitor or a continuous estrogen monitor. So, if you can develop that just like a little.

00:26:35:16 - 00:26:36:10

Mark Newman

Work on that.

00:26:37:01 - 00:26:39:16

Tara Scott

You work on that. I would like to help you patent that.

00:26:40:08 - 00:26:59:09

Mark Newman

You know, we will do that. But I will say you've giving people a really good nugget, and that is you're convincing patients to spend their money on a test. Right. Ask those questions about cycle irregularity and when there's doubt, go the extra step of figuring out a way to isolate ovulation with the reasonable accuracy test

00:26:59:09 - 00:27:17:23

Mark Newman

seven days, right? About seven days after ovulation. Seven to nine days. And then you've nailed what we call luteal. Then you're properly assessing progesterone and avoiding the frustration of having them be sort of, you know, lazy is not the right word, but less comprehensive in your approach.

00:27:18:03 - 00:27:25:14

Mark Newman

And then running the risk of them getting a really comprehensive test, but not having an assessment of the progesterone, which is really important.

00:27:26:00 - 00:27:26:11

Tara Scott

Right.

00:27:26:20 - 00:27:39:12

Mark Newman

So, you then transitioned into the woman who's having a 35-day cycle. So let's talk about that. So, you talked about short cycles causes. So, what about the women who are at you said 26 to 33 is what's your normal.

00:27:40:00 - 00:27:43:02

Tara Scott

35, even 35, you have an ovulatory yeah. Okay.

00:27:43:02 - 00:27:50:14

Mark Newman

So, I'm at 36 to 45 ish, whatever. As a female, what are some of the causal factors that might drive a consistently long cycle?

00:27:51:11 - 00:28:08:20

Tara Scott

So, most commonly we see that associated with PCOS or polycystic ovarian syndrome. And so there's three theories as to what the inciting etiology of that is. One is the abnormal pulsations of gonadotropin, and so that it ends up that LH is twice as much as FSH.

00:28:09:04 - 00:28:26:01

Tara Scott

So, they kind of get stuck in the follicular phase because FSH is not as predominant, so they don't get to day five, so it takes them a while and they obviously late. The second theory is that there's an increase in androgen and it usually happens in two cell lines.

00:28:26:02 - 00:28:41:04

Tara Scott

Either the adrenal androgens are elevated, but by definition these are usually younger girls who are going to have higher DHEAS and then high testosterone happens, which can also suppress ovulation and prevent that from coming. And the third theory is that it starts with insulin.

00:28:41:04 - 00:29:00:14

Tara Scott

You have hyperinsulinemia, which suppresses ovulation and causes the whole vicious cycle. So, we don't really know my my general theory is that it starts with the gonadotropins and that's where the defect is. They try to isolate and genetic defect, either a snip or a whole genome that would be causative of PCOS, but they haven't been able to,

00:29:00:14 - 00:29:14:14

Tara Scott

although it does run in families. So that's the most common thing that people who get stuck in the follicular phase. It can be hypothalamic, it could be somebody who's an athlete, the female athlete try it that they're just not getting that hypothalamic.

00:29:15:07 - 00:29:35:04

Tara Scott

They're suppressed, so they're not getting the foundation. LH to stimulate the follicle to grow, sometimes those longer cycles are not really even ovulatory. It's just that they have estrone, they don't have estradiol, they have a strong via peripheral aromatization still causing the increase in the lining.

00:29:35:04 - 00:29:48:09

Tara Scott

And they get what I call overflow bleeding. So it's not like progesterone is triggering withdrawal. They just that lining will keep increasing until something just triggers then to have a bleed anovulatory.

00:29:48:22 - 00:30:02:11

Mark Newman

So leads to a good question for me which is, you know, we talked about short, we talked about long, which neither of those I would describe as necessarily irregular in the sense of just sort of the woman who's unfortunately all over the place.

00:30:02:23 - 00:30:15:19

Mark Newman

Are there different causal factors from short cycles, long cycles that causes that situation where the timing of the cycle other than maybe perimenopausal though, you could speak to that as well, but that just cause erratic cycles.

00:30:17:05 - 00:30:31:13

Tara Scott

Well, in the absence of insulin resistance and PCOS, there are other things than just effect anovulation. I mean, it's you can have mold, you could have yeast, you could have stress, stress which would still fall under hypothalamic.

00:30:32:23 - 00:30:51:16

Tara Scott

Those are the biggest ones. And then I think, you know, I think estrogen dominance, just some defect in estrogen detoxification, which we can see, you know, with gut issues, we can see with methylation issues. And then high estrogen is going to suppress ovulation because you're sending the feedback, the negative feedback to FSH, and that's going to impair

00:30:51:16 - 00:31:08:10

Tara Scott

the follicular phase. So, a lot of that that can happen with obesity as well, as well as insulin resistance. So those are the things that we see. You know, there are some other rare things like primary ovarian insufficiency.

00:31:08:10 - 00:31:26:21

Tara Scott

We used to say primary of premature early on failure, but now it's called primary ovarian insufficiency, POI. And so that is genetic as well. And that can be a reason why they're having irregular periods and they don't know until later on that they're going to have premature menopause.

00:31:27:07 - 00:31:42:14

Mark Newman

Right. And you're speaking, I think, to part of the reason why we made the DUTCH Test the way that we did is, you know, you're thinking about here's one woman who's got a concurrent androgen issue, maybe too much, maybe a five alpha metabolism issue, which is making it even more androgenic.

00:31:42:14 - 00:32:02:11

Mark Newman

Or here's a woman over here who's got a cortisol issue that's also contributing to that or the the poor soul who's got both of those things going on and and contributing. And is why, I would imagine for you, it's a nice thing to have testing that offers like a window into a lot of those, those different pieces

00:32:02:11 - 00:32:20:00

Mark Newman

of the hormone milieu. So can you talk a little bit about just how how you sort of approach sort of the hierarchy intellectually of, okay, I've got this woman who's whose issue is really centered around female hormones, but then I'm trying to bring in these other things that the DUTCH Test has to offer, and maybe you'd even

00:32:20:00 - 00:32:29:19

Mark Newman

throw in some other things that come from your serum testing and elsewhere. But how does that sort of mental hierarchy go for you in terms of trying to find the source or sources of those types of problems?

00:32:31:00 - 00:32:43:21

Tara Scott

So, you know, I'm skewed because I'm a gynecologist by training. So, people really come to me for mainly hormonal issues. I mean, if you think about like the functional medicine approach as as of IFM they would start with the gut.

00:32:43:21 - 00:32:57:17

Tara Scott

Right. But I think in this instance, in these patients that their main complaints are menstrual irregularities. It makes sense to start with their hormones. So, I always start with the serum assessment for thyroid, for insulin, for metabolic things as well.

00:32:57:22 - 00:33:13:02

Tara Scott

You always it's always nice to pull the FSH and LH to see if there's any issues there as well. Dihydrotestosterone. I like to balance serum as well as DHEAS. The DUTCH test is a complete assessment of the ovulatory hormones.

00:33:13:11 - 00:33:31:03

Tara Scott

In addition, you get that nice piece of cortisol and cortisone. And so I do like that assessment as well, because it's really important piece of the puzzle that shouldn't be neglected. The semen metabolites, as you mentioned, how you're how is your testosterone metabolite metabolism?

00:33:31:03 - 00:33:53:09

Tara Scott

Is it favoring five alpha or five beta? The estrogen metabolism is a huge game changer. And, you know, personally, as a traditionally trained OB-GYN, we're not hot about that at all. And that is a huge reason why we have made all the mistakes in hormone replacement therapy is giving everybody the same dose, not testing before or after.

00:33:53:09 - 00:34:15:09

Tara Scott

And why would one dose affect somebody differently than somebody else that has problems in estrogen metabolism and then they go on and get cancer from hormones or something else. So, I think, you know, even still trying to convince my traditional colleagues that this is the right way to do things is somewhat challenging because we're just not even talking

00:34:15:09 - 00:34:38:12

Tara Scott

about this. I mean, I'm sure we are at some point taught about cytochrome p450 and liver detox in physiology in second year of med school and then never apply that to hormones. So, so I think, you know, that having that part of the test and having having, you know, the estrogen metabolism is great, then the bonus organic acids

00:34:38:12 - 00:34:56:02

Tara Scott

where you get your B-vitamin status is really great too because those are important for methylation. The 8-OHDG is great too for overall oxidative stress measurement for women, especially heading into perimenopause, because we're seeing I personally will see women with a lot of mental health complaints.

00:34:56:02 - 00:35:10:16

Tara Scott

And so it's kind of good to see that as well. But having the dopamine in the norepinephrine metabolites are really great as well too. So, you know, yes, you get four for almost every female hormone related complaint. You're going to get an assessment with the DUTCH Test, which is nice.

00:35:10:16 - 00:35:14:11

Tara Scott

You just have to do the thyroid and the other metabolic labs and the serum, right?

00:35:14:19 - 00:35:25:15

Mark Newman

Yeah. I tend to think of that. I always use the word commodity. Like to me those are like commodity tests like, you know, you can get them at this lab or that lab and you and you're they're never going anywhere like they're a staple of what of what you do.

00:35:25:15 - 00:35:37:05

Mark Newman

And then for us, like in this little specialty niche, you know, our job is to arm you with as much information to complement that as we can. You mentioned the estrogen metabolites. We know you're a breast cancer expert.

00:35:37:05 - 00:35:52:13

Mark Newman

So, I'm in the middle of the luteal phase. I'm testing my female patient. My my big questions are about estrogen and progesterone balance and all of that. And then along for the ride, I get my 2-hydroxy, 4-hydroxy 16-hydroxy estrogens and methylation.

00:35:52:21 - 00:36:04:06

Mark Newman

So, what's your thought process in terms of what you're trying to glean from those metabolites? And how does that sort of change the interpretation of some some of those and then, of course, the treatment itself?

00:36:05:18 - 00:36:20:00

Tara Scott

So I do a test and all of my breast cancer patients and all of my high risk for breast cancer, like if they have family medical history or if they have had dense breasts or if they've had, you know, DCIS, which technically is treated as cancer or something like that.

00:36:21:06 - 00:36:43:07

Tara Scott

There's there there is data that has been published because I have done literature searches to see has someone looked at, but there's not a lot of testing on estrogen metabolites has been in pubmed. Actually, I just pulled a whole other huge articles on specifically that estrogen metabolites and and other pathology that I'm planning to try to

00:36:43:07 - 00:37:09:03

Tara Scott

go through. But I think even in the serum evaluation of breast cancer patients, they didn't always do luteal levels. They were doing follicular. So, you can never include what how progesterone will be abnormal. So, the only thing that was consistently found in breast cancer patients is that is a high endogenous testosterone level seemed to be positively correlated

00:37:09:03 - 00:37:23:21

Tara Scott

with breast and increased incidence of breast cancer. There were a couple of studies that luteal estradiol—the higher it was, the higher incidence of breast cancer was. And then there was an inverse relationship with progesterone the lower it was the higher incidence of breast cancer.

00:37:24:04 - 00:37:39:23

Tara Scott

But there's just not a lot of data. And if you look at any of these meta-analysis, not all the studies are knowing when to do the testing. You're not going to get that information from day three. And I still think a lot of gynecologists think we test hormones on day three.

00:37:40:16 - 00:38:04:23

Tara Scott

So, I would love to see more data in that arena. In about estrogen detoxification, there are some studies that link methylation genetic snips with breast cancer incidence. There's some data that shows 4-hydroxy estrogen is higher in breast cancer survivors and adenocarcinoma in the actual tumor cells, too, as well.

00:38:04:23 - 00:38:25:06

Tara Scott

But again, there's just not enough data to have it widespread and have people adopt that. So, we're still fighting that fight to get that awareness out there. So so that estrogen balance of proliferation and apoptosis, you know, has been shown in the breast as well as the uterus.

00:38:25:06 - 00:38:43:18

Tara Scott

And everybody agrees in the uterus. We want we don't want estrogen to run rampant. Right. But we haven't made that connection in traditional medicine that the uterine and the breast cell are similar. Although our endocrinology textbook from residency by Dr. Leon Spiroff says that literally in his book.

00:38:43:18 - 00:38:57:10

Tara Scott

So, I don't know why again that doesn't make it so I'm just I'm lecturing the residence on Friday, so I'm reviewing my notes about all this. And, you know, I actually go from our textbook and that's where I quote that.

00:38:57:10 - 00:39:02:07

Tara Scott

So, because that's what they're taught out of. But no one's put that together in the traditional sect.

00:39:02:19 - 00:39:17:15

Mark Newman

Right. And some of the variables that we're dealing with on a daily basis with patients are still yet to be totally and unpacked, you know, by the research, which is what makes it kind of an exciting field. So, I really appreciate your time.

00:39:17:20 - 00:39:31:21

Mark Newman

And just unpacking female hormones for us. I have learned a lot and I swim in this every day, so it's great to have someone on who's got such a breadth of of knowledge of of that topic. So, thank you for joining us.

00:39:31:21 - 00:39:39:21

Mark Newman

And we will have you back to talk about other parts of the life cycle of female. But thanks for joining us and illuminating the topic for us today.

00:39:40:18 - 00:39:41:17

Tara Scott

Yeah, you're welcome.

00:39:42:09 - 00:39:58:10

Noah Reed

Dr. Scott, thank you so much for joining us and part one of a two-part series. Next week, we'll continue the conversation about the female reproductive system. We'll get in depth with the next transition that women go through (which is menopause) and how to effectively test and treat women during this time.

00:39:58:19 - 00:40:07:12

Noah Reed

A big thanks to all of our listeners. Remember to like, subscribe, and share on your favorite streaming app. Until next time—I'm Noah Reed.