Dr. Lara Briden, author of Period Repair Manual, is a naturopathic doctor and the period revolutionary—leading the change to better periods. She has helped thousands of women find relief for period problems such as PCOS, PMS, endometriosis, and perimenopause. She shares her expertise in honor of National Period Day.
What we Discuss
Why the menstrual cycle's main event is ovulation and not the period
What a normal menstrual cycle should be
How birth control impacts the rhythm of your menstrual cycle - and it's not what you would think
Lara Briden 01:58
I'm a naturopathic doctor, and the author of the book Period Repair Manual. I'm Canadian, as you can probably hear from my accent, but I live in New Zealand. And I spent nearly 20 years practicing in Sydney, Australia. So I have three I call three countries home. And I've spent the last nearly 25 years of clinical practice on the ground, pretty much nine to five, Monday to Friday, helping women have better periods with diet supplements, herbal medicines.
So I've had an opportunity, which I'm very grateful for, to learn what works and what doesn't work with thousands of women every day to the point about five or six years ago where I thought I really need to share this information with not just my own patients, but women out there. So that's how the book came into being the first edition. So it's in its second edition now and came out early 2015.
Okay, so I don't remember 2015. But I have to mention it because that was the year of the period. That was the first time there was a lot of kind of mainstream media, where they were actually using the word period. For the first time, women were talking about it openly in sports. And that's only five years ago, it's been a lot. The world is changing very quickly. But even five years ago, even back then, when I in 2014, when I was getting ready to release my book, I had a number a few people tell me say to me, “I don't know if you should put the word period in the title of the book, because it's kind of off putting. So we've come a long way. Now, in 2020, that seems pretty normal to have to say that word period. That's not a not taboo anymore.
The problem is if you are on hormonal birth control on the pill. We're in this weird situation where there's no ovulation so no hormone production, and the contraceptive drugs are not as good as our own hormones.
Georgie Kovacs 03:43
Did you write the book before that happened? So it's just amazing timing.
Lara Briden 03:50
Yeah, my book came out in February 2015, and by the end of that year, it was declared the year of the period, not because of my book, I don't think, but just because of what was happening in the world.
Georgie Kovacs 03:59
Let's talk about periods now that we're so comfortable using that word. What myths do women have about periods?
Lara Briden 04:13
I want to start with one of my key messages about periods - ovulation is the main event of the menstrual cycle, and the bleed itself is just a secondary downstream effect. The reason I start with that is because I think we put so much focus on the bleeding. From a health perspective, it's not about that.
We want the bleeding to be as easy and symptom free as possible, but the value of a menstrual cycle for women is ovulation, not just to be able to make a baby. Of course, that's part of it, but also because ovulation is how women make hormones. Men make hormones every day, they have quite a flat pattern with their hormone production, we have this monthly pattern of hormone production. But that has been treated as sort of a liability in some ways.
I like to flip the script and reclaim that it's an asset. We make hormones in this monthly pattern, but we need those hormones. Both estrogen and progesterone have many benefits. Beyond just making a baby, for example, there was just in the research mid-September, there was some new bit of research about how having more years of ovulatory cycles in reproductive years is beneficial for reducing the risk of cardiovascular disease after menopause.
Ovulation every menstrual cycle is like a deposit into the bank account of long term health. It's building what's called a metabolic reserve. And most people would know that estrogen makes bones stronger. Progesterone makes bones stronger. Both hormones are good for the heart, both hormones are good for the brain, they affect the microbiome, or the gut. They're beneficial for us, just as testosterone is beneficial for men.
So this is, this is what it all hinges on. And the thing about this is you can see it's not about the bleed. The problem is if you are on hormonal birth control on the pill. We're in this weird situation where there's no ovulation so no hormone production, and the contraceptive drugs are not as good as our own hormones. Then we have this monthly induced bleed, which doesn't mean anything. So there's no reason to have a monthly drug induced bleed, which is why we get these headlines, these crazy headlines saying things like women don't need periods. They are, what that's referring to, is women don't need a monthly drug induced bleed from the pill, which we totally don't like there's no there's no reason to bleed per se, if you're not, if it's not part of a cycle with ovulation and making hormones.
Georgie Kovacs 07:14
I love that you flip the switch. What I've been observing in women's health is when it comes to ovulation, people tie it so much to getting pregnant and even the apps they're referred to as fertility tracking apps. I wish that the whole conversation would change to just reproductive health or even women's health because when you say reproductive health, people automatically think baby, and it all runs together. I created this podcast because I want women to understand these things like it is women's health is not period, ovulation, as you mentioned, get pregnant, you have menopause. it's a whole system that is magical.
Lara Briden 08:10
Absolutely, so one way of talking about it might be to speak about ovarian hormones because they are beneficial for general health. Just as testosterone, or testicular, hormones are important for general health for men. Testosterone is not just for making a baby. It seems so obvious when you say it about men, but unfortunately, when it comes to women's health, there is kind of this idea of “If you're not going to make a baby, do you even really need any of that?” Well, that's, that's definitely what's going on with hormonal birth control because it shuts them down.
Georgie Kovacs 08:49
I recently spoke with the Ovarian Cancer Research Alliance, one of the questions that I had asked them is this very tough position that women seem to be in with birth control, because apparently, with ovarian cancer, having children is helpful in preventing it, but also being on birth control.
Lara Briden 09:15
Anything that puts the ovaries into dormancy is going to reduce the number of cell divisions happening in that tissue. So I thought about this a lot. So yes, hormonal birth control decreases the risk of ovarian cancer, just as chemical castration of men would probably reduce the risk of testicular cancer. But the thing is, in terms of that question, depending on your history could be a very strong history of ovarian cancer. That's obviously a different conversation, a conversation to have with your doctor.
Let's say your average woman has no risk factors, specifically for ovarian cancer. It's quite a rare cancer compared to other health events for which the risk is reduced by having ovulation so having active ovaries having regular ovulatory cycles, menstrual cycles, reduces the risk of a number of diseases. I'm going to quote my colleague, Professor Jerilynn Prior, who is a reproductive endocrinologist. She is in Vancouver and helped me with my book. There's a quote from her that I've used several times. She says quite boldly, that 35 to 40 years of ovulatory menstrual cycles, regular natural menstruation helps to prevent osteoporosis, dementia, heart disease, and breast cancer. And she puts breast cancer in there. Because progesterone, the real progesterone we make after ovulation, has an anti-breast cancer effect. This is a perfect example because the progestin drugs in hormonal birth control are called progesterone, but unfortunately, they're not. Progestins increase the risk of breast cancer. So progesterone lowers the risk of breast cancer and increases of breast cancer. So if we're talking about it, the cost benefit analysis of having regular ovulatory cycles throughout your life? The beneficial side is reduced risk of all those things, including breast cancer, which is obviously a lot more common than ovarian cancer. So that's kind of my short answer to, “Does the pill reduce the risk of ovarian cancer?” Yes, but big picture, this lot there.
Georgie Kovacs 11:56
Help our listeners to understand more about the impact of birth control, because I know that even in your book, you reference certain types, whether you really need them, and for certain cases they are better than for others.
Lara Briden 12:14
Okay, well, let's start with the hormonal IUD, please, as I guess I would say a better option. So we'll start with the positive rather than just bashing the pill.
Georgie Kovacs 12:24
To be clear for everyone, it's not like Dr. Briden said birth control is the worst thing you can ever take. You had definitely strong suggestions around precautions. And so this is about creating awareness so that women have freedom of choice.
Lara Briden 12:44
Let's start with, arguably through my lens, why the hormonal IUD is a bit better. So just to clarify, for any of your listeners, I'm sure people, depending what generation you're in, that an IUD is just an intrauterine little plastic device that's inserted in the doctor's consulting rooms. It's not a surgery to have that just inserted up the cervix, and it stays in there for a number of years, between three to five years depending on the type. There's a nonhormonal type as well, which will leave out of this conversation.
The hormonal IUD contains levonorgestrel - it's a drug to similar to progesterone, but also actually quite similar to testosterone. So there could be some effects from that. But the advantage of it is that it will lighten periods quite dramatically. So that can be very welcome effect - it thins the uterine lining, and licensed periods by up to 90%. It prevents pregnancy, but it does not routinely switch off ovulation. So you can kind of see why from my lens, I prefer that.
I just spent the first 10 minutes talking about how important ovulation is for women for making hormones for building long term health. The hormonal IUD is quite unique in that it doesn't switch off ovulation. Sometimes, it does suppress ovulation to some extent, especially during the first year when the dose of the drug is higher. But that's not how it works. It's working locally in the uterus.
So it's quite unique in that sense, and the hormonal IUD is one of the one of the only times when you can ovulate or cycle, but not bleed, which is very interesting. It is actually the complete opposite of what happens on the pill, which is that you bleed but don't ovulate or cycle. So there are very different sorts of things.
I have a blog post called the Pros and Cons of the Hormonal IUD, which I've been told is quite balanced so people can look there and look at all the different pluses and minuses of that technology. In terms of the other types of hormonal birth control, they all share in common the fact that they do suppress ovulation definitely any combined pill like an estrogen - progestin pill works by suppressing ovulation, the progestin only methods like the implants, the mini pill, the while the injection, I really don't recommend the Depot injection for reasons we can get into if you want, but I would say not that. The other ones, the progestin only ones don't, they don't always suppress ovulation, but they usually do. So that's through my lens.
Then there's the side effects of the contraceptive drugs themselves, which varies depending on which drug it is. They've been linked to hair loss and mood problems. So we kind of had the layer of, okay, you're being robbed of you're on hormones and the benefits of ovulation. And then on top of that, you've got potentially the side effects of the progestin drugs.
I was just actually last night having a discussion with my husband about this very topic - is the pill safe? I think an answer to that, you'd have to define safe. Is it safe in terms of severe side effects, arguably, big picture, yes. Although, some women do die of blood clots from hormonal birth control. That's a reality. But big picture, most women do not get anything sinister from hormonal birth controls. From that sense, it's safe.
On the other side of things, what we're starting to now understand that a number of women experienced mood changes, if you will, or mood symptoms from contraceptive drugs, potentially can contribute to hair loss, depending on the type. It alters metabolic function; it changes the shape of the brain. So these are things we know and are just learning about. They had no idea of any of that back when the pill was approved.
Georgie Kovacs 17:28
Lara Briden 17:32
It's a more nuanced answer. It's been used by hundreds of millions of women over the years. But not that long - 50 or 60 years. And in other ways, we've got women who've experienced, for example, depression from the pill. But we're not heard when they said that's what was happening, right?
That's the other part of this conversation. For generations, women have been saying, “Oh, this pill affects my mood.” And then sometimes the message back to them is, “You're just imagining things. That's not a thing.” But it is a thing.
So now we do have some research. There was a big Danish study in 2016. It was a correlational only, so it didn't prove causation. But they proved a definite link between all types of hormonal birth control, including the hormonal IUD, and negative mood outcomes. The authors of that study said that was probably an underestimate of the problem, because they were only measuring women who actually went on to take antidepressants, not women who just quietly stopped taking it. They weren't even counted. So is the woman who kept taking it and then ended up on an antidepressant.
And that's something I see quite often with younger patients, like teenagers. I'm looking at her list of medications, and she's on Yasmin and then on an antidepressant. I ask, “What order did those come in?”
Georgie Kovacs 19:03
That's a good question.
Lara Briden 19:05
Yeah, the Yasmin at 15. And then about nine months later, and antidepressant. Wow, I've heard that story before.
Georgie Kovacs 19:16
It’s really interesting to just hear how the OB GYNs are trained. And it does seem like birth control is such a solution. For those of you listening, I wanted to bring this up because I know this is National Period Day, but I wanted to make sure we talked about birth control, because a lot of what we think about is the period and ovulation and controlling the cycle.
Lara Briden 20:00
This semantics, right? And I know that just words and words but words are part of the problem here. Two words that we need to sort out, please.
1-The phrase that the pill can regulate is the word that I'm taking issue with. “Regulate the menstrual cycle” is wrong.
Like it, the contraceptive drugs do not regulate anything. They switch off ovarian function and replace it with contraceptive drugs that replace hormones with contraceptive drugs, that then, because of their dosing, induce a drug withdrawal bleed. So that is not regulated if the menstrual cycle is an arbitrary menstrual cycle where you make estrogen and progesterone. And the pill works by completely shutting that down and inducing basically chemical menopause. That's not regulating, right?
I think if they spoke to women in terms of what's actually happening, it would start to change the whole conversation like, “Okay, I'm going to give you this.” More accurately, it will be, “These contraceptive drugs are hopefully going to relieve your symptoms.” Okay, so that, yeah, maybe something we can work with.
And by shutting off your ovaries, something like that. I mean, that sounds bad, but that's what some women might say, “Okay, I understand what that means that I still want to do it.” And that's fair.
Keeping in mind that just circling back briefly to the hormonal IUD works differently. So it does lighten periods without switching off the ovaries. So that's a different conversation.
2-Regulate cycles is one, I'd like to see that change, and the other one is period itself.
The word period, I feel should be reserved for the bleed at the end of a proper natural menstrual cycle. I feel like a pill bleed - well, I use the word pill bleed, but it's a withdrawal blade. Like with my own patients, when they're talking about what their periods were on the pill. I say, “Okay, that's fine.”
But if they were pill bleeds, you're having your drug withdrawal bleed every month for 10 years. Those aren't periods. And we can compare them to what your own periods might be like. It's like apples and oranges. They're completely different things.
Georgie Kovacs 22:34
This is why I wanted to interview you. I can tell from even what you put on social media that you're very serious about the information women have and know about their bodies and really trying to create change. What you are doing is needed. In the five years since you wrote your book, what would you say some of the changes are that you have seen?
Lara Briden 23:20
The fact that we can say periods so easily is very beneficial, like very positive development. I think also, there does seem to be more of a sense that what women's bodies are doing is a good thing, and not always a liability.
This is gonna sound a bit extreme when I say but I actually feel sorry for men that they're not that they don't have women's hormones. I think estrogen and progesterone are awesome, and potentially give us so many benefits. Actually, the female body is the standard version of the of the of a mammal body, but when we're fetuses in utero, we're all female until week six when the maleness factor kicks in. For some evolutionary perspective, estrogen was the first hormone to evolve. There's lots of beneficial things going on with the female body, so I think just reframing it has been good.
It becomes a message of celebrating what the body itself rather than being negative about the pill. There's two sides of the same thing. So if you can't really talk about the benefits of ovulation and the benefits of hormones, without then acknowledging that these hormone suppressing drugs are potentially a problem, right?
Georgie Kovacs 25:16
I hear you. I do encourage women to continue understanding how all the hormones and our bodies work.
As an example, for the past two weeks, I've had a lot of headaches. Now it could be because my kid is starting school and the school system can't make a decision on when school is starting, but I'm pretty sure it's also hormonally related. I know that because I've been doing the podcast had been studying women's health for a decade. I probably should get the hormones checked and see which one’s off.
Lara Briden 25:57
So my next book is about perimenopause, which is our 40s. Pretty much if you're 40-something you’re in perimenopause - it's almost by definition. I'm very passionate and excited about some things about perimenopause that, once again, I feel like are not being kind of discussed in the right way.
One of the main things that happens in perimenopause is the hormone progesterone goes, not completely, but it really does start to go down. And it's nothing you're doing wrong. You could try to keep it going as long as you can and be as healthy as you can, but that's just the nature of it - it’s second puberty.
In first puberty, estrogen comes, and then progesterone doesn't kick in for a couple of years. That's why young girls, like 13 year old girls, can have quite heavy and irregular periods. There's no progesterone yet to exert its period lightning kind of calming effect.
Then, a mirror image of first puberty is second puberty where estrogen goes crazy, higher than ever before. And progesterone just slowly drops away. That can manifest in different symptoms, which of course, I've written a whole book about, which comes out in March.
Georgie Kovacs 27:28
I will definitely mark my calendar and read it.
One of the things you were just talking about, which reminded me of another point in your book that I've always wanted to ask you - how the period evolves in a woman. You were talking about how it takes a little while for the period to normalize. When a young woman first gets it, it seems like when the girls are young, and they're having that heavy bleed, a lot of people put them on the pill. Is it because the doctors aren't patient enough to wait for the period to evolve to where it's supposed to get?
Lara Briden 28:18
This is happening. Girls are being put on the pill very young. Now, to be fair, no one likes to see an 11-year old girl bleeding through her sheets at night. You want to help them. In the book, and I have a blog post about how there are ways to lighten the periods of young girls that don't involve the pill. It's not a question of just leaving them to it.
There is this other element of understanding that the menstrual cycle has to mature. It usually takes a year or two for progesterone to start to kick in. So most girls aren't going to have to go through that heavy period phase for too long. But bigger picture in terms of properly maturing, a robust menstrual cycle, one that is not going to be pushed around too much by stress or under-eating, keeps going. It takes 12 years. That's according to Professor Prior, the endocrinologist who helped me with my book. She has a stat, which I cited in the book, so you can find the reference there. So if you get your period at 13, it's not till you're 25 that you're in all your progesterone robustness. By 25 you’re in peak fertility probably around that time in terms of progesterone production.
There are other factors in fertility as well. But the interesting thing is if you interrupt that by switching off the menstrual cycle with contraceptive drugs, that maturation process can't happen, which is why you then get women coming off the pill in their early 30s and can't immediately get a regular menstrual cycle. But they should get there eventually.
When I'm working with patients, one of my first questions would be, if they're trying to come off the pill in their 30s, the thing I need to know more than anything else is, “Did you have any years of natural cycling?” I need to know if they had any opportunity to mature their menstrual cycle because my experience is, even if they had even a couple of years, even better, like three or four years, if they didn't go on the pill till 15, or 16, or 17, or something like that, and they had some semi-regular cycles before that, then I say to my patient, “You're going to be okay. Your body is going to remember how to do that.”
This is all in chapter one of Period Repair Manual. I talked about the hormonal rivers analogy. I've had some people like that analogy. It’s the hormones learning what they're supposed to do.
The best example is under eating. It can cause women to lose that period, especially if they're young, or because they don't have a menstrual cycle that's matured. Severe undereating will always shut down periods regardless, but mild or undereating or milder stress is going to be more of a problem for women who don't have a robust and mature menstrual cycle.
Georgie Kovacs 31:45
With the five years of people being more comfortable talking about periods. However, there are still questions out there. Tell us about a normal period.
Fertility tracking apps - because that's what they're calling them - will ask, “Is your period heavy, medium or low?” I was talking to somebody, and they brought up a really good point, which is, “What does that mean?” Remember, the app is just an app. You enter the data and calculate, but are we all defining this the same way?
As an example, does the woman compare heavy, medium, light between day one? And if there's a five day cycle, is it between day one of this cycle versus the previous cycle?
Lara Briden 32:58
It's very subjective. I've asked thousands of women about their periods, I get to ask how much and we try to quantify it, which I will talk about for a minute. So I get to hear women tell me my periods are pretty heavy. I mean a half-filled to regular tampons in a day kind of thing. Actually, that's not that heavy. Or I get women who are like, “Oh, I'm overflowing my menstrual cup three times a day. It's not that bad.” That's heavy!
The range of normal...because I'm Canadian, New Zealand, talking milliliters, but so 25 I'd say is quite light and normal. It can be as little as say 15 or 25 milliliters, which is really just a few a few teaspoons, over all the days of the period, or anywhere up to 80 milliliters, which is several tablespoons, over all the days of the period. The period shouldn't be more than seven days. That's it.
The other parameter for a proper ovulatory cycle shouldn't be more than six or seven days. If it's longer than that something's wrong.
It's not uncommon to have heavier than 80 mL. In fact, during perimenopause, the crazy heavy periods that some women get during can be, not 80 milliliters, but 500mL!
So you get a sense of the scale of things. Some women might lose, like a couple cups, which is a lot. Those women used to get hysterectomies, but now it's hormonal IUD usually, which I would argue is better than a hysterectomy.
Most younger women won’t have 500mL bleeds. Women in their 20s to 30s might be up and if she's having an ovulatory cycle, when she could maybe get that product right at 120 milliliters.
So in the book Period Repair Manual, you can find how you calculate that. A regular full tampon is about 5mL, a super tampon is about 10mL. If you use a menstrual cup, it's a lot easier because you could actually just look at how much the cup holds - 20mL.
The real problem with heavy periods, apart from being very annoying, is iron. It depends on how heavy- it can be quite depleting to health and being iron deficient is not good for immune function, causes hair loss and all sorts of things.
Georgie Kovacs 35:45
Now I'm curious. Tampon versus pad versus the menstrual cup? Outside of tampons, obviously making sure that they're 100% cotton and organic. Any specific preferences or concerns that women should have about either of those options?
Lara Briden 36:05
I think they're all okay. As you say, if you're going be inserting something, I think it should be an organic cotton and not have little bits of nylon fiber or dioxins, which I don't have anymore. I personally prefer menstrual cups. I think they're more comfortable, but I don't insist that everyone has to use a menstrual cup. I think it's at least worth knowing that they're out there and that they're actually pretty easy to use and environmentally friendly. For what for what it's worth, they do seem to work for women with very heavy periods. Some women claim they lightened periods. I don't know what mechanism how that would happen. But I think maybe it's just they hold more.
Georgie Kovacs 37:00
Anything else that you want to make sure on National Period Day that women should know topline before they read the rest of your book for all the details?
Lara Briden 37:24
Severe period, pain is never ever normal. Never, never, never, never normal. I differentiate in my book so called normal period pain versus severe period pain. I would argue pain is never normal, any amount of pain is really not normal. But it's common to get a little bit of cramping, you can take a ibuprofen, and it goes away. That's just sort of a normal situation.
If you're curled up in a ball, and can't go to school, and are crying and vomiting - there's something going on. That something can be endometriosis, so it really is worth mentioning at this point, that specific condition, which we do a whole podcast on one time, but it's about one in 10 women and girls, and it usually hits quite young. And unfortunately, as you probably know, it can be undiagnosed for years, and especially because it often runs in families. So then you'd have girls being told by their mother, older auntie's “This is just how it is. This is what periods are like.” The activism around endometriosis is to explain this is not a normal situation. Of course, then there's the next question of how do you treat it and that's a whole other topic.
Georgie Kovacs 38:48
I interviewed Dr. Tamer Seckin who did my endometriosis surgery. It's a quite a popular podcast. So definitely.
I appreciate what you're saying about period pain because we women grin and bear it and so when you were saying pain, I hoped you’d describe it in great detail.
Lara Briden 39:19
So my experience I just share because of course I've had the opportunity and I'm very grateful for that I've been hearing the stories by speaking to thousands of women over the years. I don't personally have endometriosis, but I've had many hundreds, if not thousands, of women who do and the patients who don't. I think women who don't have endometriosis have no idea of what pain is. The pain that women with endometriosis put up with is so off the scale compared to what other people think would be acceptable.
Georgie Kovacs 40:05
What would be your words of wisdom to the women who are in severe pain and aren't being heard, what would you say to them? And you're a little girl and a lot of pain, and everyone's saying it's fine.
Lara Briden 40:19
Just say, “It's not normal. We're going to try to get you some help.” There's so many aspects that I'm sure you spoke about on the podcast, but it's about finding the right specialist. I do feel like girls with endometriosis need to be under the care of a gynecologist who knows about endometriosis and who is going to be able to assess it properly. There's a new study on the radar where they're looking at different non-invasive methods of diagnosis. There's a couple of Australian surgeons who’ve done a couple of scientific papers recently about using ultrasound to diagnose endometriosis. A normally done ultrasound cannot pick it up, but there's a specialized way you can if people know what they're doing. To me, that's a positive development. There might just be more information without having to make that rather daunting decision of surgery, because that's hard for anyone to do.
Georgie Kovacs 41:32
So what is your greatest hope for women's health?
Lara Briden 41:43
We collectively have a greater understanding of how the menstrual cycle works and the benefits of hormones. I would really like to see new methods of birth control come down the pipeline - just completely thinking outside the box different ways of avoiding pregnancy, of which there's a couple coming, which you probably know is one called Vasalgels, a couple of male ones coming. But I just feel like the burden of birth control, and particularly hormonal birth control, has been on women for too long. We get locked into this conversation about access to hormonal birth control. Okay, fine, but it is 2020. I think we could have access to some other ways of avoiding pregnancy. It shouldn't require shutting down the entire hormonal system of a girl. There's not a lot of research or funding.
For Vasalgel, to get it into clinical trials, they had to crowdfund because no pharmaceutical company wants anything to do with it. They're actually not interested, so it's gonna have to happen in a crowdfunding space.
Georgie Kovacs 43:07
Much to be transformed. Well, thank you for your time. It's a pleasure to get to know you. And please keep doing what you're doing. We need you. Thank you for writing and thank you for now writing your next book to be published in March about perimenopause. I look forward to reading it.
Learn more about your Hormones and Menstrual Cycle.