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The Importance of Progesterone with Lara Briden

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The Importance of Progesterone with Dr Lara Briden

Ahead of her key note speaking engagement for the 8th BioCeuticals Research Symposium we are delighted to welcome back Dr Lara Briden to take us through the important, yet largely overlooked, health benefits of progesterone for bones, immune function, and mood.

In this episode, Lara will explain the crucial difference between progesterone and progestins, and how the menstrual cycle, perimenopause and menopause influence progesterone synthesis. 

Covered in this episode

[00:00:53] Welcoming back Dr Lara Briden
[00:02:13] The basics of progesterone
[00:05:41] How progesterone affects mood 
[00:08:18] Why progesterone is not included in oral contraceptives
[00:09:31] Allopregnanolone and the GABA receptor
[00:13:22] The anti-inflammatory effects of progesterone
[00:15:04] Progestin and pill bleeds
[00:19:00] Reliable testing methods for progesterone
[00:24:09] Defining the luteal phase
[00:26:35] Measuring temperature 
[00:28:40] Having a shorter luteal phase
[00:31:07] The immune surprising effects of progesterone
[00:32:41] Progesterone and heavy periods
[00:35:47] Balancing levels of progesterone in perimenopause
[00:40:53] Does pregnancy affect levels of progesterone later in life?
[00:44:28] The thyroid and progesterone connection
[00:48:13] Uncovering the possible contributors to heavy periods
[00:54:22] Saliva vs urinary testing
[00:56:30] Progesterone use in menopause
[00:59:51] Progesterone for migraine relief
[01:00:50] How gluten and dairy affect progesterone
[01:07:47] Closing remarks

Mark: Hi, I'm Dr. Mark Donohoe. Join us for our new podcast series, FX Omics. We'll be exploring the new technologies of integrative medicine including genomics, metabolomics, the microbiome, and many more fields that are transforming healthcare.

We're focusing on how they apply to practitioners and how we can incorporate them into our patient care. We aim to make these exciting and sometimes challenging fields relevant to you and your practice. Search for FX Omics on your favourite podcast platform, and we look forward to your company.

Today, we're going to cover something which is dear to my heart, with Lara. She's with us to do a preamble to her presentations on the 14th of June. But the things we're going to cover today are one of my favourite and least acknowledged hormones, but one that's her specialty. It's progesterone, which I laughed, my little Siri machine called it progesterone, all the way through the things that I listened to about it. So, it's somehow known that its name is not even well known.

I want to welcome you, Lara. It's good to talk about the forgotten hormone. We all know oestrogen, we all know testosterone, and we keep on forgetting about the most important one.

Lara: It is. It's like the ugly stepsister of hormones. I mean, like the Cinderella of hormones, it gets left behind when everybody else goes to the party.

Mark: And yet it does all the good stuff. It does all the good stuff. I think that we get so much the common knowledge, everybody knows oestrogen, and good skin, and fertility, and the feeling is that there's oestrogen and testosterone, and they're both anabolic hormones. They're both in a similar line. But the catabolics are a very important hormone, and the progesterone is gaining a very, very good reputation for a whole lot of things, besides purely fertility.

Lara: Absolutely. Yeah.

Mark: But let's start, yeah, let's start with that. Let's just go to, what is progesterone? I know it comes from cholesterol, it's a sterol hormone. It's on the wrong side of the tracks of catabolic/anabolic hormones. What does it do? Why is it such a high concentration? Why do women, especially, produce so much progesterone?

Lara: And it's a lot, isn't it, Mark? As you know, it's 100 times more than oestrogens. So, it's a difference of actually two decimal points in terms of the amount that we produce, if you look at the units, picamoles versus nanomols. So, it's kind of crazy when you think about it that way.

The other thing that's special about progesterone is that we make it only for those sweet two weeks of our cycle. I call it the lifespan of a butterfly. We make that corpus luteum, and we get it for only a short time, and then it's gone. Except for pregnancy, of course, when we make astronomical amounts of progesterone, which is also an important...

Mark: That's the job of the placenta, though, isn't it? I mean corpus luteum to placenta. So, it's in the baby's interest and the mum's interest, right the way through pregnancy. But it is only there that two weeks. It comes and goes. But it's not just the two-week hormone. It's responsible for a lot of things in the background.

Lara: It is. The way I like to think about it with ovarian hormones is, you know, clearly they're for making a baby. We spoke about this in our podcast about ovulation, a couple of months back.

Mark: Right.

Lara: But with human physiology, of course, everything is calibrated to the presence of those hormones. Just as in men, testosterone is to help with male secondary characteristics and help with sperm production, but that's the physiology you have. Everything depends on that, you know, bone density, muscle mass.

Mark: Right.

Lara: The same goes for ovarian hormones. So, our body definitely expects to have them. We function with them in mind, that's whether we make them monthly as an ovulatory menstrual cycle, or in a huge dose with pregnancy. We have two options of women, of which way we're going to make them.

Progesterone is a lot about, when I think about progesterone, I think of its effect on the immune system. It's immune-modulating, which makes sense, given its role in pregnancy. So it's anti-inflammatory, and it has a very profound effect on the nervous system as well, which I think we're going to have to cover today, particularly on the brain. It converts to a neurosteroid called allopregnanolone, which has a profound effect on the brain, is usually calming.

Mark: And that allopregnanolone, I am fascinated about it. But I'm going to just tell you the story. About five years back, a little story appeared that in rats, allopregnanolone could be increased artificially by giving a tiny dose of bio Prozac, the two milligrams of Prozac, which is fluoxetine.

It was then transferred to a little trial on humans with decreasing premenstrual syndrome. And every doctor that I know went wild prescribing two milligram Prozac for every woman, because every doctor just believed that every woman just needed to settle down. It was fascinating. It did work, but it was a drug being used to do the job that the body would normally do, itself.

Lara: Let’s because we're on the topic of mood straightaway, so we have a little poll for the audience here. Let's bring that up if that's okay, moderator? See what that looks like, about progesterone and mood.

Mark: So, you're going to ask them first and then tell them the answer? Oh, my goodness. The answer is...

Lara: It's fun to see these come in. Yeah, this is good. Okay.

Mark: All right.

Lara: Yeah. So...

Mark: That's fascinating. Okay, so you've obviously talked to these people before.

Lara: Well, let's talk about this, because progesterone, I think, you know, a lot of our audience knows that it generally has a positive effect on mood. Would you agree, Mark, that in the more mainstream narrative of progesterone, it's attributed to having a negative effect on mood? That PMS, premenstrual symptoms, for example, are blamed on progesterone? Which is...

Mark: They are.

Lara: Yeah.

Mark: No, they are. The blame is that rapid change of the progesterone. Progesterone starts low, peaks, goes to the end, and then as it crashes, everything is blamed on the progesterone, the sudden loss, the sudden drop. 

Lara: The withdrawal.

Mark: Is that not right?

Lara: So, I think that's a bit closer to the truth. I mean, certainly, I've heard some people say, some doctors or journalists say that progesterone itself is negative for mood. And this is where I would say the correct answer to that poll is "Depends." I think it is a depends situation. I'd like to talk that through, if that's okay. I just think this is actually very important.

Mark: Right. Yes, that's great.

Lara: So, the first thing to say is that progesterone is very different from progestin drugs. This has to be stated right at the beginning of our presentation today, because this is where a lot of the confusion comes from.

Because I would argue that most contraceptive progestin drugs have a negative effect on mood, arguably. Not for every woman and not severely, but in general, that's what the research now shows, that hormonal contraception can have a negative effect on mood. And I think a lot of that's attributed to the progestin part of it.

So, it's quite important that when we're talking about progesterone and mood that we don't confuse or conflate those two things: how progestins are for mood versus how progesterone is for mood. Would you agree with that? Yeah.

Mark: I agree, yeah.

Lara: So, yes.

Mark: The question that I would ask is “Why do we never have progesterone in contraception?” So, what was the value? Was it simply manufacturing issues? Was it some thing as simple as that that made progestogens the dominant hormone provider? Why not bio-identicals or body identical? Why was that never a thing?

Lara: Well, in the invention of hormonal birth control was the fact that progesterone was not absorbed orally. Of course it is now, but that's with the invention of something called micronised progesterone, oral micronised progesterone, which was only invented in the 80s, I believe, in France, and has of course now become…. and we're going to talk about that today, using oral progesterone body identical or bioidentical progesterone as an option for a lot of treatment options. It's not used as contraception.

So, I think the main issue from the beginning was that it wasn't absorbed orally. And also you need a pretty massive dose of progesterone to shut down ovarian function. Well, you need at least 200 milligrams, which certainly no one prescribes it that way for that purpose. So, that's...

Mark: Right.

Lara: ...yeah, that's a really good question. 

But just staying on the topic of mood for a minute, it's quite a fascinating story. So, I think part of it as you've just said, progesterone is generally beneficial for mood, calming for the nervous system. And then many of us can experience some withdrawal from that at the end of the luteal phase. That can cause a mild agitation or anxiety, which would just be the final three or four days of the menstrual cycle. And oestrogen's dropping then too, so that's going to be a double whammy at that time.

But there's also as some of the listeners, the viewers, I'm sure know, there's also something called premenstrual dysphoric disorder or PMDD, which is different. It is. In these women, from what I can tell from the research, they're reacting negatively to progesterone itself. Which is fascinating, to me. What the science seems to show on this with regard this is, it’s all to do with the GABA receptor in the brain.

So, everyone knows GABA is one of our main inhibitory calming neurotransmitters. Serotonin gets all the discussion, but actually GABA is huge. I think most of our neurotransmitters, 90% of our neurotransmitters are GABA and glutamate, that's the pair of the stimulating, and yeah.

Mark: One argues against the other, and is the stimulus for it. Yeah.

Lara: Exactly. And GABA is actually made from glutamate, which makes it even more interesting. But the metabolite of progesterone called allopregnanolone interacts quite strongly with the GABA receptor. And this is where it's all happening. Because of that, we have a GABA receptor that is highly adaptable to levels of neurosteroids.

So, the GABA receptor is made of these five subunits. I think of it like a transformer action figure. Just depending on where you are in the cycle, it rearranges itself to create a different receptor essentially, to not be overwhelmed by allopregnanolone, the neurosteroid. What the evidence seems to show is women who have PMDD, their GABA receptor is not doing that as well. It's not adapting. It's not resilient to the ups and downs of progesterone.

Of course, there are treatments for that, I would argue, but that's, in a nutshell, where all this confusion about progesterone for mood comes from. A) sometimes we're talking about progestins rather than progesterone, and B) there are small, about one in 20 women who react quite negatively to progesterone.

Mark: Is that a genetic predisposition, that negative reactivity? Are you born with that, and that's just the way that you do GABA and allopregnanolone?

Lara: Well, there's a genetic predisposition, for sure. And then, no surprise to all of us natural medicine practitioners, it's affected by inflammation.

Mark: Right. All right.

Lara: So, the resilience of the ability of that GABA receptor to change is affected by inflammation and also affected by histamine, which is another big player potentially, in premenstrual mood symptoms.

Mark: Okay.

Lara: So, that's why I believe, clinically, pre-menstrual mood symptoms and even PMDD can respond quite well to a general anti-inflammatory approach. Particularly, as a clinical pearl for everyone listening, particularly pulling out dairy, cows dairy from the diet for some women can, in my… that's purely a clinical observation, but can really make a difference in terms of not reacting to the luteal phase in that way. Yeah.

Mark: Okay. Now, progesterone in itself is anti-inflammatory. Is it anti-neuroinflammatory or broader? So, I know that progesterone in huge doses is being used after head injuries rather than cortisone. It's being used for head injuries, motor vehicle accidents, five gram, 10 gram doses of it. It is potentially one of those things that can stop the brain over-glutamating itself to cause the ongoing damage, and so it has a rapid calming effect.

Lara: Yes.

Mark: So, that in itself, the hormone in itself, is that self-defective?

Lara: In terms of the GABA receptor, I'm not entirely sure of that. But yes, you're right that progesterone allopregnanolone generally has an anti-inflammatory effect in the brain. It's interesting, in those trials you're talking about, they were giving progesterone to both men and women. Which is quite interesting.

Mark: Yes they were, yes.

Lara: In fact, most of the trials were done on men, which is actually a common thing in clinical research, which is interesting.

Mark: Well, you've got to keep the old white men alive long enough to stuff everything up. I mean, otherwise, we die young and, you know, you don't want that.

Lara: I'm practicing looking at the comments here. I've had a question, is the GABA receptor change/lack of change? It's high histamine. Oh, I see. We're just learning the system. I'm just looking for a little question. 

Yeah, so I think when histamine is high, that impacts or reduces the resilience or the adaptability of the GABA receptor. I have a reference for that in my blog post about this, so I'm going to try clicking that. There we go. Good. Yeah.

Oh, and someone's just commenting in the comments. So true. Isn't it infuriating when reading the literature and they use progesterone and progestins interchangeably? Have you seen that, Mark?

Mark: Yeah.

Lara: Like even in scientific studies on PMDD, half the time they're talking about, not menstrual cycles, but pill bleeds or pill cycles, which is as a little...

Mark: I know you make that distinction, that’s good.

Lara: As a little teaser to my symposium talk, you'll get to hear me be quite passionate about this topic. We need to reclaim the language around what is an ovulatory menstrual cycle, and speak about it more precisely than just, you know, oestrogen versus progestin. Okay, good. Yeah.

Mark: So, with the pill, you create an artificial bleed that has nothing to do with ovulation, that has nothing to do with hormones. It's just way of reminding people of the appearance of a slight...

Lara: This is a spot...

Mark: ...rather than it being useful for the person in any way.

Lara: Absolutely. This is a spoiler for the symposium, but it's just one of, you know, I'm speaking for what is it? Seventy-five plus 30 minutes that day, so there'll be lots to cover. But I will say here that, yeah, exactly as you said that the pill bleed is just mimicking a menstrual cycle in a very completely unnecessary way. There is zero medical reason to bleed monthly on hormonal birth control. It's done that way. It was a marketing technique to say the pill is regulating a cycle, I guess. But in reality, oestradiol, our main oestrogen and progesterone are flat-lined on the pill.

And you know that as a clinician, just as a test, you would see… if you went to measure with a serum level oestradiol and progesterone while someone's on the pill, what would you see? Nothing. Low. Essentially menopausal.

Mark: You see no progesterone. It depends a little bit on the type of the pill, the oestradiol is a crossover there. But we do see the flattened progesterone, and no sign of it anywhere through there.

Lara: Absolutely.

Mark: And we also see the cortisol rise, which I think is fascinating, you know, that when you're on the pill, the cortisone goes up by about 30%, 35%. And I've always wondered about whether that's an effect of the progestogens rather than progesterone, which does not do that.

Lara: Well, let's talk about that for a minute. Yeah, progestins, or hormonal birth control, alters the HPA or the adrenal axis, and it changes the shape of the hypothalamus. So there's, yes...

Mark: The shape? Literally it changes the shape, I had no idea.

Lara: We're going to talk about that at the symposium. I have a reference for that.

Mark: Okay.

Lara: So, no surprise, you get alterations in stress hormone levels. But to me, that just seems obvious. As to all the different mechanisms as to why that happens, I think we're still to understand that. You know, there's very little research into this. I've seen a few quotes in social media, like, you know, okay, I think it's time now to start studying the impact of contraceptive drugs on the brain. After 60 years of use, it's like, "Let's finally start looking at what that's doing."

Mark: Right.

Lara: Lots of good questions coming in. We'll cover them. You know, we'll just keep talking. I saw one about adenomyosis, which I think we should talk about later. At one point before we finish, we'll talk about the effect of progesterone on heavy periods. But, yeah.

Mark: You know what? You paying attention to the questions has just loaded the questions further.

Lara: Okay, you can check on the questions. I'll close that.

Mark: In other words, you will have nothing to talk about.

Lara: You're the interviewer. But the good thing that when I opened it...

Mark: So, I'll keep an eye on those. I will keep on reflecting those questions...

Lara: Perfect.

Mark: ...and you keep talking about the progesterone.

Lara: Should we talk about testing the progesterone?

Mark: Yeah, we could. I mean, that's an obvious question. Different practitioners have different ways of doing it. So, what's reliable? What would you use? What would you recommend actually reflects real progesterone production? What would you rely on for clinical decision making?

Lara: Temperatures. Can we have the other poll, moderator, please? I mean, of course, there are lots of ways which we're going to detail now. 

But you know, Mark, a lot of my work in my book, and my work with patients too, and my blogging, it's a lot about women's health for the people. Like doing this in a way, a do-it-yourself kind of measure. I just want to say that measuring your basal body temperature and tracking your luteal phase is a scientific way to measure progesterone. In some ways, it's more accurate because you get the whole luteal phase, not just a point in time. 

The way it works is that progesterone raises body temperature by 0.3 degrees Celsius. That temperature goes up a couple of days after ovulation, and it stays high for the entire, anywhere between 11 to 16 at the very outside, but usually fewer than 14 days.

If you ask your patients to do that, and I'm going to go into this in the symposium, I actually have an actual picture of what a temperature chart looks like for anyone who hasn't done it, just to get that information. You can start to see very clearly when there's a luteal phase, if there's not a luteal phase. If ovulation hasn't occurred, it's very obvious. And also the quality of the temperature rise, is it sustained or is it bouncing up and down, and the duration of it.

So, that's all very interesting information. I assume everyone can see the results of the poll. Most people do. So, that's great. And for anyone who doesn't, we'll look at that at that in the symposium, or there's tons of resources about that, how to do that.

Beyond that, we can certainly talk about some of the other methods of testing, because the method I use is blood testing. It's a serum progesterone.

Mark: Okay.

Lara: The trick with it is, this is really important, is the timing of it. Because I can't tell you, and you'll probably smile when you hear me say this Mark, because I'm sure you've seen the same thing. Patients bring a report to you with a day-two progesterone reading from another doctor. Like, how is that a thing? Like how is that... Yeah.

Mark: When you're not producing, yeah, why would you make it rather than... And sometimes people are not always aware of where they are in their menstrual cycle, as well. So, I mean, typically, we choose a day 21 just to stay about halfway between. How do you measure it?

Lara: Yeah, so let's debunk the day 21, because that can also get women into trouble. So, let's just say again, the luteal phase, the only time in the cycle we make progesterone is the final two weeks. So, if someone has a 45-day cycle, for example, which is normal for a woman under 22, down in that young age, up to 45 days is normal, up to 35 days even, for an adult woman.

But let's say someone has a 35-day cycle, she's ovulating on day 21. So, if you try to test on day 21, you've missed it. You're still in the follicular phase, essentially. You might get lucky and see the beginning of progesterone.

But progesterone goes up, it starts lower and then it peaks around that mid luteal and then goes down again. And even during that monthly cycle, there's a…what's the word? Not diurnal, but there's an hourly... Progesterone is cycling on a 90-minute cycle, so it's going up and down all the time. So, you do get quite a variation in the actual amount or optimal level, but it should be, if you’re week before your period, it should be, let's agree, like maybe greater than 25 or something like that, as an optimal level.

If a woman has an irregular cycle, she needs to interpret her progesterone reading after she gets her period. Does that make sense? Right? So, she needs to say, "Okay, I did this on day 28, because I normally have a 35-day cycle. So I should be mid-luteal if I'm seven days before my period." But then if the period's late, you have to go back and say, "Was that actually mid-luteal or was I still in the follicular phase when I did this blood test?"

Mark: Okay, so we do have a question.

Lara: Of course.

Mark: Just one question on that is, can you explain the luteal phase? I mean, in doctors' ones follicular is day one to 14, luteal is day 14 to bleed. 

Lara: Nope. No.

Mark: And that's not the case at all. So how do we then define the luteal phase? Is that the last 14 days of the cycle no matter what?

Lara: It's by definition, the final 14 days of your cycle. Because the luteal phase is time limited. Just remember the lifespan of a butterfly. It doesn't have long for this world, unless you become pregnant, of course, and then it stretches out for three months.

But the follicular phase can go on for weeks and weeks. If someone has a very long cycle, the follicular phase, you're just in the waiting room to ovulation. You're building up to ovulation. That can go on for ages.

Once you ovulate, basically, once your temperatures go up, once you ovulate, you know for certain that you're going to have a bleed two weeks later or be pregnant. There's no other way out of that situation. That's...

Mark: What, do we just run out of progesterone? Is it like it's got two weeks left…

Lara: The corpus luteum survives two weeks, unless it's rescued by the foetus, basically.

Mark: The pregnancy, right.

Lara: Yeah, the pregnancy rescues it.

Mark: Okay.

Lara: And this is important, because even just the other day I was talking to some practitioners who were eyeballing, it's like, "Oh, well, the luteal phase is the second half of the cycle, no matter how long the cycle is." That is not true. That is not true at all.

Mark: Yeah, it's false.

Lara: No, it's those final 14 days. And keep in mind, and again, this is all in the symposium, but we are doing a bit of overlap with my presentation, but that's okay. It'll be more formalised with slides and everything.

It is also possible to have a cycle where you don't ovulate, which makes it even more interesting. So, it's not just when is the luteal phase, but did you have a luteal phase? Because you could go on to bleed, you could have a great long follicular phase and bleed and never ovulate, never have the luteal phase. That is called an anovulatory cycle. I would say that is hormones 101, for anyone watching today. Like if you're working with women's hormones, you need to know what an anovulatory cycle is, and understand why that's happening.

Mark: What do you do when a woman comes and says, "Oh, some days it's 45 days, some days it's 28. Some days I'll miss out on a cycle entirely and go 60." Do you use the temperature at that point to determine that's the way of figuring where to look at the luteal cycle?

Lara: Yes. So you have her track temperatures. Once her temperatures go up, you can do the serum progesterone test five or six days later, which is redundant at that point, really, because if the temperatures went up, you know she's got progesterone. You almost don't have to test it. But you could test it just to have that number on paper. Obviously, I'm a huge fan of temperature tracking. I refer to it as the original bio-hacking. If you're going to measure anything with the body...

Women have this very cool built-in temperature shift that says so much about our physiology. So, the fact that the first, you know, tracking devices that Apple brought out, they didn't have anything about menstrual cycles or temperature tracking. It's like they just missed an opportunity there, because it's...

Mark: Well, I've even got a question, what's the best way of measuring temperature? So, do you go just plain old under the tongue oral...?

Lara: Under the tongue.

Mark: Standard oral. Okay, so nothing complicated?

Lara: It's not complicated. You could do it with an inexpensive temperature. I know in Australia, we have the chemists you can...I used to tell my patients to buy an ovulation thermometer, which just means it's calibrated. It’s not calibrated as a fever thermometer, because you're not going to see that kind of temperature rise. It's smaller, you're looking for two decimal points so you can... Yeah, you need to look.

Mark: That's an important message too.

Lara: It is.

Mark: That's an important message, because a lot of thermometers, they're absolutely paranoid about missing a fever at 40 degrees, and so they're calibrated to really ignore what's normal and to be very accurate in the 39 to 42 degree range. And that's often the miss, that if you just take one of those under you get an approximate then 0.3 of a degree maybe on the resolution, if you're down in the 36s, right?

Lara: Absolutely, yeah.

Mark: So, there's a couple of answers. All right. I've got, is it not possible for luteal phase to be shortened if there's issues like endometriosis or other health conditions? Is that a thing?

Lara: It is definitely possible to have a shorter luteal phase, for a variety of reasons.

Mark: Right.

Lara: A lot of that's going to depend on the quality of the ovarian follicle that made the corpus luteum. That quality of the ovarian follicle dates back 100 days, right? There's a...

Mark: Yeah, that's the fascinating story that I never told you.

Lara: I call it “the 100 days to ovulation,” in my book. For all of those 100 days as the follicles are being recruited, the pituitary is sending messages. And also it's affected by just the environment, like how much inflammation is there, how much insulin is there? All these things that could impair the quality of the follicle, including nutritional status, is there enough zinc? Is there enough iodine to get all the way there? Then the dominant follicle gets recruited, then it ovulates. And then, do you know that it grows from still quite small to a four-centimeter structure in the course of like 24 hours? 

Mark: Is that right?

Lara: It’s this crazy…there’s a quote from an Australian researcher in my book about, there's no other tissue in the body that does this. 

Mark: It’s like a flower.

Lara: Yes, it's like a flower. That's a nice image. So, no wonder when you think about all the vitality, all the energy that goes into forming a temporary gland out of nothing, that's why a healthy ovulatory menstrual cycle is a reflection of general health, right? It's why it's our monthly report card, because to be able to do that and to ovulate, you have to tick all the boxes to get there.

So, if you have a short luteal phase, one of those boxes isn't ticked. There's something, and it could just be under eating, right? It doesn't have to be complicated. But there's something that's not letting you get all the way to a robust ovulation and luteal phase.

Mark: Okay. There's one that I would like to address. Since progesterone is there right through pregnancy, and it is somewhat anti-inflammatory, is it immunosuppressive?

Lara: Yes.

Mark: Is that the trick, that it's immunosuppressive to allow the foetus to exist, a parasite in the body? Is that the story about why often joint pains and other things settle down in pregnancy?

Lara: Yeah. I think, yes. I think there's probably, like many topics, I think there's more nuance to it. But yes, in a word, yes, it's somewhat immunosuppressive. Which is why...you've just stated autoimmune conditions can, many of them, not all of them, but many of them can go into remission with pregnancy. And conversely, there are a couple of times when autoimmune conditions can flare. Those are times when progesterone drops dramatically. And those two times would be postpartum and perimenopause.

We wave goodbye to progesterone in perimenopause. You know, we, sadly, I'm through that myself, so I can speak from experience. It's a wonderful hormone, but by our mid-40s our luteal phase is not as robust as in our 30s. There's almost nothing you can do about that. I mean, you can optimise it to as great an extent as possible, but progesterone is becoming a thing of the past. That can result in flares of autoimmune disease like Hashimoto's thyroid disease. You typically see that during perimenopause, often, maybe postpartum and then again in perimenopause.

And the other thing that results from losing progesterone in our 40s, I'm going to let people chime in. I might just glance at the comments to see if people can guess what that other thing is. Let me just have a look. Losing progesterone in our 40s. No, no. Libido, someone is saying. Fair enough. Well, it's heavy periods, right?

Mark: Right.

Lara: Heavy flow, right?

Mark: Oh, really? Okay. Why so?

Lara: Well, because progesterone has a period-lightening effect, right? So, progesterone helps to mature the endometrium and prevent it from just this crazy shedding. So I'm sure you've seen, we've all, any clinicians, many of us have seen, perimenopausal women, late 40s having flooding periods. Like, crazy periods. Like, if anyone knows…

So, just to give some numbers, you know, the maximum flow of a normal menstrual flow should be about 18 millilitres over all the days of the cycle. So, really just, you know, four or five tablespoons over all the days, all the four, five days. Women with flooding periods at perimenopause can be losing like 250 or more millilitres compared to 80, right? 

And that's not everyone in perimenopause. I think the estimate is about one in four, maybe one in three women go through these years of perimenopause, when oestrogen is actually up to three times higher than it was when we were younger, and progesterone is gone.

Mark: Is that because the pituitary and the hypothalamus are picking up the loss of sex hormones and FSH, LH keep asking, and the progesterone can't respond, whereas the oestrogen can respond, being a much lower…

Lara: Think this way, it's a lot easier to make oestrogen than progesterone, right? Because to make oestrogen all you have to do is FSH stimulating the growing ovarian follicles, of which there's many of them.

To make progesterone, we have to make a corpus luteum, which is that feat that I just described, where you make a four centimetre gland out of almost nothing. And that is not easy to do. There are so many what I call “obstacles to ovulation." This is a long list, including insulin resistance, including, you know, iodine deficiency. And by the time we get to our 40s, it's just that much harder to ovulate. 

But exactly as you said, Mark, there is heaps of FSH stimulating the ovarian follicles. And it's been measured. Some women can have up to three times more oestrogen than they did in their 30s. So, that's the unopposed oestrogen. That's the ovulatory dysfunction. There's different names for that dysfunctional uterine bleeding in our 40s, when you just get crazy heavy periods.

Mark: Right.

Lara: That's when women end up going on the hormonal IUD or something, because, yeah.

Mark: Okay, so that is fixable? So is that where you use progesterone to top up, to try and get that balance right? Is that a possibility for women in their 40s? So, the corpus luteum cannot be escalated that quickly. Is that helpful to top up with bioidentical progesterone to bring say, hot flashes under control, heavy periods under control? Is that therapeutic, or not?

Lara: Yes. Let's talk about this. So, we're on the topic now of perimenopause, using oral micronised progesterone for perimenopausal symptoms, either of mood, migraines, flooding periods. I'm going to call on the research of my colleague Professor Jerilynn Prior, who helped me with my book. She runs this at the University of British Columbia in Canada, runs something called the Centre for Menstrual Cycle and Ovulation Research. And she's published close to 100 papers on progesterone.

She has protocols, for example, one of the ones I use with my patients quite a lot to share with their doctors is managing, she calls it managing menorrhagia, which is heavy periods, without surgery, without hormonal IUD. She uses 200 milligrams to 300 milligrams of oral micronised progesterone. We can put that in the show notes, the link to that.

Mark: Okay.

Lara: So that medication, it's a medication but it's a natural hormone, is called Prometrium in Australia, and the US it's called Utrogestan - these are the brand names - in New Zealand and the UK. Of course, you can also get it as compounded progesterone capsules, which is what women had to do for years because for so...we talked about this a little bit last time, Mark, do you remember? For so many years...

Mark: We did.

Lara: ...the only way women could get access to real progesterone, which is so beneficial, was through a compounding chemist, through seeking bioidentical hormones. And of course, got scorned for that and ridiculed, and the mainstream was like, "Oh, bioidentical," they're so against it. And now here we are finally, it's available as a mainstream medication, and now they love it. Like now it's like...

Mark: Well, you had to change the name.

Lara: Yeah.

Mark: They could never give up the fight. So, it was not bioidentical, it's body identical, identical in every way. But it is amazing, medicine never makes mistakes. When we criticise someone, we just give the answer, steal the answer, and call it something new, and then it's body identical. There are some well-known critics of complementary medicine that are very, very keen over the change of name.

Lara: Yes. Honestly, for me, I just want results for my patients. So, I'm rolling with the name change. It's like, say body identical when you're speaking to your doctor, your conventional GP especially. We can let the bioidentical go. Although I did speak with a clinician over in the states, who's still trying to, like reclaim the term bioidentical, because it's a perfectly good word.

Mark: I know. I know it's a perfectly good word. Is there a way to naturally, in that age 40, is there a way to naturally increase progesterone or are we bound simply to top it up? Is there a way of like bringing the corpus luteum back to life for the ripening of the follicles or is this just how fertility fails, that we go out slowly, not with a sudden bang?

Lara: I think there's ways to optimise it, managing our expectations. Like yes, I mean, we all know there's going to be women in their 40s who are still doing pretty well, not having those heavy periods, obviously, are still... Certainly, I've talked to women who kept having pretty regular ovulatory cycles, tracking their temperatures into their late 40s. So, it's possible.

I think just, like I said, you have to tick all the boxes. So, you have to not be insulin resistant, you have to have an optimally functioning thyroid. You know, you have to not have too much stress. You have to be fully nourished. You have to not be taking any medications that could interfere with it, all down the list.

And some of it's just luck too, genetically. I think, well, not think, I know some of us just have longer lasting fertility than others. There's just a normal range of about, you know, 10 years. This is one of the things, because I've just written, I'm hoping it'll come out next year, a book on menopause and perimenopause.

One of the things I want to really emphasise is that genetic aspects… so certainly, I've known many women who are very fit and healthy but still go through menopause in their mid to late 40s. That's just normal for them. So, a lot of it's a genetic blueprint when it comes to our ovaries deciding to...

Mark: It seems to be a sensible question, when did your mother enter menopause? Often is a predictor of what happens for the next generation.

Lara: Yes. For sure.

Mark: So, does repeated pregnancies have an effect on that? So, if you're not ovulating for, you know, five kids, the old days of five to 10 kids, you know, the kids were everywhere. If there's less ovulations, are you doing anything to preserve it more or is time just an inevitability?

Lara: Well, this is an interesting question. Because what you're referring to there in part, I think, is this idea that well, if we run out of eggs, does not ovulating as much, does saving eggs somehow delay menopause? Which would seem a logical extension of that idea that we run out of eggs. But the problem…it just does not seem to be the case. Because well, for one thing, being on the pill also stops ovulation for decades.

Mark: Sure. That’s true.

Lara: And actually, what the research shows is being on the pill brings menopause earlier, if anything, because it causes ovarian shrinkage. And I think for me, part of it I think comes down to, I think there is a lot more to that story that we run out of eggs. I don't think we run out of eggs. This is controversial. The research has been going back and forth, back and forth, but there's some evidence now, it's been there for a while, that we actually have what are called ovarian stem cells. That we don't run out of eggs. We do stop ovulating at some point, which is genetically programmed, I would say. There's an adaptive reason to do that.

But in answer to your question, I don't think not ovulating conserves eggs. But all that said, pregnancies themselves have different effects on health, so it is possible pregnancy alters the timing of menopause through some other mechanism. I don't know.

Mark: Okay. All right. There was a time I mean, we've got the experiment that youthful, when you could not prevent pregnancy, youthful pregnancies, repeated pregnancies were the absolute norm. And then suddenly, the pill comes along and we think of it as the pill just preventing pregnancy, but there is so much happened.  The previous generation of mine started on the pill, and it was saving pregnancies, but for the first time, gave women choice about when to become pregnant.

Lara: Of course, yeah.

Mark: And then that moved it from early in life to later in life. And I always wondered if there was some profound effect of that. That if you just shift the ovulatory cycles where they seemed to choose all a good eggs early, if you believe some of the literature. Is that the case or is it really just rubbish? That, you know, you've helped preserving your health, and you've got the capacity for the perfectly good pregnancies all the way through life until you stop?

Lara: Yeah, I don't think there's anything to that concept that you preserve eggs or anything like that. As to whether the egg quality in our late 30s and 40s, it’s not as good as the egg quality in our 20s. But that's the same for sperm, right? Sperm quality isn't as good in later years. That's going to be a genetic quality issue.

Yeah, but I mean, honestly, the fact that our life history is quite different now, women don't have a number of pregnancies when they're young, that is going to have effects on health long-term, but I don't think we quite understand what all of those are yet.

Mark: All right. Lara, I think what we're going to do is there are just so many…

Lara: It's good.

Mark: ...questions. I know. It's good. We've reached 40, and only about four of them are answered. Would you mind if I just went through a few things first?

Lara: Go through some questions, and if I think of something else burning that I really need to say, I'll just pop in with that.

Mark: Okay.

Lara: Yeah.

Mark: Okay, there are a few of them that are asking the relationship between the thyroid, and especially something that's becoming a much bigger issue mainly for women, of Hashimoto's, so the autoimmune thyroiditis. It's becoming a bigger and bigger problem.

Does managing the thyroid, the sense of the question is, managing the thyroid is essential for temperature as well. So A) you can get mistakes that if the thyroid is underactive, you're getting low temperatures. Does that also mean low progesterone? And does fixing the thyroid, or focusing on the thyroid automatically help fertility, progesterone? Does it work the other way, that if you get the thyroid right, the hormones come back to life when they may not be good at that point?

Lara: Exactly. Yes, what you just said. Well, if there's an underlying problem with thyroid, that is one of the boxes that needs to be ticked to achieve good ovarian follicle quality, good ovulation, good levels of progesterone.

So, in the past I've done for social media, a little image of progesterone and thyroid, and a two-way bi-directional. There is a bi-directional relationship in that healthy thyroid is essential for healthy ovulation and therefore, progesterone. And conversely, progesterone, well, it's a couple of things, but progesterone itself directly stimulates thyroid, so it does boost T4 levels, which is interesting.

But also, probably more importantly, is in the territory of autoimmune thyroid disease having anovulatory cycles of being in postpartum at the time of low progesterone potentially increases the risk of autoimmune thyroid disease.

Also, with my perimenopausal patient groups I have observed that taking progesterone can help with thyroid antibodies, and help to stabilise autoimmune conditions, including thyroid. So, in terms of the temperatures, yes. Ideally, what you want is a baseline healthy thyroid, then that's your baseline temperature. And then you still get the luteal phase on top of that.

Mark: The relative in place.

Lara: Yeah. But if you have an underactive thyroid, typically what happens with the cycles, anyone who in the audience, I'm sure there are many people who do fertility awareness method or fertility tracking, and use really deep dive looking at the temperatures, what you see with underactive thyroid is the luteal phase doesn't hold. You get this rise and then you get these drops in the luteal phase, which is usually a giveaway that something's going on with the thyroid. Plus, you'll see that overall, the baseline follicular phase is lower. Yeah.

Mark: Okay. Does that impair fertility? So, hypothyroidism is typically associated with relative infertility, but we think of that as just a metabolic issue, but it can be directly in the progesterone not being sustained over the cycle…

Lara: It's also the health of the ovarian follicle, probably, and yeah, the sustainability of the corpus luteum, the whole picture. Plus, the thyroid antibodies, the autoimmunity is not ideal for fertility either. Yeah.

Mark: I know, and we have a gluten relationships with thyroiditis and Polycystic Ovarian. There's a lot of fiddling between the gut, food, diet, autoimmunity and how our hormones function.

Lara: Yeah, for sure.

Mark: While we're dealing with one big one today, I have a sense that if we look at every hormone, we would see the same fiddling going on. When you've got autoimmune endocrine disorders, the whole hypothalamus is trying to organise how. Where is my progesterone, where is my thyroid hormone? And sending messages which are not stable and able to maintain stability for months.

Lara: For sure.

Mark: I've got a group of questions about, can you just manage? People who present with heavy periods at whatever age, is that a) likely to be progesterone-related? So, if there's been a change, they've had a normal cycle and it becomes worse as they're in their, say 30s, is it progesterone-related? And can you stop heavy periods by just simply supplementing progesterone in the second half of the cycle?

Lara: Okay. The short answer is yes, progesterone always has a period-lightning effect. So, if it's an appropriate treatment, that's an option. But it's not the whole story. So of course, my approach, and I know yours would be as an integrative doctor, is to try to go back to the underlying cause of heavy periods, which sometimes is anovulation, or not making enough progesterone, or not making any progesterone.

Sometimes, that's the main cause. In which case, the solution could be to get progesterone but also to correct the reason for the anovulation. In the case of a teenager, that's just because she's young and needs to, you know, have a few years to develop her menstrual cycle. You can support her, in the meantime, with some other period-lightening strategies which I use, which I'll talk about in a minute.

But the other thing with heavy periods, of course, you also, especially with, well, any woman really, but especially into the 30s and 40s, you need to identify what else is going on. Like, is there adenomyosis? Which is, as you know, quite common, the major cause of heavy periods, and requires treatment beyond just progesterone, I would say. It's an inflammatory disease.

Mark: Got it.

Lara: Is there a fibroid that's causing the heavy periods? And there could be fibroids present, but they're not the cause of the heavy periods. But if the fibroid is the cause of the heavy period, then that needs to be understood.

Also, I'm curious about if you've sort of worked much with this, but my understanding from the research is about one in five women who are having heavy flooding periods have, is it Von Willebrand’s, have coagulation disorder, a genetic coagulation disorder.

Mark: Oh, right.

Lara: And sometimes the heavy periods can be the only sign of that. Well, they might have heavy periods all their life, easy bruising, maybe haemorrhage after delivery, those sorts of things for the mild, just some of the milder coagulation disorders.

Mark: Okay. So that, I mean, that suggests that if you work through all the other obvious, all other not so obvious causes of bleeding, that's the fibroids, the adenomyosis, if you don't have clotting and coagulation, that it's more or less progesterones at the end of that line. That as long as you've excluded pathology and made sure that there is nothing serious that needs to be addressed, then the progesterone trial is a reasonable thing to do to to modify?

Lara: Progesterone always lightens periods. And this goes back to Professor Prior's managing menorrhagia without surgery, I would argue even without the hormonal IUD. So, let's talk about the hormonal IUD for a minute, because I'm not against it. As you know, it can be, for women with very heavy periods, it can be a lifesaver. Especially if it means she doesn't have to have a hysterectomy, then I would say a hormonal IUD is preferable to hysterectomy.

So, that's the drug. There's no progesterone in that, even though they call it a progesterone IUD, right? That's levonorgestrel. That's a progestin. And it does lighten periods quite dramatically, but it potentially can have side effects, because progestins affect mood, for example. So, that's where trying some progesterone instead, at least trying it, can be helpful in combination with...I really do need to mention a couple of other things for heavy periods for anybody who's out there and that's one of their main concerns, or they have patients who that's their main concern.

There is a role of mast cells and histamine in heavy periods, and that is because the uterine lining is full of mast cells. And in addition to releasing histamine, they release heparin, which is a blood thinner, as you know. So as a naturopath, my approach with heavy periods is also to address that inflammatory mast cell side of things.

Once again, that comes back in my clinical practice, to trying some months without cow's dairy. It's not a perfect fix for every single person, but I think if someone's dealing with heavy periods, they need to at least try some months without cow's dairy. They might find that it lightens periods quite a lot. That is particularly true for teenage girls, young teens, because I don't want to give a progesterone, who wants to give a progesterone capsule to a 13-year-old girl, right? Like, that's just not what we're doing, and certainly not what I want to do. And they can...

Mark: At that stage in life.

Lara: Yeah, if you take dairy out, give iron, because they're probably iron deficient, or if they need it. Also, being iron deficient makes periods heavier, so it becomes a vicious cycle. Also make sure she's fully nourished, especially with zinc. You will find those girls again, the period lightens pretty quickly, and then hopefully, she starts to ovulate and then makes her progesterone, and then, you know, she grows out...

Mark: That's the critical thing that I got from your writing, is getting to the ovulatory cycle has a natural cycle forming effect. So it's chicken and egg, you know, how do you get to that point? And you're saying diet can bring you back to the point where the normal ovulatory cycle repairs the very thing that you thought you were trying to fix, which was menorrhagia.

Lara: Exactly.

Mark: And so you can do it with diet indirectly, as how long-term sustainable.

Lara: Exactly. So, put it this way, the body, well, if you're under 45, under 50, your body wants to ovulate. It's going to do that. It wants to do that. And so it's really about, as I said earlier, identifying what are the obstacles to the body doing that, and removing those obstacles so it can get there. Yeah.

Mark: Great. That's great advice. There's two things that I want to do.

Lara: Okay.

Mark: We've got a couple of minutes. One of them is there's a lot of questions about why are you measuring serum progesterone, why not the salivary or the urinary test? Or why not test all the metabolites of it and go, so there is a list of other types of tests around that do this. Why would you choose serum rather than the urinary, for example?

Lara: Well, for a lot of testing, I'm sure you can agree, anytime you choose a test the question is, what am I asking with this test? What am I trying to understand with this test? So, certainly, there are questions that could be asked, where you might need to look at the metabolites, questions around that.

But if the question is, is my patient ovulating and making progesterone, and does she have a luteal phase? A serum reading...

Mark: That's a simple answer, isn't it?

Lara: ...answers that question. For me, I'm a very for-the-people kind of clinician, like, it's also the cost of it actually, for me. It's inexpensive, and simple, and simpler in a way. It answers what I'm trying to answer. If I was going to order more testing and more complicated testing with my patients, it's always going upstream from ovulation to try to identify what's inhibiting it, including insulin resistance. I can't emphasise that enough.

We're going to talk about that next Sunday in my presentation. I'm going to show a glucose tolerance test with insulin, we're going to look at a case study about PCOS and insulin resistance. But for a lot of women, insulin resistance is the major obstacle to ovulation. So, if you don't identify that with your patient, you've missed an opportunity to actually correct the problem with progesterone, if that makes sense. I'm connecting the dots between insulin via the ovarian follicle to progesterone. Progesterone is the reward. It's the ultimate downstream hormone.

Mark: All right, so in that reward, the final question is going to be, what do we do about menopause? There's good and bad oestrogen and progesterone. There's so much confusing information out there. Is it safe to simply provide progesterone unopposed? Do you try and match the body's response, or do you let women enter menopause and then work at diet or other things? How, I don't know if this is the question, is how do we manage menopause?

Lara: Okay, I'm going to answer and then I'm going to let you chime in, because I'm sure you've prescribed hormones and have worked in this field as well. But yeah.

Mark: I'm old enough to have been through menopause but, I am the wrong sex to have it, so I'm not an expert there.

Lara: Okay. I'm just thinking in which order to say things. It is safe to use progesterone alone. In fact, Professor Prior, we saw her face pop up earlier, she's got a couple of clinical trials using progesterone alone for symptoms of both perimenopause and menopause. So it's safe.

Now, that is not to say that oestrogen cannot be used. So, progesterone is safer than oestrogen. Progesterone is safer for breasts, there's that. In fact, Professor Prior argues that progesterone helps to reduce the risk of breast cancer, which is quite interesting and important.

But some women with menopause, especially early menopause, do require, also require oestradiol, preferably transdermal. If you're going to take oestrogen, let me say you really want to take it through a patch, or a cream, or topical. It's a lot safer that way, in terms of clotting risk. And if you are going to take oestrogen, you should take it with oral micronised progesterone as your progestin. And that's true even if you don't have a uterus. Would you agree with that, Mark? Yeah, because... Yeah, what do you think?

Mark: What are you protecting there? So, it's for the neurological effects?

Lara: Breasts.

Mark: Breasts? Of course.

Lara: Breasts, and brain, and mood. So, I know the narrative, the prevailing narrative is that we only need progestins for the uterus. But that is just not the case. That all dates back to the historical... This is the crux of the problem, actually. Progestins were only ever seen as a…well, they're part of hormonal birth control, but also as a way to protect the uterus. They were an afterthought, right? No one looked at progesterone for its own merits, and had how beneficial that could be for all the different systems, except for Professor Pryor, and obviously, you know, various clinicians.

But progesterone can be used for perimenopause and menopause. And then what I say with my patients is try progesterone first, or try magnesium first. Try all the other lifestyle things first. If you need something, try progesterone. If you still need something, bring in a transdermal oestrogen. It's valid. It's much safer than the, as you know, much safer than the old style oral primer and oestrogens. That old style HRT from the 80s, 90s, I started practicing in the mid-90s, those were horrid medications. I mean, those days are gone.

So, okay, and I just...I see a question just popped up.

Mark: I just put a poll up for do you want to go…

Lara: There was something else I was going to, oh, I was going to say about progesterone for perimenopause, very specifically for migraines. Because as you know, it has an anti-migraine effect, because it has a calming effect on the nervous system. And migraines, recurrence of migraines or an increase in the frequency of migraines is a classic symptom of perimenopause, and it's from losing progesterone.

Mark: Okay. All right. So, is this migraine some people had early on in life or is are these new migraines? Is it just simply…

Lara: Usually, here's the pattern, which I've seen with my patients. Someone might have had migraines when they were a teenager, like at puberty first started getting migraines, then they grew out of them. Then they got migraines when they tried the pill and then they stopped them. And then their migraines start up again in their 40s, or become more frequent in their 40s. Progesterone is quite good for that, in combination with magnesium.

Mark: Okay. Any other thoughts? Beyond milk in the diet, have you found any of the things that are, I mean, all of us hate gluten to a greater or lesser extent, because of the groups of people who are not coeliac, but gluten and non-coeliac, gluten intolerance. Gluten tends to be a pro-inflammatory part of the diet, is it important in this area, or is this more thyroiditis that the gluten reactivity is?

Lara: Well, as you know, gluten can affect every system. It absolutely can affect progesterone. So, the way I come at it, there's a certain portion of the population you have the genetic, the genotype, the haplotype, who reacts to gluten.

Mark: Yeah, it's a decent proportion. I mean, it is around 15% to 20%, so it's not trivial. And only 10% of them ever get coeliac disease, which is the only thing that doctors ever think of, related to that. But that's not true, is it?

Lara: I've actually started just ordering that genotype for my patients. I think it's really quite helpful to know if you have that coeliac autoimmune gluten genotype.

Mark: Yeah, I agree.

Lara: If you do, that is going to affect everything, including ovulatory cycles and progesterone. So the very first patient story in "Period Repair Manual," my book is, I think her name, I called her Meaghan in that story. She had irregular cycles coming, you know, every two to three month-long cycles. And her doctor said, "Just take the pill," of course, which is not a solution for irregular cycles.

But we discovered that she was sensitive to gluten, not coeliac, but gluten-sensitive. As soon as she removed, not as soon, but four or five months after she removed gluten, she got a regular cycle. Her progesterone would have gone up. Just having a more regular cycle means more progesterone, because you're ovulating more frequently, and her levels, you know, went up as well. So, that's an example.

The other place where gluten and the coeliac genotype plays a role is in endometriosis and adenomyosis. This is a little bit off topic, but it's really worth mentioning, because I won't be speaking about endometriosis next weekend, unfortunately. I'll have to have me back for a whole talk about endometriosis.

But the...

Mark: Don't worry, there's a Q&A section.

Lara: We could talk about it in the Q&A. So, there was a quite fascinating reproductive, his qualification was a reproductive immunologist, Jeffrey Braverman, who unfortunately has passed away now. But he was doing this fascinating work with his infertility patients, where he was testing everyone for coeliac genotype, for the haplotype, the HLA haplotype. And he found amongst his patient population that 95% of endometriosis sufferers have that.

So, I would say, this is my approach to endo. It's, you know, it's a disease of immune dysfunction. I'd say adeno, it's probably in that same category. So when there's that type of thing happening, or as you say, Hashimoto thyroiditis, then you really need to bring gluten front and centre as something to think about, and probably eliminate quite strictly. Yeah.

Mark: Okay, so the answer seems to be that you would take people off milk as the primary thing, all milk products, dairy, all milk products.

Lara: Yeah, keep going. Yeah.

Mark: Yeah. And secondarily, you still look for other foods that may be proinflammatory. Is it inflammation control you're after, or is it specific foods? Why is it that milk is so…?

Lara: Yeah, it's A1 dairy. So it’s that A1 casein stimulates mast cells in certain people.

Mark: Right.

Lara: So the A2 dairy would include goat and sheep products, and A2 milk as well doesn't seem to have that same effect. So in terms of just a general, because of the mast cells in the uterine lining, I would do general, try no cow's dairy for a while, for anyone. And that doesn't have to be strict. If it's not someone with an autoimmune tendency, I'm like, "Just dial down the cow's dairy." From the histamine mast cell perspective, that seems to be enough.

I put people who have that coeliac genotype, I put them in their own category. They're like in their own room, unfortunately. You know, that's a different situation. I sometimes use thyroid antibodies as a surrogate marker for that, or a family history of autoimmune thyroid disease. If you've got those autoimmune genes, you're now in a different room. We go into that room, and now we have to have a conversation about strictly avoiding some of the antigens, and possibly casein, gluten would be right up there. Sometimes eggs, you know.

Unfortunately, once you're in that autoimmune territory, you can't just probably just dial down things. You really have to make a decision to try to avoid them strictly for a while. Would you agree? Yeah.

Mark: Yeah, I do. I do agree. I think this is another one of those areas where if you can get the gut right and the foods, and the non-histamine release on the gut, make sure gut permeability is right, you do so much to settle down a hyper response in the...

Lara: For sure.

Mark: ...immune system. That it's in that surveillance area, and if the gut is forever switching it upwards, then you have to drop it down. The funny thing I thought was some people would prefer all the worst bits of premenstrual syndrome, of heavy bleeding or anything else, and to still have their bread. I'm amazed that gluten almost seems to be addictive. I'd be surprised if it wasn't, that people would sacrifice anything to get their bread and their pizza, even when they're well.

Lara: Well you know about the opiates, the case of morphine and gluten. Like, so literally, for some people...

Mark: I do.

Lara: ...yes, casein and gluten are quite literally addictive. Not for everyone. But yes, for the unfortunate people who, and those are the people who most need to avoid them, they form an addiction to them. It's not easy.

Mark: I know. I know. I am amazed that people come and say, "Help me with thyroiditis." So, women with thyroiditis. And when you say, "Okay, you're going to have to come off gluten," and there's a "You know, the thyroid, honestly, is not that bad. I can get by with that."

But when they do come off it and they get the benefits, I am surprised to this day that if the gut is right and the diet is right, and you put that effort in, about a half of the downstream specialties of medicine are irrelevant. You know, the rheumatologists and some of the immunologists, we've ignored the gut for so long, and now we're suddenly discovering it again. The basic parts of the diet, exercise, gut, I'm sure we're going to hear more about these from you. 

I want to thank you for today, but it's easier for anybody. They're going to be back in...I think it's the 14th, is that right?

Lara: It's the 14th in Australia, so I guess that would be the 13th in other parts of the world, because we live in the future.

Mark: We do live in the future. But New Zealand is even ahead of us, so that's serious, maybe. So, I want to thank you for the time.

Lara: Yeah.

Mark: It's been great to cover all these areas. It's a teaser for what's yet to come, but it does help us cover progesterone and its different focuses for your presentations on the 14th. But everyone should be back. I think everyone will be back there listening a second time.

So, thank you, Lara Briden, it's been fantastic.

Lara: Yeah. Thank you, everyone. Thank you, Mark.

Mark: Thank you very much. This is Mark Donohoe, with Lara Briden for FX Medicine, and we'll see you all tomorrow. We start the Bioceuticals Symposium, 2020, a whole different way of doing it. I'll see you all online tomorrow. Bye.

Other podcasts with Lara include:


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