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Interpreting Pathology: Hormones Beyond Fertility & Reproduction - Emma Sutherland and Rhiannon Hardingham

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Interpreting Pathology: Hormones Beyond Fertility & Reproduction

Lab diagnostics are critical for guiding and monitoring treatment plans. But are we using them to their full potential?

So often women’s hormone pathology results are viewed solely through the lens of fertility and reproduction. Listen in as Emma Sutherland and Naturopath Rhiannon Hardingham discuss how these test results can be used for so much more: from identifying hormone dysregulation to determining overall health and wellbeing to getting a patient’s “mojo” back.

Covered in this episode

[00:55] Welcoming Rhiannon Hardingham
[01:27] Why pathology is important
[02:53] Rhiannon’s background
[05:02] Practicality in natural health
[06:59] The importance of pathology testing
[10:16] Testing hormones on cycle day 2 
[11:29] Hormones to test for at the luteal peak
[12:41] How hormone receptors impact the hormone’s effect at a cellular level
[16:19] TSH and DHEA: key hormones essential for “mojo” 
[22:09] Diagnostics for oestrogen dominance
[28:01] The great Vitex debate
[32:17] When to use the steroidal saponin herbs
[33:51] Black cohosh and migraines
[35:34] Pathology indications for using adaptogens:  rhodiola, Withania and Panax ginseng
[40:57] Herbs for adrenal androgen production vs for ovarian androgen production
[43:25] Rhiannon's advice for a successful practice
[48:04] Thanking Rhiannon and final remarks

Emma: Hi, and welcome to FX Medicine, where we bring you the latest in evidence-based, integrative, functional, and complementary medicine. I'm Emma Sutherland, and joining us on the line today is naturopath and nutritionist, Rhiannon Hardingham. We'll be discussing hormones and lab test results, and how to interpret them as overall indicators of women's health. Welcome to FX Medicine, Rhiannon.

Rhiannon: Hi, Emma. Thank you so much for having me. It's good to be back at FX Medicine.

Emma: Yeah, we're loving having you back.

Rhiannon: Great.

Emma: Now, today we've got such a chunky topic. But in clinical practice, lab diagnostics are critical as they help both guide and monitor treatment. They're also a brilliant tool for educating and empowering our patients in taking ownership of their health. 

Now, I don't know about you, but I'm endlessly fascinated with reading both my own and my patients' lab reports because I feel we can learn so much about the inner workings of that individual in front of us.

Rhiannon: Absolutely. It is an under-utilised tool often, especially considering that there is so much that can be seen and interpreted through just basic standard Medicare-rebated pathology. A lot of these patients will already have a history of some of this bloodwork and if you really thoroughly understand what you're looking for, then you can go back through their history and understand a lot more about where they are in their health journey now based on what they've been through, without having to go ahead and do a lot of expensive and complicated tests.

Emma: Yeah, yeah, I feel that's a good point. Just cover the basics and glean information from what they've already had done before you start doing some fancy stuff yourself. 

Now, Rhiannon, you've been a guest on the show in the past, but for those listeners who may not be familiar with your work, can you tell us a little bit about your background and also what inspired you to become a naturopath?

Rhiannon: Yeah. Well, I guess my story is a little bit usual in that it was a health crisis in my early 20s. I think like a lot of especially female naturopaths, a hormonal reproductive health crisis in my early 20s. And that led me to want to better be able to heal myself. So from that perspective, it was really about me, to begin with. 

But also prior to that, I had a fairly unconventional upbringing, as you might be able to ascertain from my name. You might just say “hippie parents,” so vegetarian diets, very alternate healthcare, wherever possible, as little conventional healthcare as my dad, in particular, could avoid. So I guess it was in my genes. 

I did think earlier that I wanted to do something creative and had two false starts with art degrees. And turns out I wasn't a terrible student, just absolutely terrible at picking what I was good at.

Emma: It's not easy to work out.

Rhiannon: Yeah, that's right. Yes.

Emma: Yeah. I really love that. I mean, I was lucky I grew up with parents that gave me Echinacea and vitamin C all throughout winter and looked all of that side of things. So I think for naturopaths like us, it almost feels like, well, that's the first choice, isn't it? Like, that's sort of just what you do. But I find it fascinating what inspires people to become naturopaths. I really do.

Rhiannon: It is interesting. A little non-conventional path.

Emma: Yeah, exactly. Now I've done a heap of your courses, I have to say.

Rhiannon: Thank you.

Emma: And I just love how practical you are. Now, that practicality, it's not something that we're born with a lot of the times. Were you born with it? Did you have to learn it? 

But being practical as a naturopath I think is a big success marker because we have to be able to work with our patients in a way that they can roll out the advice that we give them, and practicality is a success piece, I think. But how do you find it?

Rhiannon: I think that, as an extension, actually, the story that I was just giving, I found actually that I was quite practical when I started studying naturopathy. I guess in an academic way I found that I was practical. I ended up getting...I was definitely not a straight HD student by any means. The amount of effort I put in would hardly allow that outcome. But I did get HDs in biochemistry and I loved, loved biochemistry. I'd get right into these assignments and get right down to a molecular level of understanding what was going on in the body. And my mind was blown by that. And it just, if I can knock something out from a physiology and mode of action perspective for our medicine, then I feel really empowered in my capacity to be able to understand what's going on to my patients and to help them really holistically. But that finite level really makes such a big difference to my overall understanding.

Emma: Yeah. And I think when you understand it on the micro, then you understand it on the macro, and you can see how it all falls into place. And with that lens of you really loving mechanisms of action and working out the why behind things, can you first explain the importance of working with pathology tests in clinical practice? And then, secondly, tell us why we need to be testing certain hormones on specific days of the menstrual cycle.

Rhiannon: Yeah, as I say all the time, my mentor has been Rachel Arthur now for many years. So clearly she has influenced me in many a way, but probably no greater one than the practicality and accessibility of pathology interpretation. 

From a hormonal perspective, I think that we have a lot to learn, and we are uniquely positioned to help women to better understand their hormones than most other practitioners. Because for better or for worse, conventional medicine doesn't have a lot to offer women beyond pharmaceutical hormonal interventions that for some women, obviously, are contraindicated and for many women are unfavourable for all sorts of reasons.

Emma: Yeah.

Rhiannon: But what is often missing also from a conventional perspective and it's entirely reasonable considering that the interventions that they have to offer are not really reliant on the complexity of hormonal interpretation, but what patients often haven't had thoroughly explained to them is what their hormone tests are showing about their underlying hormonal health status. And there is so much that can be gleaned from a day 2 or day 3 hormone test and a peak luteal, maybe sometimes conventionally known as a day-21 hormone test. From those two tests alone, you can understand so much about what's going on with her menstrual cycle and all of the hormonal symptoms.

Emma: Yeah, I actually find it really fascinating clinically when you explain to that woman sitting in front of you what those hormones are, what the purpose of them are in her body, and what her levels are telling us. It's like this inner window to her that she perhaps has never heard before.

Rhiannon: It's amazing, isn't it? And you see the light bulb go off. And so many times women have said to me, "How did I get to 35/40/45 and never know this about myself?" Well, it's just, unfortunately, it's not common knowledge.

Emma: Exactly. It is not common knowledge, and I think that's one of the big things that we as clinicians can be educating and helping women with in understanding their hormones, is when they do their testing and why they do them on those specific days. 

So what hormones, in particular, are you looking for on day two/three?

Rhiannon: So on day two/three, I absolutely ensure that I'm getting the gonadotrophin, so an FSH and LH, and certainly an estradiol. And then if I had my way, I would also ensure that I had a prolactin. That time of the menstrual cycle the prolactin should be at its lowest. So it's a good time to assess whether or not there is any potential for hyperprolactinemia. 
And also it's not essential to do it at the early part of the month, but certainly, anti-mullerian hormone is slightly advantageous earlier than later in the cycle. And androgens also are slightly advantageous, not so much

DHEAS but androstenedione and testosterone tend to be a little bit lower at that time of the menstrual cycle.

Emma: Right. So capturing the baseline level of a woman's hormones is the goal, right?

Rhiannon: Yeah.

Emma: But then what about that peak luteal phase? What are you looking for at that point of the cycle?

Rhiannon: Yeah. So, of course, the standard test that's done then is progesterone. And of course, we're just doing that to ensure that she's ovulated, or conventionally they're doing that to ensure that she's ovulated. But from our perspective, it is also to give us an indication of how functional the ovaries are because, of course, your progesterone level is a reflection of the corpus luteum size, and the corpus luteum is directly affected or influenced by our ovarian functionality. And also then the relationship of that progesterone to estradiol gives us a lot of information about her luteal phase symptoms as well as her potential fertility, of course. And if there is that real potential of hyperprolactinemia or latent hyperprolactinemia, then that is another important time to assess prolactin.

Emma: Yeah, yeah, it's just so fascinating, isn't it? I absolutely love it. But, I mean, we're looking at these blood levels of these hormones. So that's one thing. But how do hormone receptors actually impact a hormone's cellular effect?

Rhiannon: It's so important to always keep this in mind. It's not just what you're seeing on paper that gives you evidence that this patient has, let's use progesterone as an example, sufficient progesterone. Because the localised impacts of that progesterone in the uterus have a lot more to do with the capability of the progesterone receptors in the endometrium as opposed to how much progesterone there actually is. 

So if those progesterone receptors are overwhelmed by the relative oestrogen receptors, then they will be less functional. And if that progesterone is less available than it might look, then there may be insufficient progesterone to interact with those receptors. So then, despite decent looking progesterone levels on paper, you might see some luteal phase deficiency signs that makes you think that actually her body is not picking up that progesterone in the way that it probably could be.

Emma: Yeah. And I think this is a great example of that perfect interplay between how much weight and value do you put on the numbers in front of you compared to how much weight and value you put to what the woman is saying in her signs and symptoms. And marrying that and finding a good balance between the two is always so critical.

Rhiannon: Isn't it? And that is the art of nuanced clinical practice that you absolutely continue to build on through your whole career, I'm absolutely convinced. Every year I will look back and go, "Oh, wow, I'm actually much better at that this year than I was last year." 

It just is so important to take everything into account when you're seeing an individual. Everything that they're saying about themselves, all the things that you're gleaning about, those answers that she gives you to those critical questions that you really need to ask in every consult alongside the pathology. And then putting it all together so that her individual picture makes sense, not trying to fit her into a wrong-shaped box, if you like.

Emma: Yeah. And I think that's something that we will cover a little bit later on in relation to oestrogen dominance. But I think that this is truly an art and it does take a lot of practice. So for those practitioners out there listening that feel like that they're not there yet, you never feel like you're really there. So just keep your mind open to more and more learnings as you go along.

Rhiannon: Yeah. And, again, absolutely something that I've entirely borrowed from and been influenced by Rachel Arthur, but mentoring, it just makes all the difference. I certainly wouldn't be where I am today without the mentors that I've had. And I think that all of us no matter what level we're at really benefit from generational mentoring.

Emma: Yeah, I would 100% agree, and something that I'd do myself as well. 

Now, I'm really curious, Rhiannon, we're here to talk today about diagnostics, lab diagnostics, women's health. But when I think about women's health, I kind of want to zoom out and talk about something that I call “mojo," that sense of when a woman feels really good in her own body and she feels strong and healthy. What are the three key things that you want to see on a blood test that reflect potentially that sense of mojo?

Rhiannon: It's an interesting question, isn't it? And again, of course, that clinical art of interpreting what is normal for her is key, and one that always springs to mind around that is thyroid function. If a woman is carrying a little bit more weight and her TSH is sitting in the low ones, then that is probably not the correct thyroid. So the TSH might look good according to what we consider to be optimal reference ranges, but actually, her TSH should probably be sitting over two so that it is telling her body that her metabolism needs a little bit more oomph to it. That's a well responsive thyroid. 

So thyroid would be one of them, for sure. And certainly, I want to say a TSH of 1 and a T4 of 16. I would say more so that it is relevant to her picture if she is naturally slim and her body doesn't need a lot of metabolic push, then you'll see her TSH sit low and her T3, T4 sit in the good moderate, high normal levels, and she'll sit like that forever. But as I said, if on the other hand her metabolism needs a bit of oomph, then her TSH should sit a bit higher with the T3 and T4 in good ranges. 

Probably my key one though, and you, Emma, have had me talk about this a lot but DHEAS is, I think, really undervalued routinely from a, let's say, mojo perspective.

Emma: Yeah, agreed.

Rhiannon: Yeah, it just shows us so much about our adrenal resilience. Of course, probably most of us know it more routinely as an androgen and a marker of PCOS or otherwise. But it is, of course, an androgen produced by the adrenals. It is a pre-androgen. So it's a precursor, of course, to androstenedione and testosterone. 

But more importantly, from a mojo perspective, if our adrenals are not competent at producing adequate DHEAS, and the research is now showing that our resilience to stress and our long-term resilience to disease is actually significantly compromised. So I'm always looking at that in relation to the impacts of chronic stress and the impacts of chronic exhaustion.

Emma: Yeah. Yes. Yeah, I love that. I mean, when we think of those big metabolic organs, your thyroid, your adrenals, I mean, they're just so critical. But I do notice, working with women, that their DHEA levels are often right at the bottom of the reference range. And the woman is telling me, "I'm exhausted. I'm tired. I’ve just got brain fog." So you see this rolling out with your patients. It's such a good marker for us to keep an eye on.

Rhiannon: It really is, isn't? And it's both confirming and concerning. I mean, I always talk about postpartum depletion. And most women will show low DHEAS in the year after having a baby as a direct result of the exhaustion. However, those who bounced back well, you see their levels come back. And those who really are fundamentally… and one of my gorgeous patients who I spoke to last week had a picture of this, she has twins, and, not uncommon for twins, a somewhat traumatic pregnancy and birth and a really significantly depleting postpartum period. And her girls now are close to two and her hormones are still looking like a mum six months postpartum. 

So it's patients like that whom I'm like, “Okay.” I really pulled her up last week, I'm like, "Okay, you need to get sleep. These kids need to be looked after but someone else - thanks, husband - needs to do a little bit more work around here because this is actually integral for the future functioning of your family that we get you rested and restored and we get your adrenals back on track." And it's possible but it actually needs to be conscious and it needs to be a priority, otherwise it may never happen.

Emma: Yeah. I know from personal experience to bounce back from having very low DHEA is so much harder than to maintain a reasonable level of DHEA. So...

Rhiannon: Yeah. It is.

Emma: Yeah, that's a really good point. 

I wanted to talk about something, a bit of a catch-all phrase, oestrogen dominance. I just wanted to delve into it and just perhaps debunk it a little bit or go through it a little bit. So, technically, what is it? I've noticed more and more patients coming in to see me stating, "I have oestrogen dominance." 

But I want to know is how do I identify it, and when do I actually look for it? Because it is a catch-all phrase, but I think when is oestrogen dominance truly the issue, or when is the issue actually excess estradiol relative to progesterone? I've got so many questions about this.

Rhiannon: And it is, I mean, you're right, it absolutely has become a catch-all, and then there's this sort of resistance movement going on in our profession a little bit denying that it exists at all. And, honestly, I think that it just comes back to what we were saying about nuanced clinical interpretation of the circumstances for the individual in front of you. 

Which is that it absolutely exists for some women and it absolutely does not exist in other women who have been told that they have it or who had been treated for it, but for whom the practitioner or, in the case of a self-diagnosis, the individual, hasn't actually done the investigations that warrants that, let's say, diagnosis.

Emma: Yeah. Run us through what diagnostics would you consider to be gold standard for someone to be actually oestrogen dominant?

Rhiannon: Well, the basics are the two well-timed estradiol assessments. So at baseline on day 2 or day 3 of your cycle, you really ideally want to see an estradiol below 200. Above 200, certainly even medically is technically — when I saying medically, I mean from a IVF perspective — is considered to be excessive. And then again, in that peak luteal phase test, and by that what we're technically saying is ideally seven days after ovulation, whenever that may fall, whatever day that may fall on for her, we are wanting to see an estradiol somewhere not too much higher than, as you know, there's a bit of nuance to this, but let's just say, for ease sake about 600 or 700. But the relationship to the progesterone matters. So if her estradiol is 500 but her progesterone is only 30, for example, then you might actually consider that that estradiol is excessive at 500.

And then of course the other factors really involve her symptom picture, whether or not she's presenting as having challenges with oestrogen detoxification and whether or not she's suffering from the symptoms of excess oestrogen. I'm not going to treat a woman with an estradiol of 700 in the luteal phase for major oestrogen excess if symptomatically she had absolutely no issues whatsoever, her progesterone was doing well, her cycles were normal, her fertility was fine. That's not going to bother me. But if she's suffering, of course, then we're going to investigate whether or not that is part of the picture for her.

Emma: Yeah, I think that's a great conversation because I think sometimes we are a little guilty of going looking for a problem and then applying a set protocol to it. 

Rhiannon: I agree.

Emma: And I really want people to expand their mindset and first question that diagnosis. If a patient comes into you and says, "Oh, I have X, Y, Z," really look for where's the evidence for that both in her labs and in her signs and symptoms, rather than just taking it on face value. And I think over the years, I've had so many women come in and say, "Oh, I have polycystic ovarian syndrome." And then when you look at where is the evidence for that? It's like, oh, someone just mentioned it to her along the way and it's not actually a problem. So I really want the listeners to start questioning what they're being told and looking for the actual evidence that tells you is it or is it not the problem? Yeah.

Rhiannon: And it can be naturopaths, it can be conventional doctors, it can even be specialists who have said those things to the patients in the past. And when you go digging into that, you find that actually there's been no justification for that label she's been carrying around. 

But as naturopaths, I do think we need to be really cognisant of not being too enthusiastic about perfectionism when it comes to our patients and especially their pathology levels. If they feel fine but on paper something doesn't measure up to what you consider is optimal, you don't need to start diagnosing her with an issue and tell her she has a problem that she's not even physically experiencing. It's just a bit of scaremongering and a bit... It's not really evidence-based practice most of the time, I would say.

Emma: No. And that's what we want to be practising, is evidence-based clinical practice. 

Now, I wanted to move on to what I call the “great Vitex debate.” And I'm really keen to hear more about what you would see on pathology to indicate the effective use of Vitex. Because I feel that Vitex is just randomly thrown at women that have any kind of hormonal imbalance. But you hear from patients that they took Vitex and they felt worse, they've got heavier periods or more painful periods or whatever it might be for that woman. So can you enlighten us on when you would use Vitex?

Rhiannon: It is I think one of the most confusing and scary herbs actually for new graduates. I don't think that we give the education around Vitex as many warnings as we probably should. And so I find a lot of practitioners learn the hard way that they can actually cause problems by prescribing Vitex to some patients. And then because they haven't been given any framework around indications for when Vitex is safe and effective as opposed to when it might cause more problems, they really shy away from using it further. 

And the other thing about Vitex, the key thing is that it absolutely can exacerbate oestrogen-dominant conditions and then absolutely can exacerbate luteinising hormone dominant conditions. So if you're not doing those pathology investigations and you're not really aware of what to look for and when to look for it, then you can give Vitex to somebody who will walk away and feel a lot worse for it and maybe never come back to you. When you look at the list of what Vitex is indicated for and you look at the side effect list of Vitex, they're exactly the same.

Emma: Yeah, okay.

Rhiannon: And it's absolutely true, it can cause acne or cure acne. It can cause a worsening of premenstrual symptoms or, of course, improve them. Clinically, I've had many patients for whom breast tenderness has been significantly made worse by Vitex. And obviously, it's considered to be one of the key benefits. So I've worked out exactly for whom Vitex will be beneficial and for those, for whom I just wouldn't touch it with a 10-foot pole.

Emma: Yeah, it's really interesting. So I think, for me, I think of Vitex for the low oestrogen or low progesterone type picture. And if there's any signs to me of oestrogen excess, I'll say, "No way. We are not going near that." Is there any other little clues you can share with us?

Rhiannon: Yeah, there are really the key ones for sure. As you know, I'm a really big fan of Vitex for premature ovarian insufficiency. And in my practice, it's probably obviously a fertility-focused practice, but that's probably the key utilisation for it, especially when it comes to trying to conceive, IVF preparation and support. I genuinely don't think it's an exaggeration to say that a lot of my patients wouldn't have their babies today if it wasn't for Vitex in those circumstances. 

And I do also like it for some presentations of the changeability in perimenopause, it can make a big difference there. But it would be extremely rare to see me use it in a case of PCOS and extremely rare to see me use it in the case of endometriosis.

Emma: Yeah, I love that. Okay, that's some great clinical guidelines for everyone out there listening on the great Vitex debate. Thank you for sharing those with us.

Rhiannon: My pleasure.

Emma: I would like to look at, let's just move the bar now to steroidal saponin-based herbs like Shatavari or dong quai or black cohosh. What pathology signs would you say that would indicate, "Okay, let's go for those steroidal saponins here?"

Rhiannon: Again, they are really beneficial for low oestrogen state. To a degree, it's believed that they work a little bit like phytoestrogens from an oestrogen receptor modulation perspective. But also, I think there's plenty of evidence clinically with the application of these herbs that they do promote ovarian estradiol production. So, again, really big on them for low oestrogen conditions. 

Not a big fan of them in oestrogen excess, and maybe similar to the Vitex, I have seen patients come who would have, let's say, for example, menorrhagia and had seen a practitioner in the past who had given them a lot of steroidal saponins for that and have just come in with heavier, more painful, more significant bleeds than they've had in the past.

Emma: Yeah, it can be really problematic and this is where this art and science of naturopathy is so interesting. 

But black cohosh, there's that thing there around migraines with black cohosh that I think a lot of practitioners are not aware of either. Can you talk us through that one?

Rhiannon: Yeah, that's interesting because it is both potentially beneficial for migraines, but also I do find that if it is — and I'm not alone, after learning the hard way, I had conversations with some experienced herbalists and found that it was not only me that had found this clinically — but the patient has a real concern with menstrual migraines, black cohosh certainly tends to throw them into a really bad migraine episode the first time they take it. 

So when introducing black cohosh to most of my patients or certainly those with any hormonally-related migraines or even headaches, I just start by giving them drop doses. I'll give them a separate bottle of black cohosh and just get them to start by dropping five drops into their medicine cup along with the other herb mix until we get up to a point where the dose is adequate. 

Counter-intuitively to that, the evidence would have us believe that the most efficacious dose of black cohosh is the higher end of the reference range, especially for menopause. So you do want to get their doses up there, but I just always introduce it gradually, especially if I'm concerned about her particular risk.

Emma: Yeah, go low and slow is always such a good approach if you're not sure as well.

Rhiannon: Yeah.

Emma: Now let's move on to adaptogens. I think that we're using truckloads of them over the last couple of years. 

Rhiannon: Aren’t we all?

Emma: Yeah. So some of my key ones, Withania, rhodiola, Panax ginseng, which I know you love. What are the key differences between when you would use each of those ones? Like, is there something that you see on pathology or labs that makes you think, "Okay, that's when I should use rhodiola?"

Rhiannon: Yeah. Well, they're all so different, those three, and probably the three that I use more than any other also. We have a lot in common you and I. 

Rhodiola, of course, is dopaminergic. Meaning that it should be considered contraindicated for patients with bipolar or any history of psychosis or episodes. However, it also, of course, therefore is very beneficial for patients with depression and a low effect, basically an inability to enjoy life or find joy in things. And the further benefit back to my area of special interest is that dopaminergic activity, of course, helps to lower prolactin. So in cases where particular stress or anxiety is a trigger for hyperprolactinemia, rhodiola can be a really efficacious intervention for that presentation. So it can literally allow her to ovulate, for example, if the prolactin has compromised her menstrual cycles. Rhodiola is very much then actually a hormonally acting herb but in an indirect fashion.

Emma: Yeah. Yeah. Like so many of our herbs, they have one direct action but many indirect actions.

Rhiannon: Yes, that's right. That's right because we are one complicated system.

Emma: Yeah, that is true. What about Withania? I have to say this is the most prescribed herb in my liquid dispensary for so many reasons, but what makes you look at pathology and say, "Yes, that one needs Withania?"

Rhiannon: Yeah. I mean, you've heard me joke many times that I'll look at a lot of patients and go, "Ah, she has a Withania deficiency. Okay, we'll work on that one." 
But as you know, I'm really keen on us all understanding that herbs both have, not just indications, but also potentially have some contraindications. And for Withania, of course, it is potentially going to exacerbate a hyperthyroid. And because of some really impressive actions on haemoglobin promotion, it is also probably something that you would avoid in iron excess and certainly in full blown hemochromatosis. 

Outside of that, I do really like it for the opposite of those things, of course, compromised adrenal function, exhaustion, depression with anxiety because it's got that nervine side or that nervine activity as well. But also for those women with low iron who have great trouble building their haemoglobin levels or women with a slightly sluggish thyroid and that low adrenal picture, it's really the perfect herb.

Emma: Yeah, yeah. And so many of our patients are all of those things at the same time. Lastly, Panax ginseng, what are your little insights on that?

Rhiannon: Panax, of course, when you look at the literature, really, it's been significantly researched regarding testosterone levels, both in men and in women. I think there's about three studies regarding testosterone response to Korean ginseng, sorry, it might be one. I'd have to refresh my memory for that a few weeks ago. But either way, we do know that Korean ginseng does have a positive effect on androgens and, of course, it is really beneficial for a very heavily depleted HPA axis and low functioning adrenal. So I would use it with low DHEAS, with low testosterone. Excellent, of course, traditional use really for that menopausal transition or that postpartum depletion, or just any woman or man for that matter of who is suffering from those really flat line adrenal consequences of chronic stress.

Emma: Yes, yes, yes. I think it's the chronicity there that really gets me with the Panax ginseng. To be so depleted that the DHEA and the testosterone is all low would be a nice key indicator for the Panax perhaps.

Rhiannon: Absolutely.

Emma: Okay. And then I wanted to ask you about the adrenal androgen production, so herbs for the adrenal androgen production and also herbs that support ovarian androgen production, because I still think a lot of practitioners are not quite aware that there's a difference here.

Rhiannon: Yeah, and there's such a difference. And it's so easy to understand what's going on if you're doing the thorough androgen assessment on their pathology. But, of course, the DHEA and DHEA-S, the sulfate version that we're measuring, produced at the adrenals and are the precursors, as I said before, for androstenedione and testosterone and therefore, of course, for estradiol. But the key consideration when the DHEA-S is low on the blood work is that adrenal functionality. So Korean ginseng is a key one for that. But, of course, the, I was going to say king, but let's say queen of the herbs for this action is, of course, tribulus.

We know, of course, that tribulus is well regarded for its testosterone promotion in men, but we have evidence in the literature that DHEAS in women is increased with long term, so the study was 90 days, that long term tribulus prescription. And clinically, I just have to say it's undeniable that the most efficacious intervention for low DHEA-S outside of rest, sleep, eating well, avoiding stress, is tribulus. But not pulsed in the way that maybe we have sometimes been taught to use it around ovulation induction, but actually just using it all the way through the menstrual cycle to see those levels come up. It usually takes two or three months to see it on paper.

Emma: Yeah. And it's nice to be able to say to patients, "This is a fantastic herb. Here's the research. It's going to take three months until perhaps you really notice the impact of it." And setting those expectations is so critical.

Rhiannon: It really is. Yeah.

Emma: Amazing. Now, I wanted to finish up with a couple of questions that will give us some more insights as practitioners. What is your key to running a successful clinical practice? Because a lot of people that listen to this podcast are clinicians and they may be in all phases, just studying still to graduating just recently, to have been doing what they do for a long period of time. But you're enormously successful as a clinician and I'd really love to perhaps get a couple of insights on why you think you're successful in the way that you are.

Rhiannon: I mean, my immediate answer is “I don't know,” but, no. I was just reflecting as you were saying that on how different times are these days, aren't they? And that from when we graduated and literally, in my final year of study, one of the key things that they were talking about regarding promoting your business was getting a listing in the yellow pages. I'm not sure how we were still talking about that in the early '00s, but we were.  Anyway, I really think that for me I fell on my feet working at Fertile Ground. I practised in my own practice for five years before I was lucky enough to get a position at Fertile Ground. I think we're probably a little bit more of the old fashioned way of building a successful practice, which is through letter writing and lots of communication with, in our case, fertility specialists and obstetricians, so medical professionals for whom you are working towards a collegial relationship with. And we certainly do. There is not a day that goes by that we don't have referrals from specialists directly to our clinic and directly to individual practitioners. 

And it's not a social media-based business, it's really a grassroots business. And that means that the patients referred to us are really in great need of our expertise because they're often complex and heavily medicalised. But for me it's actually about reaching out in a professional but, of course, friendly way to those practitioners of different modalities to whom you could build a referral base with in the future.

Emma: Yeah. Yeah. What I do notice looking from the outside is that you are always focused on up-skilling, using mentors and whatever is in front of you to up-skill, and never ceasing to learn. And also that collaborative care model, working with other healthcare practitioners. Those two things for me really stand out and shine brightly as to why you are so successful in clinical practice. And I think that...

Rhiannon: Thank you.

Emma: ...for those listening, finding a mentor is so critical. It kind of compresses time. You get ahead faster because you can piggyback on their knowledge.

Rhiannon: Yeah. I say that often to the mentees that I work with. From my experience both as a mentee and mentor, it really gives you that confidence to be able to say to your patients, "This is what we find in situations like yours. This is what we find works." Even if you've never treated that condition before, you can go in with the confidence of your profession in your mind backing you up so that you can really reassure that patient that you know what is the best intervention for their circumstances to get them the results that they want. And that flies with patients. They love that.

Emma: That's true.

Rhiannon: And it just feels so good to clinically have that confidence, as you say, well before your years of experience would otherwise grant you.

Emma: Yeah. Yeah. It's a really exciting thing as well to be mentored and to have that fast growth in knowledge.

Rhiannon: It's so great. I can't emphasise it enough, to be honest.

Emma: Amazing. Well, thanks, Rhiannon, for being with us today. We've discussed this topic from a broader perspective than just fertility or just looking at it from that reproductive angle, which I've really loved. And so often we get laser-focused on testing hormones as part of fertility, but we can sometimes forget how important it is to look at the hormones and the lab results as an indicator of what I call mojo, that overall health. So thank you so much for all of your very clinically relevant pieces of wisdom today.

Rhiannon: That's great. Thank you so much, Emma. It's such an important topic and so close to my heart as I know it is yours. So, yeah, it's been a real pleasure to be able to come on and talk to you about it today.

Emma: Brilliant. Now, thanks, everyone, for listening today. Don't forget that you can find all the show notes, transcripts, and other resources from today's episode on the FX Medicine website: fxmedicine.com.au. I'm Emma Sutherland, and thanks for joining us. We'll see you next time.

About Rhiannon Hardingham

Rhiannon is an experienced fertility naturopath, presenter, practitioner mentor and author, and a lead member of the specialist team of multi-disciplinary practitioners at Melbourne’s Fertile Ground Health Group.

Rhiannon is committed to the successful integration of natural and conventional medicine, regularly working alongside Melbourne’s top fertility doctors to achieve the best outcomes for her patients. As testament to this, Rhiannon is routinely invited to present on the topic of collaborative patient care to medical professionals and naturopaths alike.

After her many years of experience in the area of infertility and IVF support, Rhiannon provides professional mentoring for naturopaths in both group and individual settings. This highly specialised area is outside the scope of standard naturopathic education and as such, her mentoring program at Fertile Ground Health Group is a rare opportunity for naturopaths to further their skills.

Alongside her colleagues at Fertile Ground Health Group, Rhiannon has co-authored the book Create A Fertile Life. This comprehensive pre-conception healthcare guide for both patients and practitioners, is set to become a staple for those wishing to overcome infertility and prepare for a healthy pregnancy. 


The information provided on FX Medicine is for educational and informational purposes only. The information provided on this site is not, nor is it intended to be, a substitute for professional advice or care. Please seek the advice of a qualified health care professional in the event something you have read here raises questions or concerns regarding your health.

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