Healthy Birth Control, Irregular Periods, and UTI’s

This one is for the ladies! We grouped together a number of questions we’ve received on topics ranging from mammograms and pap smear recommendations, to how to treat bacterial vaginosis during pregnancy, to what to do about irregular periods, to healthy methods of birth control.

In this episode, we cover:

2:36 The latest mammogram and pap smear recommendations
11:46 How to safely treat UTI’s or Bacterial Vaginosis during pregnancy
17:55 What to do about irregular periods
29:31 Healthy methods of birth control

Full Text Transcript:

Steve Wright:  Hi, and welcome to another episode of the Revolution Health Radio Show brought to you by ChrisKresser.com.  I’m your host, Steve Wright from SCDLifestyle.com, and with me is integrative medical practitioner, licensed acupuncturist, and healthy skeptic, Chris Kresser.  How’s it going in the Bay Area, man?

Chris Kresser:  I feel like I almost wouldn’t know.  It’s been pretty crazy for me around here just getting the High Cholesterol Action Plan out the door, and my daughter, Sylvie, is teething and has had a pretty brutal cough for about a week, and she’s recovering well, but she’s been keeping her mom and dad up at night.  So I’m gonna practice what I preach, and we’re gonna do a shorter show today so I can take some time to just chill out a little bit.

Steve Wright:  Well, I can’t say I’ve been there, but I completely understand.

Chris Kresser:  Haha, yeah, I know what you mean.  I had a sort of vague idea of what it would be like before I got into it.  I have six nieces and nephews, and so I saw a little bit of it behind the scenes, but it’s certainly different when you’re the one getting up and changing that diaper or whatever!

Steve Wright:  Haha, doing it!

Chris Kresser:  Yeah.

Steve Wright:  The act of doing it is different than thinking about it.  I think you have a quote about that somewhere.

Chris Kresser:  That’s absolutely true.  But we got some good questions.  We’ll get into as many of them as we can, and then we’ll be back in a couple weeks full strength.

Steve Wright:  Yeah, this is gonna be the ladies’ show.  And in the meantime, Chris, go take a nap.  I’m gonna tell the listeners about Beyond Paleo.  If you’re new to this radio show, you’re new to the paleo diet, or you’re just interested in optimizing your health, you’re gonna want to check out what Chris has put together.  It’s an email series, 13 parts in total, and it covers Chris’ best tips on burning fat, boosting energy, and preventing and reversing disease without drugs.  It’s called Beyond Paleo, and you can sign up at ChrisKresser.com in the big red box.

All right, Chris, wake up.  Time to go!

Chris Kresser:  All right, I’m back.  I’m here.  Got my green tea.

The latest mammogram and pap smear recommendations

Steve Wright:  Awesome.  Well, let’s get started.  This first question comes from Torea.  She says:  “I’m a 41-year-old female.  For years, I’ve used a standard American gynecologist and have always followed their advice.  But as I educate myself more on health, the status of the American health system, etc., I now have doubts about the advice that I was getting from the OB/GYN.  I know that I’m about to face quite a few hormonal changes with pending menopause.  What would be your recommendation on such things as annual mammograms and Pap smears for ongoing health monitoring as I move from pre- through post-menopausal?”

Chris Kresser:  Yeah, this is a controversial issue.  It seems like we’ve been talking a lot about those lately, and it seems like there are a lot of those in the health and nutrition world.  The background on this is that in 2009 the US Preventative Services Task Force recommended pretty dramatic changes to the breast cancer screening guidelines that were in place up until then.  And the proposed new guidelines recommend starting regular screening later at age 50 rather than at age 40, which was the previous recommendation.  And then they recommend screening before age 50 only for women who are at much higher than average risk of breast cancer.  And then the new guidelines also called for mammograms to be done every other year instead of every year as the previous guidelines suggested.

So there’s been a lot of debate about this, and there are pretty prominent groups, like BreastCancer.org, that have strongly objected to the new guidelines.  And they lay out a few reasons why they think they’re not a good idea.  Number one, the analysis of the task force was based on older mammography techniques, meaning the researchers mostly looked at the results from film mammograms instead of digital mammograms, which are known to be a lot more accurate.  The analysis was based on some inaccurate assumptions about optimal treatment after breast cancer is diagnosed.  For example, it’s assumed that women diagnosed with hormone receptor-positive early-stage breast cancer would receive and benefit from hormonal therapy but not chemotherapy even though there’s some data that many of those women do receive and benefit from chemo after surgery.  So assumptions like that may have caused the researchers to underestimate the number of lives that would be lost if the proposed changes were put into effect.

The analysis also didn’t adequately consider the combined benefit of early detection with current screening guidelines and new treatments that have resulted in improving survival rates in recent years.  And their point is kind of that screening can’t be looked at in isolation as a snapshot.  It happens as we continue to improve both diagnosis and treatment, but you can’t, of course, treat what isn’t diagnosed.

Steve Wright:  This is BreastCancer.org’s refuting?

Chris Kresser:  Yeah, exactly.

Steve Wright:  OK.

Chris Kresser:  And then they also claim that the proposed changes would mean that a lot of breast cancers would be diagnosed at later stages, which make them a lot harder to treat, and the survival rates, of course, decrease the later that they’re diagnosed.  Because when you’re diagnosed at a later stage, it’s more likely that it could evolve into metastatic cancer that spreads to other parts of the body.  And then lastly, they claim that the proposed changes would mean that younger women would be diagnosed later.  And breast cancer in younger women tends to be more aggressive than it is in older women, so early diagnosis and treatment is more critical for them.

So in contrast to the US Preventative Services Task Force, the BreastCancer.org group recommends that if you’re 40 or older and you have an average risk of breast cancer, they do recommend yearly screening mammograms.  And then if your breast cancer risk is higher than average, they even suggest talking to your doctor about a more aggressive breast cancer screening plan that may include breast MRI or ultrasound in addition to mammograms.

I’m not sure, frankly, where I come down on this at this point.  I feel like I need to investigate it further before I can make any kind of recommendation.  I’ve started to wade into it several different times, but I quickly realized that I wasn’t gonna be able to reach a kind of coherent conclusion just in a few hours of reviewing the research.  It’s a pretty vast topic, and like a lot of these topics, there’s a lot more than meets the eye, so the best I can do at this point is direct people to the BreastCancer.org site.  They have a pretty interesting discussion of the US Preventative Task Force recommendations.  I think, in general, where I tend to come down on these screening tests is perhaps with an appreciation of the risk involved in some of the screening tests, the exposure to radiation.  And then the other thing to consider is — and this is more true with prostate screening, for example — is the additional treatment that often comes from additional screening and the risks associated with that additional treatment.

Again, I’ll just have to keep digging before I can make a recommendation, but check out BreastCancer.org as an alternative viewpoint.  It’s something that you probably are gonna have to run through your own filters, too, because everyone has different risk tolerance and threshold with this kind of thing.  You know, we talked about this in the context of raw milk.  There are some people who if there’s a 1 in 100,000 chance of them contracting an illness or a serious disease from eating a food or drinking something, they feel absolutely fine doing that.  They’re not concerned about that.  But for other people, even a 1 in 100,000 chance is enough to scare them away from doing that.  So there’s some element of that here, individual risk tolerance, and what kind of sense these guidelines make for you will have to be run through that filter.

So, let’s talk a little bit about Pap smears because I think it’s not quite as controversial as the breast cancer guidelines.  In the 1930s, cervical cancer was actually the deadliest cancer for women in the US.  At that time, it killed more women each year than breast cancer or lung cancer.  But over the past 80 years, there’s been a huge decline in the death rate from cervical cancer because of improvements in treatment and screening, and today death from cervical cancer is relatively rare in the US.

In March of this year, the US Preventative Services Task Force, same group, announced new recommendations for Pap tests to screen women for cervical cancer, and the guidelines advise women to reduce the number of tests they receive over their entire lifetime to ensure that they get the benefits of testing while minimizing the risks.  There was one big change in their recommendations, which is that women under the age of 21 shouldn’t be tested.  And women over 21 should undergo a Pap screening test every three years instead of annually, which was their previous recommendation, because HPV can take more than a decade to progress to cervical dysplasia or cancer.  So their recommendations now are that all women should start screening at age 21.  It used to be that screening was recommended three years after starting vaginal intercourse, but they’ve backed away from that.  Women age 21 to 29 should get a Pap test every three years.  For women 30 and over, Pap tests should be done every three years, and the guidelines recommend against annual or more frequent Pap testing in that age group.  And they suggest combining the Pap test with HPV testing every three to five years for women 30 years and older.  I haven’t seen much controversy about the changes in those guidelines, so I don’t see really any reason not to follow them in the case of Pap tests.

Steve Wright:  Well, thanks for clearing those things up.  I know that’s gonna help a lot of people.

Chris Kresser:  We’ll do an update in the future once I have a chance to look into it a little further.

Steve Wright:  Yeah, I’m sure that everybody will be very grateful when you do get a chance to dive into the breast cancer research.

How to safely treat UTI’s or Bacterial Vaginosis during pregnancy

OK, well, we have a slew of questions here that were asked by men and women alike, just a lot of questions that all kind of were grouped together, so I just am gonna go ahead and say that these questions are from the crowd, because I whittled them down to one-line statements, and then Chris is gonna go ahead and tackle them one by one.  So, we want to thank everybody who sent these in.  I apologize if I trimmed your name off.  So, the first one from the crowd is:  What happens when you’re pregnant and you get a UTI or bacterial vaginosis?  How do you handle this, and is it gonna hurt the baby?

Chris Kresser:  Yeah, that’s a good question.  I get that a lot.  Bacterial vaginosis, or BV, as we’re gonna refer to it for convenience’ sake, is really common.  Current studies suggest that the prevalence of BV among non-pregnant women is something like 15% to 30%, and up to 50% of pregnant women have been found to have BV, so 1 in 2.  That’s really, really common.  That said, the majority of cases of BV are asymptomatic, so they don’t even get reported because the woman doesn’t even know that she has it, and they don’t obviously get treated.  BV was previously considered to be benign, but recently it’s been associated with a lot of gynecological conditions and complications of pregnancy, including pelvic inflammatory disease, post-hysterectomy vaginal cuff cellulitis, endometriosis, amniotic fluid infection, preterm delivery and labor, preterm rupture of the membranes, and possibly spontaneous abortion, although there’s not really enough data to know for sure about that.  BV usually involves an overgrowth of gram-negative bacteria and a reduction in the amount of hydrogen peroxide-producing lactobacilli, which is one reason that some women use hydrogen peroxide wash as a treatment.  BV can resolve and recur spontaneously, but the environment, you know, the behavioral, hormonal, microbial milieu that determines whether it resolves or recurs is not completely clear yet.

The most common treatment for BV in the conventional world is Flagyl, which is a pretty heavy drug with a fair amount of side effects.  And it’s usually fairly effective, but I, of course, worry about the impact of Flagyl on mom’s flora, her gut flora and her vaginal flora, and thus the baby’s flora.  Antibiotics are generally considered to be safe during pregnancy, but when drugs are studied in pregnancy, the safety profile often really comes down to whether they cause birth defects or not.  Antibiotics in most cases haven’t been shown to cause any birth defects, but that doesn’t mean they don’t have other effects that could harm the mother and baby possibly much later in life.  What I mean by that is we know now — and I’ve talked about this before and written about it several times — is that the changes in the baby’s gut flora at birth can actually affect their lifelong health.  It can predispose them possibly to obesity and diabetes and other metabolic problems when they’re in their childhood and even increase their risk of dying from a heart attack under 60 years of age.  So it’s definitely something that is getting an increasing amount of attention but still isn’t really referred to in these kinds of discussions about the safety of certain drugs during pregnancy.

So I would consider other possibilities that might be less harmful to the mom and the baby’s microbial environment, and one possible option is monolaurin, which we’ve talked about before.  We talked about it in the episode where I discussed treating viral infections.  When lauric acid, which is in mother’s milk and coconut oil, is attached to glycerin, it forms a monoglyceride known as monolaurin, and that is effective not only against viruses, which we discussed, and yeast and fungi, but also parasites and bacteria.  I haven’t seen any studies of the safety of monolaurin in pregnant or lactating women, but it is a component of mother’s milk and it’s been used by pregnant and lactating women for years without reported problems.  I have seen several studies suggesting that taking probiotics can increase the efficacy of antibiotic treatment of BV, so I’d assume the same would be true with monolaurin.  For example, in vito studies have shown that lactobacillus strains can disrupt BV and yeast biofilms and inhibit the growth of urogenital pathogens, and other studies have found that vaginal probiotic suppositories may also be effective.  So I’d probably suggest trying monolaurin and probiotics first.  The brand of monolaurin I recommend is Lauricidin, and that was developed by the researcher that first isolated monolaurin extract, and it’s the most standardized and potent form, I think.  So you could take both an oral probiotic and a probiotic in the suppository form.  Jarrow makes a specific probiotic called Fem-Dophilus that contains two strains that are particularly beneficial for the vaginal tract.  You could either open some capsules in water and make a douche with that, or you could try a probiotic suppository such as PurFem.  I think the Jarrow Fem-Dophilus product works pretty well both orally and then in a douche form.  So give that a shot, and let us know how it works.

What to do about irregular periods

Steve Wright:  OK, great.  Great ideas to start with.  Let’s move on to the next one.  This question comes for all the women out there who might not be having regular periods even though their overall health markers are OK and they eat clean paleo, they probably exercise pretty well, and they’re trying to mind their stress and their sleep levels.

Chris Kresser:  Yeah, of course, I see a lot of these women in my practice.  You kind of described one of my main patient populations.  Most of my patients are already on a primal/paleo type of diet and they’re already living a pretty healthy lifestyle, but they’re still having issues.  And problems with the menstrual cycle are one of the main things that I see in my practice.

I’m really a strong believer in testing for this kind of thing.  I like to do a full cycling monthly hormone profile where we test estrogen and progesterone levels throughout the entire month.  And a lot of naturopaths and holistic kind of practitioners and some MDs will do this kind of testing.  It’s really, really important because as all of you women out there know, I mean, you don’t need me to tell you this, your hormones fluctuate throughout the month, right?  That’s part of the natural cycle.  If you look at a chart of what a woman’s estrogen and progesterone levels should be through the month, it’s not a flat line, right?  So if you only do a single hormone sample at one day during the month, you’re only gonna get an idea of what the hormones were on that day, and that certainly can be useful information, and especially if you time that test in a certain way around day 21, you can get a pretty good idea of what’s happening in the luteal phase with progesterone and estrogen, and that can give you a starting place.  And I often do that with patients as a beginning thing, just because the monthly test takes a while, and depending on when they come in and when the first day of their next cycle is, it might be at least two months before we get results back.

But if you really want an idea, an accurate idea of what’s happening with female hormones, you have to do a monthly cycling panel, because when you look at a chart of estrogen and progesterone throughout the monthly cycle, you’ll see they’re both fairly low early in the cycle, and then estrogen starts to increase gradually, and then you should see a spike right around mid-cycle, which precedes the LH spike, and that indicates that ovulation has occurred, and then you’ll see the estrogen levels kind of taper off a little bit and then increase a little bit and then go down again in the second half of the cycle.  So that’s an optimal estrogen curve.  And then for progesterone, you’ll see it kind of stay low the first half of the cycle, and then as soon as ovulation happens, progesterone starts to go up and the corpus luteum is made, and then progesterone stays high — should stay high through most of the second half of the cycle and then drop along with estrogen right before menses begin again.

And what’s really incredible to me is now that I’ve seen so many of these cycling monthly hormone panels is how rare it is to see a woman who actually has a normal graph, you know, a normal estrogen and progesterone level in the way that it should look all the way through the cycle.  Now, you have to consider that the women that I see in my practice are dealing with health issues and oftentimes hormone issues, so it’s not a representative sample.  Surely there are a lot of women out there who have normal hormone levels, but what I mean is that for the women that I’m testing that are complaining of all of these symptoms that are related to their monthly cycle, it’s very common that something is off.

And there can be three possible problems, really, and they happen kind of in a sequential way, like from less serious to more serious.  So the first thing that tends to happen is that you’ll see progesterone levels dropping too early in the later part of the cycle, and that can cause all kinds of problems, like PMS, spotting, early bleeding.  It can cause longer periods.  It can cause headaches, all of the kind of typical signs of progesterone deficiency.  And you can actually even, like if a patient comes in and says:  Wow, I get these headaches every month.  And I say:  OK, do you chart your cycle?  Do you have any idea about that?  Oh, yeah, I do.  OK, so what day of your cycle?  Oh, well, geez.  Now that you mention it, it seems like they always happen on day 24 of my cycle or, you know, day 23.  And then we look at the chart, and sure enough, on day 23, you can see the progesterone levels dropping out.  So that’s the first problem.  That’s a problem of distribution, like the distribution of progesterone throughout the cycle is not optimal.

The second problem is one of production, and that means that not only is the distribution not right of the hormones through the cycle, the overall amount of hormone that’s being produced is low.  And that usually corresponds to some significant amount of hypothalamic-pituitary-adrenal stress or fatigue, which a lot of people refer to as adrenal fatigue, because keep in mind that the female hormones don’t just go out of balance for not reason; 7 or 8, 9 times out of 10, they usually go out of balance because something else has happened first, like the adrenals have gone out of whack.  Pregnenolone is the precursor hormone to all of the hormones in the body, and it can be either channeled into the DHEA pathway, which goes down to estrogen and testosterone, or it can be channeled into the progesterone pathway, which eventually goes to cortisol.  So if a woman is under a lot of stress, either emotional, psychological, or physiological stress, then what’s gonna happen is something called the pregnenolone steal, where an excessive amount of pregnenolone is stolen or diverted into the cortisol pathway to help support the stress response.  And there’s a lot less left over for sex hormone production and even for progesterone production.  So initially in that process progesterone levels will go up, but over time in that chronic stress response, progesterone levels will eventually go down; cortisol levels, which were high initially, will start to go down; and that whole system gets depleted.  And then over time, estrogen levels will also start to drop because of the pregnenolone steal.  So stage two, you have this problem with production, and it usually corresponds with the adrenal fatigue, so you really have to treat the adrenals along with the female hormones or it’s not gonna be a successful treatment.

And then the last stage is a timing issue, where ovulation is either not happening at all, it’s happening too early, or it’s happening too late.  So then that throws off the whole cycle, and of course, for women who are trying to get pregnant, that’s the really important part.  And there are things that we can do to push the ovulation forward if it’s happening too early, or move it back if it’s happening too late, or get it going again if it’s not happening at all.

All of this, though, depends on accurate testing, and I should say that in Chinese medicine, there are other ways of diagnosing these problems that use a completely different language, a completely different system of diagnosis, which involves reading the pulses and looking at the tongue, and I’ve seen that be very effective both in my own experience and in working with teachers and mentors when I was in school and things like that, and I do use herbal medicine still in treatment of hormone issues, but I prefer to use modern testing, partly because I work with patients over the phone, and it’s pretty hard to read their pulse and look at their tongue and do that kind of thing, but also partly because that’s just my bent.  I’m really more of a functional medicine practitioner than a Chinese medicine guy at this point.  So yeah, that’s what I would do.  Try to find someone that’s doing that kind of hormone profile.  I think it’s really important.  Unfortunately, it’s not as common as it should be, so you could maybe ask practitioners if you’re interviewing a practitioner whether they work with that kind of testing and what kind of treatment they use as a result.

Steve Wright:  So Chris, I want to get everyone crystal clear here.  If you’re a woman and you’re not experiencing regular periods, that’s a bad sign, right?

Chris Kresser:  I think that’s a normal part of female physiology and from an evolutionary perspective that that’s part of our developmental history, and I do think it’s normal, and I think it usually reflects some kind of hormone imbalance that’s not happening.  Obviously we’re talking about premenopausal women.  There’s a pretty wide difference in age in terms of when women enter menopause, and so we’re not really having a discussion about that.  We’re talking more about younger women who haven’t entered menopause that are not cycling normally.

Steve Wright:  Right, so if you’re not cycling normally, that’s a bad sign.  That’s definitely a sign that even though you’re doing your best to get your health under control that there’s something else you need to investigate.

Chris Kresser:  Yeah, I think so.  It’s a sign that more investigation is warranted, and particularly looking at adrenal hormones and sex hormones like estrogen and progesterone.

Steve Wright:  OK, so what about PMS symptoms?  What’s your take on that?

Chris Kresser:  That’s very often due to progesterone deficiency.  I mentioned those three stages that we see in the test, and the first stage is a distribution problem where progesterone drops out early in the cycle, or too early in the second phase, the luteal phase of the cycle.  And that is very often caused by progesterone deficiency, in my experience.  I mean, there are other potential causes, but that’s the first thing to look for.

Steve Wright:  OK, and I’m just trying to get a little more specific here, because I think a lot of people that I talk with, they’re not really sure what optimal is or how life could be, such as having a regular cycle and not having PMS problems.

Chris Kresser:  Yeah.

Steve Wright:  So I just wanted to hear from you to just kind of clarify that.

Chris Kresser:  It is possible not to have PMS.  That’s, I know, difficult to believe for some women, and it’s kind of part of the cultural — you know, we all grow up hearing about it as being almost kind of a normal thing, and I have a lot of women that I treat that don’t have PMS even to begin with, and then I have women that have come to me with PMS as their main complaint and that then after treatment don’t have PMS.  So yeah, just to make that clear, strong PMS symptoms are usually a sign that something’s out of balance.

Steve Wright:  Awesome.  Thanks for clearing that up.  OK, you got time for one more, Chris?

Chris Kresser:  Yeah, we can do one more.

Healthy methods of birth control

Steve Wright:  OK, well, let’s wrap this one up for the ladies.  A ton of questions come in about what is the best method of birth control.

Chris Kresser:  Yeah, well, the first thing I want to say is that as a man, I’m probably not ideally qualified to answer this question.  I recognize there are a lot of considerations that go into this, many of which I’m not personally familiar with because I have a different body with different —

Steve Wright:  Anatomy.

Chris Kresser:  Yeah, exactly!  And so, I just want to be sensitive to that, but I’ll just give you a few considerations of things to think about.  Number one, as I said with the Pap screen testing, this is really personal, obviously.  It depends on so many variables.  For example, are you using birth control for protection against an STD?  Are you using it for contraception?  Are you using it because you have really irregular cycles or painful periods?  I mean, there are so many different reasons that women take birth control.  So the answer to what’s the best form of birth control completely depends on what the goals are, because different goals will lead to different answers, right?  Planned Parenthood has a pretty extensive questionnaire that’s designed to help women choose what the best form of birth control is based on their preferences and their goals, like are they using it for STD protection or for contraception.

If someone asks me from a purely health perspective, you know, without taking all of those other things into account, which is, I realize, kind of ridiculous, but from a purely health perspective, the fertility awareness method is the best, which is a woman charting her cycle, measuring her basal body temperature, measuring her cervical mucus to determine when she’s ovulating, and then avoiding intercourse within a few days before ovulation and a few days after ovulation.  But of course, this method is far from fool-proof as a method of contraception, and it’s best used by people who could live with getting pregnant, you know, people for whom getting pregnant wouldn’t be a terrible thing or the end of the world, maybe a couple that is not planning on getting pregnant, but if they got pregnant, they would welcome the conception.

Of the other methods that are safer from a contraceptive standpoint, the cervical cap or the diaphragm might be the safest from a health perspective after the fertility awareness method along with the man wearing a condom, and those could be with or without spermicide.  And then there’s the copper IUD, which has a success, well, about 6 in 1000 women who use that become pregnant in the first year of using it, so pretty good odds, but I’m sure most women know that there’s always a chance with most forms of contraception of it not working.

So, I would love to hear from women out there and maybe women who have a particular expertise in this subject area.  Maybe you could post something on my Facebook page or on Twitter or submit an email through the contact form of my website.  This is something I’d like to learn more about, so if you have any wisdom to share on this topic, I’d be happy to hear it.

Steve Wright:  And I’m sure we’ll be all happy to learn about whatever your expertise is, and I know nothing, so I just default to Chris.

Chris Kresser:  Haha, well, I know a little bit more, but still I definitely don’t consider myself to be an expert in that area.  All right, I think that’s where we’re gonna stop.  It’s a nice sunny day out there.  I’m gonna go lie in the sun and get some vitamin D and rest a little bit.

Steve Wright:  All right, great.  Well, I hope that the rest of the family gets well soon and you can get some rest, and we’ll be talking again soon for our next episode.

Chris Kresser:  Sounds good.

Steve Wright:  We want to thank you for listening today.  Please keep sending us your questions at ChrisKresser.com using the podcast submission link.  If you enjoyed the show, please head over to iTunes and leave us a review.  It helps get the word out and spread the show to others who might be helped by it.