HER Expert Panel
Fall Roundtable

HER Health Collective roundtables provide an opportunity for us to bring our panel of experts together to discuss important issues that are relevant to mothers in our community. The topics discussed in this session include: Diastasis Recti and common myths, Prolapse, Endometriosis, Perimenopause, and Self-Advocating when feeling dismissed by a provider.

Featuring:
HER Expert Panel

The Fall Roundtable includes the following panelists:

  • Eva Miller: Eva Miller in Raleigh and I’m an art therapist.
  • Dr. Lindsay Mumma: Hi, I’m Lindsay Mumma and I’m a chiropractor and I focus on women’s health including the pelvic floor.
  • Dr.  Elizabeth Sierakowski: Hi I’m Dr. Elizabeth Sierakowski and I am a primary care MD and I am also trained in functional integrative medicine and I own and operate Essential Health and Wellness in North Raleigh.
  • Dr. Lindsay Moses: I’m Lindsay Moses at Grace PT and I specialize in physical therapy for pelvic rehabilitation.
  • Anna Lutz: Hi, I’m Anna Lutz and I’m a registered dietician and I specialize in family feeding and eating disorders.
  • Dr. Amanda Seavey: Hi, I’m Amanda Seavey. I’m a licensed psychologist at Clarity Psychological Wellness.
  • Jessica Altemara: Hi. I’m Jessica Altemara and I’m an IBCLC, a lactation consultant with a focus, among other things, on the endocrine aspects of lactation. 
  • Dr. Polly Watson: a board-certified OBGYN, a North American Menopause Society Certified Practitioner, and one of about 1,000 providers in the US certified from the Institute for Functional Medicine Certificate Program.
  • Katherine Andrew: a Registered Dietitian Nutritionist passionate about gut health, food sensitivities, hormones, family food dynamics, and intuitive eating

Crissy:

This month’s roundtable covers a wide variety of different topics and we are so excited to be joined by this fantastic panel of experts.

 

We are starting off with diastasis recti, an issue that is becoming more and more well-known. While that is wonderful, as it becomes more prominent in social media we know that also comes with a lot of misinformation, well-intentioned as that might be.  So, what are some common myths you’ve seen about diastasis recti and what harm could those myths be causing women? And what messaging, in your opinion, really needs to be pushed to women. I’m going to go ahead and pitch this over to Dr. Mumma first and then maybe we can have Dr. Moses and if anyone else wants to pop in after we hear from them.

 

Dr. Mumma:

There’s a long list of myths regarding diastasis. A separation of the rectus abdominis muscles is an adaptation of pregnancy. It’s not a bad thing in and of itself.

 

Diastasis is not actually a problem, it prevents all your major organs from being smashed by a baby, so it’s an adaptive process and it is a normal part of being pregnant. There is a myth that diastasis is a bad thing and you need to prevent it during pregnancy. But if you’ve done this during pregnancy, you’re preventing your baby from growing or you’re preventing your organs from functioning.

 

I prefer that we would be able to adapt to the changes of pregnancy. Another myth is that surgery is the only way to fix a diastasis, or that that’s just how it’s going to be once you have a baby. Other myths include if it’s two finger widths, it’s never a problem. Really, the other myths are innumerable at this point.

 

I actually learned about diastasis when I was a student and nobody was really talking about it in regards to pregnancy. They were talking about it in a dynamic neuromuscular stabilization class that I took and it was centered around normal human physiological development. It was a diagnostic tool that was being utilized in cerebral palsy patients that were being diagnosed. And they were studying babies that had a persistent diastasis and how they were moving and comparing them with normal development.

 

One of the myths that are not specifically said, but are kind of acted out, is that you need all these tips and tricks in order to take care of the diastasis. But really, human movement and development and how we all learn to move are actually hardwired in us in order to build a stable core and if we return to those kinds of movements, we are actually able to heal from the diastasis.

 

It’s not just pregnant women who get diastasis.  Anyone can get a diastasis. There are plenty of babies that are born with persistent diastasis. Babies are born with a diastasis of the rectus abdominal muscles that are physiological in nature because their diaphragm muscles haven’t completely developed yet because they weren’t breathing in utero, even though the diaphragm is formed at 6 weeks in utero.

 

There are men who get diastasis, there are weightlifters who get diastasis, there are plenty of people who have never been pregnant who can actually have a diastasis that shows up as a non-functional use of their core. And so, it’s not just about pregnancy.

 

When I learned about diastasis, I’d never thought that I was going to be working with a lot of pregnant women or postpartum women, so that wasn’t my intention. It just so happens that the pelvic floor and pelvic floor rehab that I had focused on was really, really useful for my patients who were pregnant and postpartum.

 

What I often tell people is that if you are breathing functionally, you are already starting to heal your diastasis. And if you are not breathing functionally, then you are actively working against healing. So there are a lot of simple things that can be utilized in order to help heal, and healing is not the same as fixing. We could close the diastasis if we could just suck everything in, and then hold it like that. And then there is no healing that is happening there, just approximated muscle bellies. You haven’t healed any tissues or caused any change if you are just holding something together. We can band things in or cinch things in, but unless we actually want tissues to heal, and give them functional movement patterns, nothing can change.

 

We also need to not think of diastasis as a vacuum. This is your core, your powerhouse of movement. It functions within your whole body. That’s why we don’t just focus on separation between these two muscle bellies. We have to ask how does this impact the rest of the system, how does this impact you as a bipedal creature, or for people with different abilities, how does that impact a non-bipedal person and recognizing how many different implications there are from having a destabilized core.

 

There’s a lot of myths, but it’s human physiology to have a stable, functional dynamic core. And when we don’t have that and we give people these quick fixes, -“Oh, just do these quick exercises ten minutes a day and you’ll have your diastasis good to go in no time…”- that’s crap. That’s not true. And it’s also not honoring the beautiful wonderful changes that happen so we can house other people within our bodies. Which is pretty freaking rad, if you ask me. I went on a whole tangent there. I got excited.

 

Crissy:

No, I love it. Thank you Dr. Mumma. And very quickly, hello to Dr. Watson and Katherine. Welcome to the party. Dr. Moses, did you have anything additional to add about the diastasis?

 

Dr. Moses:

Yeah, I think Lindsay really summed it up. To add a little bit to that, a lot of the new research by Lynn Shulty and Dianne Lee shows that all women, by the end of the third trimester have a diastasis. That’s a big take-home message when I see patients in the office. It’s  normal, it’s going to happen. There’s no way around it.

 

Another question that I often get is, if I do a sit-up am I going to screw everything up? I highlight for these women that it took nine months to get the diastasis and doing a few sit-ups is not going to change the game here. It’s a matter of how you can control your core, while you are doing these exercises.

 

Patients will say, ‘Should I do a plank, should I not do a plank?’ Again, it’s about observing their movement, dynamically, and seeing how their form looks while they are doing these exercises. A plank may be appropriate for a person who has a four-finger separation if they can maintain the integrity of their core and their alignment and posture while they are doing these things.

 

The myth that “I should never do a crunch,” for example, is nonsense at this point. Is that the best exercise to do? No, probably not. There are many other appropriate choices, but one single movement is not going to take a small diastasis and magnify it.

 

Another myth I hear a lot of is, “I just have to focus on my core, I just have to work on my transverse abdominis.” And it’s something that we have to look at more globally and we have to appreciate that there are a lot of other muscles that are working to control the core. We have to look at the pelvic floor and we have to look at the back muscles and the hip musculature as a whole unless some of this is genetics. There is also tissue elasticity that we just might not always be able to rectify. Some people just have a little more laxity than others. So again, it is nothing dangerous, as Dr. Mumma was pointing out. It’s not a hernia, but it can be indicative of a bigger, more global problem that we have to pay attention to.

If you are breathing functionally, you are already starting to heal your diastasis. And if you are not breathing functionally, then you are actively working against healing.

- Dr. Lindsay Mumma

Cindi:

Thank you. We’re going to move into another topic called pelvic organ prolapse. It’s become more well known over the past two to three years. However, women may still feel confused about what it is and who to see for a diagnosis. They are confused as to how it is diagnosed, various treatment options, and when surgery may be the best option.

 

I’m going to direct these questions specifically to Dr. Watson and Dr. Moses now, but I would love to have some of the other experts jump in after they’ve talked a little about it, perhaps how their patients have been affected mentally or emotionally by having this diagnosis. Every woman’s treatment is different, however, on average, what course of action do you recommend in your practice and is there medical research that indicates pelvic organ prolapse is preventable through diet, exercise, pelvic floor rehabilitation, bowel management, etcetera. What physical, mental, and emotional effects have you seen on your clients?

 

Dr. Moses:

I’m happy to kick this off. It is obviously probably half of our practice.

 

Pelvic organ prolapse is when some of the organs can descend from their resting position. That can be the bladder, it can be the uterus, it can be the rectum. And there are different stages of prolapse. There can be a very mild situation and then there can be a very significant prolapse and some of these organs have actually descended down and have become external to the vaginal opening. And it’s very concerning to many women when they come in and say, ‘I’m seeing something and I’m feeling something that I’ve never seen or felt before.’ It’s a very scary feeling for women.

 

What I like to tell patients is that there is research – there was a study done by Bracken in 2010 – that shows that pelvic floor training can help to reduce a pelvic organ prolapse. Conservatively we can typically reduce a pelvic organ prolapse by one level. So if a woman comes in with a grade 2 prolapse, with appropriate training, we can probably take it from a grade 2 to a grade 1. We are unlikely to be able to take a grade 4 to a grade 1.

 

A lot of women think that prolapse is simply caused by weak muscles. Weak muscles that develop during pregnancy can no longer adequately support the pelvic organs and ultimately those pelvic organs start dropping. It’s not always because the pelvic floor is weak though. Sometimes, it can be the opposite, where the pelvic floor muscles are a little bit overactive and shortened and tight.

 

I like to tell patients that happy muscles are muscles that can fully lengthen and fully shorten just like the biceps. So if we totally relax our bicep muscle, our shoulder doesn’t just fall out of place. A lot of women are afraid to just let go of all the tension that they tend to hold on to, feeling like the organs are just going to drop out if they do. So they walk around keeping the muscles really tense, really guarded, overactive or hypertonic and that can trigger pain. The bottom line is that strengthening is not always the best option for some patients. Sometimes it’s actually the opposite that is needed. We have to work on pelvic floor muscles down training, relaxation, lengthening, working on diaphragmatic breathing, and other things that can help to make those muscles fully lengthen and fully contract.

 

Dr. Watson:

I have a little bit to add, I really appreciated your starting from the beginning on how much physical therapy can do because I think that physical therapy is such a great and important tool. As a gynecologist, it kind of breaks my heart that people have surgery as the first step instead of starting off with a less invasive measure and then they have cervical complications. Maybe they weren’t adequately educated that there is a less invasive way to go about this, so I really appreciate that.

 

The way I think about pelvic organ prolapse is often the conjunction of the fascia. The fascia is the connective tissue, it’s sort of like if you were taking apart a chicken, in that you would see that white, shiny connective tissue. And sometimes the connective tissue will split or break. So just like a little kid who has a hernia and you can see their belly button pushing beyond that connective tissue, we can have a split in the connective tissue either in the anterior vaginal wall, the front vaginal wall, and that forms what’s called a cystocele where the bladder comes down or in the posterior vaginal wall where the rectum almost pushes into the vagina. And so, absolutely, we want to start with less invasive things first and make sure that we are not doing things that exacerbate the prolapse. So somebody is not lifting 50 pounds of mulch incorrectly, they would address bowel issues if they are having soft stools, those kinds of things. 

 

I would recommend surgery to someone when they are having bladder or bowel dysfunction such that if the cystocele is so pronounced that the bladder is sinking down in the pelvic floor. If someone is not able to completely empty their bladder, sometimes they have to put their finger in the vaginal and push it up, so that they can actually drain their bladder. A lot of times those women are having more frequent urinary tract infections and when they’ve had five rounds of antibiotics, it might be time to think about surgery or a less invasive option might be a pessary, which is kind of like a rubber donut to push things up and hold it there.

 

I have a little bit of a pet peeve, not a pet peeve, but a thought that as a generalist gynecologist – I don’t operate anymore, but when I did – I felt very strongly that urogynecologists, people who had done another three years of training beyond an OBGYN, are the people who should be doing surgeries. You don’t want someone to do your surgery who also delivers babies, and also does hysterectomies, and also does a little bit of infertility training. You want someone who, that’s all they do is pelvic surgery. Because I think that surgery is kind of a big deal and if you don’t get it right the first time, the chances are that the second surgery working well is about 40%. So I am just a huge advocate. So let’s let the sub-specialty trained surgeon do these kinds of procedures.

 

Jessica Altemara:

In the scheme of the specialist for a urogynecologist, what if someone has a combination of issues? A hysterectomy and some kind of prolapse, for example.

 

Dr. Watson:

So oftentimes, surgical teams work together, where if you are the generalist gynecologist is going to do the hysterectomy, then the urogynecologist would come in and do the rest of the procedure. In some instances, urogynecologists are certainly trained to do a hysterectomy, right. They went through 4 years of OB-GYN residency after medical school.  They just did another three years of pelvic floor surgery. So, depending on your comfort level,  they could do the whole thing. Or sometimes, particularly in more rural communities, I used to work in Wisconsin in a not a very busy place, and a urogynecologist wasn’t around very much so they might come in for the surgery and then leave and go to a different city. There are team approaches that can happen.

 

Dr. Moses:

Can I just maybe add, maybe Dr. Watson can elaborate, but I’ve made the mistake of sending patients with what I consider to be a pretty significant prolapse, to see a urogynecologist within that first year postpartum, and just something to highlight for your members, but most urogynecologists will say wait until you are done breastfeeding and come back and see me at that one year mark because things do tend to improve once the hormone levels regulate themselves and breastfeeding is one thing that can fuel some ligament laxity, and fuel a prolapse. And again to highlight, no one wants to dive into surgery when there are so many conservative options to consider first. But certainly, until a woman is at least that six weeks past that breastfeeding mark, it wouldn’t be appropriate necessarily to consult with a urogynecologist for surgical intervention.

 

Dr. Watson:

I couldn’t agree more with that. I think it’s a really important thing to add and, let’s say you had that postpartum patient that was absolutely miserable and was wetting their pants and was really uncomfortable, your gynecologist could offer them a pessary and that would be a non-pharmaceutical thing that they could do while they are nursing and get some comfort. I have patients who only leak when they go to boot camp and they do burpees and they do a jump and maybe they throw in a pessary for that hour three times a week, and that fixes their problem.

 

Jessica Altemara:

I just want to pipe in on the breastfeeding front. One of the main concerns of doing these things while breastfeeding is relaxin, a hormone that stays more present when you’re lactating. And there is recent research suggesting that that it fades primarily at about 14 months if somebody is still breastfeeding. I’m only mentioning that because there are many people who breastfeed for years. And I see that more culturally. It’s recommended by many professional organizations to nurse for 2 years. And thinking of delaying for one year might be more feasible than for somebody who thinks they might be breastfeeding for 2 or 3 years and continuing to have a lot of these problems long term.

I think that physical therapy is such a great and important tool. As a gynecologist, it kind of breaks my heart that people have surgery as the first step instead of starting off with a less invasive measure and then they have cervical complications.

- Dr. Polly Watson

Crissy:

Thank you so much. That was a wonderful discussion into both diastasis and pelvic organ prolapse. I know it’s going to be helpful to a lot of moms.  Endometriosis is another issue that we see a lot of women dealing with. What is it? Is it preventable? Can women do anything to control their symptoms? How have you seen your patients affected by this diagnosis? And how do you personally work with patients in your practice? We would love to discuss this from both a conventional treatment perspective as well as alternative treatments.

 

Dr. Watson:

Ok. So I am going to jump in if that’s ok. Endometriosis is the presence of endometrial tissue or uterine lining tissue that is outside the uterus. So you can imagine all that bleeding that happens each month when someone has a period happening up inside their pelvis so that there’s literally blood and inflammation that is uncomfortable. That’s what endometriosis is.

 

We are not really clear, there are three different theories about why endometriosis happens. One thought is that there is retrograde menstruation, meaning that if the uterine lining doesn’t all flow out, it flows out into the fallopian tubes and then lands in the pelvis. There is some emerging data, an idea that some folks are responding to endometrial tissue almost like an autoimmune disease. So it is an inflammatory process where the body is almost attacking itself.


When I am looking at endometriosis from a functional standpoint, where you try to fix the root cause of the problem rather than from a conventional standpoint, I break it into four categories. I don’t really have a lot of time here so I made an infographic and maybe it got posted on my Hormone and Wellness Facebook page. I mapped out what I was going to say and so if that’s helpful for people, it’s there.

The first area is that this is an area of estrogen excess and so we want to think about how do we get the excess estrogen out of the body and how can we prevent excess estrogen from happening in the first place. So we would look at how the liver breaks down estrogen. If in the body estrogen is adequately methylated, to sort of say hey you’re able to leave the body, and then estrogen is fecally excreted and so is the gut healthy enough and gut microbiome healthy enough to allow estrogen to go ahead and exit. And the health of the microbiome really influences something called beta-glucuronidase which basically takes that luggage tag of estrogen that basically says you’re labeled to leave the body. It takes that luggage tag off and it recycles the estrogen your liver was trying to get rid of.

 

So we look at the liver, we look at the gut, and we also want to really regulate blood sugar. So if I have a high sugar inflammatory meal, my insulin goes up, my sex hormone-binding globulin goes down, my body feels and appreciates free available hormone. So in sex hormone-binding globulin, the binder of the hormone is lowered. It’s like all that estrogen gets kicked off the bus and onto the sidewalk. So controlling blood sugar is another great way to regulate your hormones. So I think that this is often overlooked. So this is the first way to deal with estrogen excess.

 

The second way is sort of addressing the immunomodulatory if we are attacking the endometrial implant like an autoimmune process. What we do to get the immune system back on track so it can calm down again. So there are some natural things that can kind of calm down an immune storm, which is sort of interesting in light of COVID.

 

Some of them are really simple. One of them is arabinogalactan fiber, which is large bark fiber, is great because it kind of does two things.  One thing is, it’s fiber, right, so it binds things up, helps you poop, and get estrogen out that way. But it also has some immune modulation properties. There is an ongoing research trial right now looking at low-dose naltrexone which is a medication that’s used in very small quantities that can help with a lot of autoimmune diseases. So that is at the forefront of research right now.  And then, medicinal mushrooms, things like reishi, cordyceps, those are immune modulators.

 

So the first thing is we want to get rid of estrogen excess. The second thing is we want to modulate the immune system. The third thing is we want to overall lower inflammation in the body. So again, back to a really low sugar anti-inflammatory diet, and then also healing the gut. So if someone has been eating foods that they are allergic to, if their microbiome and their digestion is off, healing their gut to lower inflammation that way. And the last way is sort of addressing the mind-body connection. If the mind-body constantly feels like it is in pain, it is going to up-regulate my ability to perceive that pain. So trying to learn meditation and visualization and trying to break the pain cycle and cultivate some lowering of the stress response, lowering of the sympathetic response can be really helpful. So that was sort of a whirlwind. I hope that made sense.

 

Dr. Moses:

Dr. Watson, can I ask a quick question? This is something I have been doing quite a bit of research on during quarantine because I’ve had an influx of patients with endometriosis. But it is my understanding that the gold standard of treatment is excision surgery and, I guess at what point do you suggest patients go that route? From what I’ve been reading, it seems like the sooner the better. You have an eleven-year-old presenting with endometriosis and the doctor on Nancy’s Nook saying that’s when we should get in there and remove these lesions and preserve fertility and prevent pain. That seems very aggressive to me, so again at what point do you recommend going that route with a specialist.

 

Dr. Watson:

So, that’s not how I was trained. But in full disclosure, I haven’t done surgery for about twelve years, so it’s been a while. I was trained that any time in the conventional space wherein regular Western medicine training, the conventional approach with endometriosis is to turn off the ovaries with birth control pills, or with something else like Depo, or even the Nexplanon implant. High dose hormones for the whole body to tell the body it’s pregnant to turn off cycling.

 

We were taught that any time you do surgery, you are going to potentially run the risk of scarring.  And so particularly for someone who is eleven, right, that person would be just barely beginning to cycle. The act of doing surgery could cause adhesions that could therefore negatively affect her fertility. So, I was trained that you do conservative therapy, you could try to get someone pregnant on their own. If you can’t get pregnant, then you test to see make sure their fallopian tubes are open. And you put the diagram up, you put the dye through the uterus and you see it’s filled up the fallopian tubes. And if it is blocked, then that’s an indication for surgery. And someone’s best chance to get pregnant is right after the surgery before they have additional scar formation. So, I think, I agree with you that taking an eleven-year-old to the OR is pretty extreme and it’s not how I was trained.

 

Dr. Sierakoswki:

No, I think that was a fantastic question. And, Polly, this is the first time I’ve seen your face but we share a number of patients and I have tremendous respect for what you do.

 

Dr. Watson:

Thanks! I can’t see you because I am on my phone.

 

Dr. Sierakoswki:

Hi, Elizabeth Sierakoswki. You know I love your explanation. I practice very much the same way myself. The only thing that I have to add that we really haven’t talked about is two pieces.

 

One is, like many other autoimmune diseases,  or other things that we wish we could fix as if we were broken, I really want to address that myth of, but what if I could be perfect if I ate perfect, and acted perfect, and took super-perfect supplements, then I wouldn’t have this problem. I wouldn’t ever need conventional medicine.

 

There are times when Dr. Watson and myself do conventional medicine. And there are cases where that doesn’t happen, either because their lifestyle prevents them from really being able to do all the recommendations that we would have somebody do, or they have a very severe case and the pain is so severe that they can’t function, etc. So I’m just thinking that making sure that that’s walking the line between when to use conventional treatment and when to use alternative treatment. My goal will always be to heal from the inside out, but we meet people where they are. 

 

So, I think that having some grace for one’s self is really important. And the other case is, what do I do until I’m better and I’m having this blood hanging out in my pelvis that really hurts, what do I do about it? I think it is important to remember that blood is an irritant if it is anywhere outside the blood vessels where it belongs. We really want to assist the body in reabsorption of the bleeding. We want to help with the cessation of flow. So a menstrual flow is called flow for a reason, because we like things to move out of the body and the same is true if you have flow that’s stuck inside the body, what can you do about it? And that’s really some of the basics, like very gentle exercise to the degree that you can, even if it’s walking or yoga or cat-cow, deep diaphragmatic breathing, and breathwork can help us mobilize free fluid in the pelvis. A very gentle abdominal massage can be helpful as well.

 

Dr. Mumma:

I just want to tag on to what Dr. Sierakowski was just saying.

 

The best way I help my patients who are dealing with endometriosis as a chiropractor is to increase proprioception with adjustments. That’s one of the benefits of getting adjusted. And when you increase proprioception you decrease nocioception, a kind of basic way of looking at it, so if you increase your body’s awareness of where you are in space, it can help them figure out what is pain and what isn’t. This can be really helpful for those women who are really suffering and feeling all of their inflammation.

 

Like Dr. Sierakowski talked about, diaphragmatic breathing is really going to…, we can actually see on functional MRI’s that the kidneys will lower by up to four inches when you take a deep diaphragmatic breath. So talking about the flow of our organs, if we are breathing deeply, we actually can increase flow within all of our organs. And this is one of those things that I tend to refer to traditional Chinese medicine as well because I think acupuncture is a really helpful thing. So you know,  within our office, thankfully, we have that as well. Recognizing of course, that not all of the things are going to be available for people.

 

Diaphragmatic breathing is free, so you don’t have to pay me for that when you don’t have to see anyone else and it is really helpful for down-regulating the nervous system, like  Dr. Watson was talking about, increasing that flow and also decreasing some sensation of pain in the moment while you are doing it.

My goal will always be to heal from the inside out, but we meet people where they are. [Regarding when to use conventional treatment and when to use alternative treatment].

Dr. Elizabeth Sierakowski

Cindi:

Thank you so much. That was such an enlightening conversation. And I really enjoyed having a lot of the panelists chiming in. That was lovely. I want to take it to perimenopause now. I think this will be a topic that a lot of the panelists will be able to talk about because it does affect people in so many ways. I would love to have you chime in to let us know the signs of entering perimenopause and how to lessen the impact of the hormonal shift as well as how do you specifically work with perimenopausal patients. And if changing diet is suggested, –I know that Dr. Watson had just mentioned a little bit of gut healing and adjustment of diet within the discussion of endometriosis that we just had,– but if changing your diet is suggested in helping with perimenopause, how do we prevent women who have previous eating disorder diagnoses or tendencies from being triggered? So I’m just going to open this up and not specifically address anyone in particular, but if you have something to say just jump right in.

 

Dr. Watson:

So perimenopause is sort of like puberty in reverse.

 

It can take a really long time. So what is happening is that estrogen levels are fluctuating while progesterone levels are falling. Progesterone is a really grounding hormone. Progesterone goes to gaba and that’s an inhibitory neurotransmitter so that helps you sleep, it helps me with reactivity, so low gaba and low progesterone is a PMS stage, right? So imagine being in a PMS state sort of for years, that’s kind of what perimenopause can feel like for some people.

 

So again, just like we are trying to deal with estrogen dominance with endometriosis, and controlling blood sugar and cleaning out the liver and looking at the those pathways of amyloid estrogen and looking at the gut, we kind of do the same thing in perimenopause.

 

Trying to be respectful of someone’s history if they have had a disordered eating pattern, or they tend to take food things to the extreme, is something that we have to be really careful about. I will often use a lot of intermittent fasting or timed eating to help lower insulin resistance. I really like that because it is not a lot of carb counting,  and it’s free, and all those things. But I might be a little cautious if someone had a significant eating disorder history about recommending fasting. I do think, and I’d love to hear from Katherine, I can’t see her, but I’d love to hear from her about, sort of, shifting the focus of food from what you can’t have to what is in the food you are eating.

 

When we present all the beautiful phytonutrients that are in fruits and vegetables and all of those healing properties, so that instead of presenting someone with, like “You can’t have any pizza,” or “You can’t have a BoJangles biscuit,” and “You can’t have that,” just sort of shift it to a plate of abundance of, “Look at all the color on this plate and how healing that is and what a gift that is to yourself.” I’d love to see how others in the community are addressing that because I think it can get really tricky.

 

Katherine Andrew:

I’ll step in. So it’s Katherine, Polly. I know you can’t see this. And I’m going to pass this on to Anna after this, so I want to hear what she has to say as well.

 

But, you know, you spoke my words. You know me well enough to know that the first thing, especially when there is a history of disordered eating, which to be fair is probably, what, 90% of women with some level of orthorexia these days. How many of us don’t have clients or ourselves deal with body image issues. I don’t want to make it sound like a bad thing either. It is part of who we are as women, right, is walking through that journey and exploring it.

 

The idea of abundance is where I always start. Correct me if I am a broken record, but I’ve probably said it before, but really change the conversation when it comes to nutrition about how we are maximizing our diet, rather than how we are minimizing it. It always comes down to, when you look at our culture, what do I need to remove, how little can I be, how small can I get, what am I eating that I shouldn’t be eating, right? And there might be some of that involved at a point, but I always want to start with what can I add more of, how can I get more color, how can I get more fiber.

 

We do see a shift, and I think Polly would agree with us, that as we enter into the peri- and post-menopause, many women do better with higher fat percentages in our diet and lower carbohydrate percentages. But I always want to start with adding up that fat and bulking up the protein and really looking at how I am building out my plate, rather than what am I taking away first. And then, when we get to a place where we can revise based on when I’m actually in tune with my body, and what I’m feeling, and do I have energy, and am I able to do that deep diaphragmatic breathing that Lindsay was talking about, and all those pieces are integrated, then we can talk more about shifting the diet. But I always want to start from “what can I get more of,” and that question. So Anna, I’m making you talk next.

 

Anna Lutz:

Ok. And I agree, Katherine, with everything that you said.  I mean I would echo everything that you said. A dietician that I trained with a long time ago, Jessica Setnick, talked about using universal precautions regarding eating disorders.

 

So, rather than thinking this person has an eating disorder, I’m not going to do these things, really assuming everyone has an eating disorder until it’s been ruled out, or everyone has an unhealthy relationship with food until it is ruled out. We do this because of, one, how deadly eating disorders are, but also the impact of an eating disorder in someone’s life that can be triggered by recommendations among health professionals. So that’s kind of, when I am approaching my patients, kind of the lense that I practice under is let’s approach this from what are we going to add in, rather than what we are going to take away for that reason.

 

Also, when I’m thinking about perimenopause, I’m thinking about my clients who are feeling really uncomfortable in their skin because of weight gain around their middle. I’m  really thinking about the fact that there is a function to that. Our society doesn’t talk about that, right? Our society talks about how you should figure out how to keep your body the same and how to not gain weight as you approach menopause. And you know as the estrogen decreases, the weight gain happens, the fat gain happens as a way for your body to produce more estrogen in order to protect your bones.

 

So again, rather than thinking how am I going to stop this and how am I going to keep my body a certain way, again thinking about how am I going to support this body, how am I going to eat in a way that keeps me mentally and physically healthy. Of course, there is a lot of grief in that. It’s of course difficult in that bodies change and that might be something that Eva and Dr. Seavey can speak about.  But I really do kind of think about approaching it from the abundance standpoint that Katherine said so well.

 

Jessica Altemara:

While we are on the subject of perimenopause, before we move on, I just wanted to express a lot of appreciation to everyone. You guys who have all spoken about this and the balance and the understanding of that . As someone in the midst of perimenopause, I think that it is something that frequently isn’t talked about. That menstruation, pregnancy and birth are subjects that most people who are doing those things are largely comfortable talking about. But I’ve found that perimenopause is still a subject that really isn’t talked about yet. And I really appreciate hearing from you guys. And this whole topic is being brought up, because I really wish that I had heard people talk about this before I was in the middle of experiencing it.

 

Dr. Sierakowski:

Absolutely, Jessica. To speak to this, one of the things that I end up talking about often to patients is that this can happen across the female life cycle, there’s sort of common time that this happens. I think there is a perception that all women have menopause at exactly 50 years old and that is just what happens and all of us, we just stop and shrivel up after that. That’s not the case at all.

 

I’ve definitely treated women in their 30’s and I am sure that Dr Watson can speak to the age range at which we see hormonal shifts happening. Perimenopause really is this giant spectrum. Some women have hot flashes for 20 years. My 89-year-old grandmother still has hot flashes. She’s very round and has a lot of estrogen and is on zero medication, so there’s lots and lots of ways to do this.

 

Speaking to abundance, a lot of times when women come to me with perimenopause or menopause, it’s not all maladaptive to say I feel like the invasion of the body snatchers and this body isn’t mine any more. Everything I’ve ever known all of a sudden doesn’t work and I just feel overweight, tired, and unhappy. Some of this is, I would like to know what to do to fill up my abundance. And I give them two things to do, primarily. I do very little with the restriction of diet anymore. I did a lot early in my functional training, because their is a lot of rhetoric around categorical restriction of food in becoming paleo or keto or whatever, whatever, but I don’t like it.

 

So, one, you’re going to want to add a whole lot of fiber, speaking again as to what Dr. Watson said. Fiber really is absolute magic Fiber, in helping bulk stool and bind and remove estrogen helps the flow. Getting back to that word flow,  even though perimenopause or menopause is a low estrogen or relatively low estrogen state from what you are used to in your lifetime,  it doesn’t mean that whatever you do have we want to hang around  once it’s been utilized. We really want to make sure that it exits the body as it is supposed to. So fiber is wonderful.

 

The second part is movement. Add movement. Move the entire conversation away from what you should and shouldn’t be eating and towards this idea of moving your body. If you added a ton of vegetables, fruit, and supplemental fiber, and you moved your body every single day, that would go a much longer way towards healing than thinking about all the things you can’t have.

 

Dr. Moses:

One more thing, here. We have to talk about sex briefly. During the time of estrogen depletion, the vaginal tissues are negatively impacted, and can become brittle and thin and ultimately very tender. I see alot of patients that had a very normal, healthy, enjoyable sex life,and then hit this period and all of a sudden  they are experiencing dyspernia, which is pain with vaginal penetration and that can be scary and very disheartening for women. Women should know that we can do a lot of things to target that for that from a medical standpoint, lots of  natural options, — coconut oil, for example, is something that I recommend to a lot of patients who take coconut suppositories just to nourish those tissues a little bit. But again, pain with intercourse is not just something we see in the postpartum phase, but it kind of comes back and can haunt women during the peri- and postmenopausal period as well.

 

Dr. Watson:

I’d like to jump in real quick here if I could, just to say amen, sister. We do have sexual pain.  I see so many women that are afraid of any sort of topical vaginal hormone administration because they hear “hormone” and they think that equals breast cancer. And I just want to put out there that there is really good literature on bioidentical estradiol or DHEA vaginally doesn’t show elevated levels of estradiol or testosterone in the bloodstream after the first two weeks of use. The American College of Obstetrics and Gynecology have even come out and said we can use vaginal estrogen in women who have estrogen-sensitive breast cancer. We just don’t absorb it very much. So I hate to see women suffering for years and years out of fear and misinformation.

 

Oils and lubricants are fabulous. They make things glide better. But if we can get some estrogen or DHEA in the vaginal epithelium, we make the tissue stretch and we get some more blood flow so hopefully we feel the sex as a positive experience. So I just want to put that out there for your viewers that if people have fear about cancer risk with topical vaginal hormone administration, particularly bioidenticals –estradiol, estriol, or vaginal DHEA– is very low risk, is very safe and it works very well. So please don’t suffer out of misinformation.

 

Eva Miller:

I want to say something about a word that Dr. Sierakowski used earlier and I heard a couple of times, “the flow.”  About the physical flow, blood flow. And I use that word “Flow” with my clients a lot being in the flow of creativity. Different. But I’m thinking about how we talk about life changes and body changes and how dysregulating and frightening and disorienting it can be, and how there are so many different ways to get into another kind of flow, of checking in with ourselves, and how we are perceive ourselves and how our bodies are changing or working. A couple of times I have been  talking with clients who are so upset and freaked out because the unknown is scary, and change is scary, and I just like that idea of the word flow having so many different levels of meaning in this conversation.

Rather than thinking how am I going to stop this and how am I going to keep my body a certain way, again thinking about how am I going to support this body, how am I going to eat in a way that keeps me mentally and physically healthy.

- Anna Lutz

Crissy:

I definitely agree with that. I love that. Thank you Eva. Just being mindful of time, we are going to hop to our very last question which I am very excited to have a very brief conversation about.  Many women are presented with normal lab tests, normal results, and yet they still struggle with a variety of symptoms. Many women are also met with responses from providers such as it’s just part of being a mom,  you’re just getting older, just deal with it type of statement. I actually just heard someone say  this the other day that they just heard this statement from a doctor. So, it’s there. How can women effectively advocate for themselves when they know something is wrong? In your opinion, what shift do we need to see in the medical field to better serve these women who are struggling?

 

Dr. Mumma:

I just had a patient  last week who asked me to, was…it seemed kind of weird, recently, in the last two weeks…She asked her doctor if he would run the test that she had determined she thought she needed. She had been doing a bunch of research on her own based on the symptoms she had been having. And he was like, I don’t really think that is necessary. Your lab ranges are normal. She said, I want to run this test because I am pretty confident that we are going to find something and if you won’t run this test for me, then I would like to document your refusal to do that.

 

As soon as she said that, it completely changed the conversation, because he had to think about it for a second. Wait a second. My note isn’t going to say she asked for this and I said no, right, but her notes are now going to say, I asked for this and my doctor said no. And now she has that in her personal record. She’s a total baller of a woman. She’s just really serious and will advocate for herself until the cows come home, and I love this about her. She said I’d like to document your refusal, so you are absolutely  not going to run this test? I think she pulled out her cell phone to put it in the notes section of her phone or something, but she just said she was going to document the refusal.

 

And he says, well, we can run it…So she was really staunch that she was going to advocate for herself and  she had a very specific test she wanted to have done. I think if more of us would just be as serious about documentation as providers are. As a patient, if we are serious about documenting what is going on with us, then yeah, I’ve been asking my provider for  “x” number of things for years and that is also more information for providers. This is not just “I’ve been complaining about X,Y, and Z for the past week. I have documentation here that I’ve been dealing with this stuff for awhile.”  And she was like, “I’m going to document that you are refusing if you are not going to do that. Thank you” and moving on.  And he was like, “We can order it.”

 

So I think that that is a very tangible way of when you are advocating for yourself, make documentation of it. And then you have it. And you have more information to share with your providers and you also kind of give providers who aren’t as willing to actually meet patients where they are a little more pause about just sending them right out the door.

 

Eva Miller:

I love that! I wouldn’t have thought of that. That’s pretty awesome.

 

Dr. Seavey:

Yeah, that’s wonderful.I love that idea and I see a lot of this. I hear a lot of stories about the ways in which people feel dismissed or disregarded, or whatever the request is or whatever their concerns are.  Across time it really has a profound impact psychologically as well as healthwise. There is going to be a lot that comes from that.  And so I end up working a lot with people to look at the ways in which it is reinforced that we stay small and stay quiet and stay, sort of, non-confrontational, and where those messages have come from. And thinking about what is my relationship with these ideas. What is my relationship to them so I can take a look at whose voice is this. And then I think that in doing so, often people end up feeling really empowered. Wait a second, that’s not my voice! My voice is the following and therefore, it strengthens the place from which it’s coming, to be able to say like, just like that, like  can I document that? You know, let me write that down that you’re refusing to do this or whatever it might be. 

 

Dr. Watson:

I think that as I’ve made this transition from an insurance based model, to not taking insurance, and I realize that not everybody can do that and there are a lot of issues there. I’ve seen less and less and less of the lab reports coming in, because I think that insurance is covering less and less, right.  

 

I have a Blue Cross Blue Shield state health plan. They won’t even cover a basic TSH, not even a complete thyroid workup, but just a plain TSH. They won’t cover that as part of my wellness, so I think that in part of the advocating for yourself, I think part of the doctor’s end is that we get exhausted and tired of people saying you ordered this test and it’s not covered by insurance and I want you to spend two hours of your lunch time that you don’t have fighting with your insurance company to get it covered. 

 

I think another way you can advocate for yourself is to find out what is and isn’t covered by your insurance. Like, if you want a complete thyroid workup, like a reverse T3 – it’s really hard to get that covered by insurance. Figure out if you can pay cash for it. Bypass the insurance company. That’s another way that you can advocate for yourself. Instead of figuring out the money and the insurance part on the back end, when it’s a disaster, say I really want these tests and I don’t want the insurance company to dictate what I can and cannot have. It’s my health, it’s important to me. I value this. Figure out what they will and won’t cover. Say to the doctor as you are saying you are going to document this if he refuses, say I understand that this may not be covered and that’s ok. I’m willing to take this cost. It’s important to me to get this test.

 

Jessica Altemara:

I think it is really interesting that everybody is describing people who are being blown off and we are all talking people getting more in touch with their bodies, while also talking about a lot of providers who are blowing off people being in  touch with their bodies.

 

Dr. Sierakowski:

I think it is an important opposition to be aware of. You know, I like what I’ve heard so far because I think there is a lot of patient advocacy that turns into doctor vs. patient/ patient vs. doctor. Sometimes it feels very much like we are not playing on the same team. But we should, right?

 

The goal would be to have your medical team, whoever your providers are, be on the same team as you, the patient. We really want to foster that to the best of our ability. Sometimes that’s not going to happen. If you have a doctor that looks at you, doesn’t have five minutes to stop talking, and just hear your story, and just doesn’t want to even talk about ordering anything, …and as a side note, I don’t know that I would want a doctor is isn’t familiar with those tests at all or ordering those because I asked and then trying to interpret them if they are not used to reading or interpreting those tests…You want to find the right relationship.

 

But some of the ways you can foster and get what you are looking for is to know yourself. So it’s a little bit like going to the hairdresser sometimes, and saying, “I don’t know what I want, but I don’t like what I have.” And then you hope you have a really great hairdresser who can kind of figure it out for you. But, on the doctor’s side, if you want to go and say, “Hi, I’m your patient. I don’t feel well. These are all the ways that I don’t feel well. This is when it’s better and this is when it’s worse. This is what I’ve tried and this is what has worked and this is what hasn’t worked. I can’t figure out a pattern here, but maybe you can.” That would be a great way to partner with your provider. You might not have that relationship. And if your provider is not willing to have that conversation with you, or he says that’s common, or that’s normal, –common is not the same as normal–, or he says that’s common and you say, but I don’t feel good, and they can’t hear that, you probably need a new provider. And it’s ok to look and find a new relationship with someone who hears you and can help you get farther down that direction to your better optimal self.

 

Crissy:

Ok, I have goosebumps about how amazing that conversation was. Thank you so much to everybody. I am really bummed that we didn’t get to all the questions, but that was such a fantastic conversation. I know it is going to be so incredibly helpful to so many women.  And we are so appreciative to all of you for taking the time to join us and I hope you got something out of the conversation too.

 

Cindi:

It’s always a pleasure to spend time with all of you. Thank you so much for joining us today. Have a great weekend.  Bye everybody.

Find full bios and contact information for each of our panelists here.

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