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Women’s health

The 10 Foods You Should be Eating During the 2-Week Wait

By | Fertility, Women's health | No Comments

You’ve made it through!

Through the countless appointments, medications, and procedures! Now all there’s left to do is wait, and maybe wait a little more. These two weeks are a time for you to do absolutely nothing: love yourself, hug yourself, and reflect on how you’re stronger than was ever thought humanly possible!

 

I’ve heard from my patients that the hardest part of the 2-week wait is feeling like there is nothing else they can do, which makes the wait that much…crappier. They want to support their body in every way they can and they’re not sure how to do this after the embryo transfer. Luckily there IS something you can do, and that’s optimize diet! There are simple foods you can eat to increase pelvic circulation, build blood, decrease inflammation, and support progesterone. Eat them often and feel confident that you’re supporting your embryo and overall health!

 

  1. Blackstrap Molasses

    1 tbsp of molasses has the same iron content as half of a small steak! Iron is needed to build nutrient rich blood. You can add it to oatmeal, smoothies, and in place of sugar in baking and cooking.

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  2. Beets

    Beets produce nitric oxide (NO), which dilates the pelvic blood vessels. Beets allow your nutrient rich blood to be delivered to where it matters most – your embryo!

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  3. Spinach

    Not only does spinach contain lots of iron, but it also benefits pelvic blood flow so that you can build a thick and plush uterine lining.

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  4. Lentils/ Beans

    They’re the ultimate vegetarian source of protein, iron, fiber, zinc, potassium, and b-vitamins…everything your growing embryo needs.

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  5. Beef/Tofu

    Organic, grass fed, hormone-free beef for the omnivores and non-GMO, organic tofu for the vegetarians. Both are powerful blood building foods. Beef is a source of heme iron, which is better absorbed than plant based irons for a quick boost. If you’re feeling adventurous, liver and oysters contain even more iron but they’re a hard sell with my patients!

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  6. Oats

    Are you tired of hearing about iron yet? You need a heck of a lot of it to grow a baby and oats are another great source! Oats also contain beta-glucans, which support your immune system which takes a pretty big hit when you’re growing a baby.

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  7. Nuts: Almonds & Walnuts & Brazil nuts

    Almonds and walnuts contain anti-inflammatory fatty acids AND nitric oxide for improving blood flow. The embryo implantation process actually requires a small amount of inflammation to succeed, but too much inflammation is detrimental.

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  8. Salmon

    Alaskan, non-farmed salmon is the healthiest and highest source of omega- 3 fatty acids (EPA & DHA). These fats are found in every cell in your body, even your embryo’s. They support hormone production and cellular regeneration.

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  9. Seeds: Sunflower & Sesame & Hemp seeds

    These 3 seeds have fatty acids that mimic progesterone, thus increasing overall progesterone levels in your body. Progesterone is needed to maintain endometrial thickness.

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  10. Pineapple

    It’s a well-adopted symbol for the fertility community, and for more reasons than one! Pineapple contains an enzyme called bromelain, which can support embryo implantation and endometrial receptivity.

 

The 2-week wait is all about doing things that support your body and mind and make you feel happy; the hardest part of the IVF process is over. If you can fit in some of these healthy foods too, your embryo will thank you.

Book an appointment to prepare for your upcoming IVF or FET cycle

Confessions of a Tap Water Drinker: How To Combat Environmental Estrogens Without Losing Your Mind

By | Women's health | No Comments

I drink tap water and it is one of the major sources of xenoestrogens in our environment. I don’t have one of those fancy reverse osmosis water filtration systems, but I do have a water pitcher filter that I surely don’t replace often enough. But you know what? I’m doing the best I can, and so are you!

There are so many things you can do to reduce your chemical load and you don’t have to turn your life upside down to do them. I’m here to tell you that even small changes make a BIG difference when they all add up.

Xenoestrogens

Maybe I’ve gotten ahead of myself and you’ve never heard of these “xenoestrogens” I’m talking about? Xenoestrogens are chemicals we encounter daily that behave like estrogen in our bodies; they interfere with the functions of our hormones.  They’re in our water, our pesticides, our shampoo, our coffee cups, our cans/plastics and the list goes on. Well, they’re seemingly inescapable.

The bad news: When there are more xenoestrogens in our environment, we end up with more estrogen in our bodies.  These xenoestrogens are unfortunately much stronger than the natural estrogens our bodies produce, so you may experience symptoms of excess estrogen, like: breast tenderness, irregular menstrual bleeding, ovarian cysts, fibroids, PCOS, endometriosis, PMS, headaches, excess fat tissue, low libido, etc all due to environmental exposure. Xenoestrogens affect men and women.

The good news: Thankfully, our bodies are brilliant machines that have the amazing ability to remove the majority of these toxic estrogens through liver detoxification and elimination. It is only when we are over-exposed, and our bodies are over-exerted, that we start to feel the symptoms because our elimination pathways just can’t keep up with the chemical load.

There’s more good news.  The purpose of this blog is to teach you how to reduce your load of xenoestrogens so that your body is better equipped at getting rid of them.

Here’s what you can do:

 

  1. Enjoy foods and drinks that help your body eliminate harmful estrogens, you’re already eating anyways!

The following foods/drinks decrease the binding effects of xenoestrogens in the body:

  •      Almonds
  •      Walnuts
  •      Ground flax
  •      Sunflower seeds
  •      Sesame seeds
  •      Non-GMO, organic soy
  •      Green tea
  •      Hibiscus tea
  •      Alfalfa sprouts

The following foods/drinks increase the elimination of xenoestrogens from the body:

  •      Broccoli
  •      Cauliflower
  •      Brussels sprouts
  •      Cabbage
  •      Collard greens
  •      Arugula
  •      Bok Choy
  •      Kale
  •      Turnips
  1. Know the common sources of xenoestrogens and make small changes to avoid them

  •      Xenoestrogens can be found in a wide variety of household products: cosmetics, cleaning products, body products, cookware etc.The next time you you run out of laundry detergent buy a natural one instead, and skip the unnecessary dryer sheets full of chemicals.
  •      Skin Deep is a site where you can search cosmetics and determine whether they have hazardous chemicals, without having to read a single label!
  •      Avoid plastics as much as possible: use glass containers, use a reusable water bottle, do not heat plastics in the microwave or dishwasher, bring a travel coffee mug to work.
  •      The “dirty dozen” is a list of the top 12 produce with the most pesticides. You do not need to buy everything organic, in fact buying organic in only these 12 foods reduces your pesticide exposure by 60-90%.
  •     Avoid tap water when you can- reverse osmosis water has the fewest toxic compounds (although it is not great for the environment).

Other tips for healthy elimination of estrogens:

  •      Opt for high fiber foods, including: complex carbs, fruits, veggies
  •      Drink at least 2L of water daily to support elimination
  •      Limit alcohol intake to 1-2 glasses of red wine a week for optimal liver function
  •      Get outside in the sun and exercise: vitamin D and sweating both contribute to lower estrogen levels

Even if you only choose to make one tiny change after reading this blog, you’re still better off than you were before. I do the best I can but I don’t treat it like a full time job! I use natural cosmetics, body products, and tampons. I try to use glass containers and avoid heating plastic, but I do love coffee shops and my faithful dishwasher!

Book an appointment with Dr. Sumner HERE. Learn about her healthy hormone program HERE

References

Wozniak, M., & Murias, M. (2008). Xenoestrogens: endocrine disrupting compounds. Ginekologia polska79(11), 785-790.

Paterni, I., Granchi, C., & Minutolo, F. (2015). Risks and Benefits Related to Alimentary Exposure to Xenoestrogens. Critical reviews in food science and nutrition, (just-accepted), 00-00.

Arya, G., Tadayon, S., Sadighian, J., Jones, J., de Mutsert, K., Huff, T. B., & Foster, G. D. (2017). Pharmaceutical chemicals, steroids and xenoestrogens in water, sediments and fish from the tidal freshwater Potomac River (Virginia, USA). Journal of Environmental Science and Health, Part A, 1-11.

Michałowicz, J. (2014). Bisphenol A–sources, toxicity and biotransformation. Environmental toxicology and pharmacology37(2), 738-758.

The Top 10 Hormones Worth Testing in Blood Work & The EXACT Results You Want to See

By | Women's health | No Comments

You know the drill when it comes to hormonal blood work; it’s a lot of poking and prodding on multiple days of your menstrual cycle. In my experience, my patients have had all the right testing done (mostly), but no one has taken the time to sit down with them and explain what the results truly mean.

 

The biggest pitfall of serum (blood) hormone testing is that the reference ranges are MASSIVE. Which means it is highly unlikely that your results will be deemed “abnormal” even though you know something is wrong. So that’s what this blog is for; I’m going to break it all down for you and discuss what the results mean and the REAL range you’re looking for. Note: the following reference ranges are for women and are Canadian units.

 

1) Estradiol

What it is: Estradiol, along with LH and FSH, stimulate follicle (egg) maturation. It’s also responsible for female sex characteristics, thickening of the endometrial lining, and bone protection. Estrogen can also be converted from fat, in both males and females, by an enzyme called aromatase.

What it means: Low estradiol is present in peri-menopause and menopause. Elevated estrogen is present in early premature ovarian insufficiency (followed by low levels), and in estrogen dominant conditions like: PMS, endometriosis, PCOS, and obesity.

Reference Range:

Follicular 77-921 pmol/L

Luteal 77-1145 pmol/L

The “real” range: The width of the above ranges is ridiculous! Estradiol should be tested on day 3 and should be lower than 200 pmol/L and higher than 80 pmol/L. A level higher than this is a sign that the body is trying too hard to stimulate egg development, and the ovaries are not responding. In this case, you will likely see elevated FSH too.

 

2) FSH (follicle-stimulating hormone)

What it is: The name says it all. FSH is in charge of the development and maturation of follicles.

What it means: High levels are diagnostic of menopause, ranging from 27-133 IU/L. When your body is pumping out more FSH than normal, it’s a sign that the ovaries are not responding (just like estrogen). Low levels of FSH are typically present in PCOS.

Reference Range:

Follicular 3-8 IU/L

Mid-cycle 3-22 IU/L

Luteal 1.5-5.5 IU/L

The “real” range: Higher than 8 IU/L on day 3 (that’s the 3rd day of your period) is too high and the value is only going up from there. 6 IU/L is as good as it gets on day 3.

 

3) LH (Luteinizing hormone)

What it is: Ah, the hormone everyone knows and loves! The LH surge triggers ovulation and is measured by urine strips. LH also contributes to the maturation of eggs. You may not know that estrogen surges right before LH, which can also be used to detect ovulation.

What it means: On day 3, an LH to FSH ratio greater than 2:1 is indicative of PCOS. LH is elevated in PCOS for so many reasons I’ll need to dedicate another blog to it. Elevated LH also stimulates elevated testosterone production, and in turn estrogen production. Contrary to what you may think, high LH actually inhibits ovulation instead of stimulating it.

Reference Range:

Follicular 2-12 IU/L

Mid-cycle 8-90 IU/L

Luteal 1-14 IU/L

The “real” range: LH should be almost equivalent to FSH on day 3. 6-8 IU/L is ideal.

 

 

4) Progesterone

What it is: Most of the body’s progesterone is produced by the outer coating of the egg, called the corpus luteum. After you ovulate, progesterone levels increase to maintain the endometrial lining and prepare for embryo implantation. Progesterone also stimulates the production of a thick mucous that covers the cervix so no sperm can enter the uterus (FYI this is the basis of hormonal birth control).

What it means: A low level of mid-luteal progesterone indicates anovulation and luteal phase defect (short luteal phase) and predicts implantation failure/ early miscarriage.

Reference Range:

Luteal 4-50 nmol/L

The “real” range: On day 21 the minimum value is 10 nmol/L to have ovulated and 20 nmol/L to carry a pregnancy. Day 21 is arbitrary if you don’t ovulate on day 14. Progesterone is best-tested 7 days after you ovulate.

 

5) Prolactin

What it is: The main function of prolactin is to stimulate breast milk production. However, elevation can also occur due to the following: benign pituitary tumor, periods of high stress, hypothyroidism, PCOS, and certain medications.

What it means: Elevated prolactin inhibits the release of GnRH, which then inhibits the release of LH and FSH. Without LH and FSH, follicles will not develop.

Reference Range:

5-30 ug/L

The “real” range: Prolactin levels as high as 50 ug/L can inhibit ovulation, but small increases by a few points are relatively harmless. One-time elevation should be followed by repeat testing. As mentioned, stress is a major influence on this hormone.

 

6) DHEA

What it is: A precursor hormone to both estrogen and testosterone.

What it means: DHEA is often evaluated in PCOS, as elevations in this hormone increase androgen levels. It may be prescribed to improve ovarian reserve (but not without fun side-effects).

Reference Range: <9.8 umol/L

 

7) Androstenodione

What it is: Produced from DHEA, this hormone is the precursor to testosterone.

What it means: Elevated androstenedione is found in PCOS and adrenal hyperplasia. Both conditions inhibit ovulation. It may be elevated in isolation, or with testosterone.

Reference Range:

Follicular 1.2-8.7 nmol/L

Luteal 1.1-8.2 nmol/L

 

8) Testosterone

What it is: You know this hormone for its role as the primary male sex hormone, but it’s important for women too! In the ovaries, testosterone is produced by the stromal cells and converted to estrogen. It participates in follicle growth and development, not to mention male and female libido.

What it means: Too much is present in PCOS which is far from ideal, but too little can inhibit ovulation and egg development.

Reference Range:

Total testosterone 0.3- 1.8 nmol/L (some labs up to 4 nmol/L)

The “real” range: Testosterone is extremely tricky to test accurately. Free testosterone is a better measurement than total and the reference ranges (depending on the lab) have huge variability. In order to test free testosterone you need to test total testosterone and sex hormone binding globulin.

 

9) AMH (Anti-Mullerian Hormone)

What it is: It’s a hormone that can depict the female egg reserve because it is secreted by the eggs in the ovaries. The more eggs you have, the higher the value will be. Not surprisingly, AMH decreases with age. This is the only hormone test we have for predicting ovarian reserve.

What it means: A lower value for your age means you have a lower number of eggs than the average female. A much higher value for your age is indicative of PCOS, as the cystic ovaries in PCOS secrete excess AMH.

Reference Range: The numbers are averages based on age:

< 33 = 2.1 ng/mL

33-37 = 1.7 ng/mL

38-40 = 1.1 ng/mL

> 41 = 0.5 ng/mL

The “real” range: At any age, a value > 3.15 – 4.45 ng/mL warrants further testing for PCOS. A value of 6.8-10 ng/mL is diagnostic.

 

10) TSH (thyroid stimulating hormone) & Antibodies (anti-TPO, anti-TG, anti-TSH)

What it is: TSH is released by the anterior pituitary, which then stimulates the release of thyroid hormones (T3, T4) from the thyroid gland. TSH above the reference range with symptoms present is diagnostic of hypothyroidism, and below is hyperthyroidism. TPO and TG antibodies cause the thyroid condition known as Hashimoto’s, anti-TSH is more commonly present in Graves’.

What it means: Deficient thyroid function affects egg quality, embryo quality, and implantation rates. Combine that with thyroid antibodies, and there’s an increased risk of miscarriage.

Reference Range:

TSH 0.32-4.0 mIU/L

Antibodies should all be negative

The “real” range: TSH should be < 2.5 to prevent miscarriage. A full thyroid lab panel (with individual thyroid hormones) is certainly necessary in cases of recurrent miscarriage.

Book an appointment with Dr. Sumner HERE to request & review lab work. Learn about her hormone balancing program HERE

References

Zadehmodarres S, Heidar Z, Razzaghi Z, Ebrahimi L, Soltanzadeh K, Abed F. Anti-mullerian hormon level and polycystic ovarian syndrome diagnosis. Iranian Journal of Reproductive Medicine. 2015;13(4):227-230.

Wiweko B, Maidarti M, Priangga MD, et al. Anti-mullerian hormone as a diagnostic and prognostic tool for PCOS patients. Journal of Assisted Reproduction and Genetics. 2014;31(10):1311-1316. doi:10.1007/s10815-014-0300-6.

http://tests.lifelabs.com/Laboratory_Test_Information/Search.aspx

Huhtinen K, Desai R, Ståhle M, et al. Endometrial and Endometriotic Concentrations of Estrone and Estradiol Are Determined by Local Metabolism Rather than Circulating Levels. The Journal of Clinical Endocrinology and Metabolism. 2012;97(11):4228-4235. doi:10.1210/jc.2012-1154.

Kumar P, Sait SF. Luteinizing hormone and its dilemma in ovulation induction. Journal of Human Reproductive Sciences. 2011;4(1):2-7. doi:10.4103/0974-1208.82351.

What I Take for Endometriosis

By | Women's health | No Comments

Endometriosis (or “endo” for short)

It’s a female condition in which uterine tissue grows outside of the uterus. If you have this condition then you know it’s a real b!@*% and that’s the understatement of the century. The growth of uterine tissue on the ovaries, fallopian tubes, rectum, bladder, intestines, diaphragm….you name it….causes constant, excruciating pain. This is not your typical “period cramping”, this unrelenting and incurable pain has made headlines by the likes of fearless warriors Lena Dunham and Halsey (to name a few).

The tricky thing about endo is that there’s no known cause. It’s chalked up to be an autoimmune phenomenon, oh and yes there’s a genetic link (my mom was diagnosed in her early 20s). I care about endo because it’s one of the leading causes of female infertility, and have I mentioned enough that it hurts like hell every single day?!

Conventional Treatment

So what are your treatment options? Well, there’s laparoscopic surgery, suppressive hormones, hospital stays, and a crap-load of painkillers (I’ll take the full cocktail, thank you for asking). Then there’s the integration of naturopathic medicine.

Naturopathic Treatment

Naturopathic medicine is NOT just about replacing pharmaceuticals with “natural” pills. The naturopathic approach to treating endometriosis looks at lifestyle and dietary changes. There is a significant amount of research on the avoidance of caffeine and gluten (I know, I’m Italian!), daily exercise, maintenance of detoxification pathways, and limiting exposure to endogenous estrogens. But sometimes you do need a few evidence-based supplements to take the edge off, so let me finally get to the punch line and tell you what I use to help manage my endo.

NAC

Patients treated with NAC show a statistically significant reduction in the growth of endometriomas compared to placebo, leading to cancellation of surgery

EGCG (and other antioxidants like pycnogenol)

It significantly inhibits endometrial cell proliferation, and reduces symptoms by 33% compared to drugs like lupron

Omega-3: EPA & DHA

Potent anti-inflammatory and antiangeogenic (stops the formation of new blood vessels supplying the endometriomas)

Herbs for decreasing flow:

capsella bursa-pastens & rubus idaeus

Herbs for reducing pain and spasms:

piscidia piscipula, viburnum opulus, dioscorea villosa

 

Check out my program on endometriosis HERE

The Quick Cheat-Sheet On Body Changes to Expect During Pregnancy

By | Women's health | No Comments

Healthy body changes are inevitable during pregnancy. A lot goes into making a tiny human, especially when your body is the vessel for that human’s life! The most supportive thing your can do for yourself is to love your changing body, there’s no space for self-judgment when you’re pregnant (quite literally).

Not all changes discussed here will happen for every pregnant woman or every pregnancy you may have, but when you know what to expect there are fewer surprises and so much about pregnancy can be a surprise for a first time mommy. It’s not all bad news! I’m just giving you the honest facts

Weight Gain

There’s no perfect amount of weight gain during pregnancy. Even though some research may recommend that you only need to eat an extra 350 calories a day (that’s about two cookies), I subscribe to the philosophy that you should eat when you’re hungry and stop when you’re full. Opt for healthy, nutritious meals most of the time but it’s okay to give in to your cravings too! If you are considered a “high-risk” pregnancy due to weight, please be mindful of your specific dietary concerns.

What to Expect: First Trimester

  • General fatigue – It’s tiring making a human!
  • Nausea/ vomiting – Potentially due to gradual displacement of gastro-intestinal organs upwards as the uterus enlarges, or the presence of hCG
  • Breast tenderness – Due to estrogen and progesterone developing the breast tissue for milk production
  • Blood pressure – It falls for the first 20 weeks, normalizes in the second trimester, and increases in the third
  • Increased heart rate and respiratory rate – To accommodate increased metabolic processes
  • Nasal congestion – Progesterone can affect the respiratory mucosa and lead to increased respiratory infections and mucus production
  • Sleep – It’s common to sleep more in the first trimester, and less in the third trimester

What to Expect: Second Trimester 

  • Leg cramps – Occur due to calcium stores being taken for fetal skeletal development
  • Reflux/ Heart burn – Due to slower stomach emptying, and progesterone decreasing the esophageal sphincter tone allowing stomach acid to raise into the chest
  • Increased urinary frequency – Due to increased progesterone, displacement of the bladder upward, and the bladder not emptying completely so it feels like you have to go more often!
  • Increased UTIs and yeast infections – Due to more urine collecting in the bladder and attracting bacteria, and estrogen causing vaginal pH changes
  • Increased vaginal discharge – This occurs because there is extra blood flow to the reproductive tract
  • Diarrhea or constipation – Both result from either increased or decreased motility of food in the intestines. The bowels are a little too relaxed under the influence of progesterone during pregnancy
  • Hemorrhoids, varicose veins, vulvar varicosities – More blood volume can cause venous pooling and the enlargement of the uterus can also exert extra pressure
  • Stretch marks – The growing fetus demands more space!
  • Foot growth & hip flexibility – The same hormone, progesterone, that loosens the pelvic ligaments for labour, loosens the ligaments in the feet. Don’t worry they shrink back

What to Expect: Third Trimester

  • “Hives- like” rash – Typically presents on the belly and legs. It is more common when carrying multiples, but the cause is unknown
  • Cholasma – Areas of darker skin on the face stimulated by estrogen and progesterone, which goes away after labour or breastfeeding. Can occur during any trimester  
  • Linea nigra – Vertical line on the belly due to increased melanocytes. Can occur during any trimester

Signs of Labour

  • “Nesting” – Desire to clean/organize weeks to days before labour
  • Dropping of the uterus – 2-3 weeks before labour
  • Loss of mucous plug – Clear, pink, or bloody fluid days to hours before labour
  • Water breaking – Gush or trickle of fluid that signifies cervix dilation
  • False labour “Braxton Hicks” – Contractions that are irregular, they don’t get more frequent or stronger, they stop when talking/ resting/ moving positions, only felt in the abdomen and pelvic region
  • True labour – Regular contractions at 30-90 sec intervals, continuous, increase in frequency and strength, start in lower back and move to abdomen

 

Self-care is critically important when it comes to pregnancy. Make sure you rest when you need to and find support we you need to. Also make sure you check-in with your doctor or midwife and let them know if you experience unexpected or concerning symptoms.

 

Book an appointment with Dr. Sumner HERE. Learn about her pregnancy services HERE

 

References

 

Descamps, P., Marret, H., Binelli, C., Chaplot, S., & Gillard, P. (2000). Body changes during pregnancy. Neuro-Chirurgie46(2), 68-75.

Singh, S., & Urooj, A. (2015). Influence of Pre-Pregnancy Weight, Food Habits and Lifestyle on Gestational Diabetes. Current Research in Nutrition and Food Science3(2), 156.

Pomeranz, M. K., & Dellavalle, R. P. (2015). The skin, hair, nails and mucous membranes during pregnancy.

Murkoff, H. (2016). What to expect when you’re expecting. Workman Publishing.

Davis, E. (2004). Heart and hands: a midwife’s guide to pregnancy and birth. Random House Digital, Inc..

The “All You Need To Know” Guide to Hormone Changes During Pregnancy

By | Women's health | No Comments

You’re pregnant! Now what happens? Whether your journey to pregnancy has been a roller coaster ride, or a pleasant surprise, all women go through similar hormonal changes during pregnancy. The female body is absolutely incredible, resilient, and intuitive when it comes to pregnancy. It knows exactly what to do, even if you’re unsure of what might be happening in your body! Don’t worry; in this post I will guide you through all of the hormonal changes during pregnancy so you know exactly what’s going on. After all, knowing what is happening in your body can make you feel more empowered and in control during your pregnancy. Let’s see how incredible the body can be!

Fertilization

It starts with an egg breaking free from the ovary during ovulation.

If that egg is fertilized with sperm, the fertilized egg begins differentiating into a group of cells called a trophoblast. This occurs about 6 days after ovulation. It is this trophoblast that produces the pregnancy detection hormone known as human chorionic gonadotropin (hCG). On average, hCG is detectable in your urine 10 days after ovulation/ fertilization.

 

hCG

When your egg ruptured from the ovary, it left behind its outer coat called the corpus luteum. It is the job of hCG to maintain the corpus luteum so that the corpus luteum can make progesterone and estrogen to support embryonic growth. If your egg is not fertilized and you do not produce hCG, the corpus luteum slowly disintegrates and you will get your period. hCG is present throughout your whole pregnancy but reaches peak levels around week nine to ten, at this point the placenta is able to take over hormone production.

 

Estrogen

Estriol (E3) is the predominant form of estrogen during pregnancy. Cholesterol from your circulation enters the placenta and is required to make all steroid hormones. The production of estrogen depends on the mother and the fetus. You work together with your baby to make estrogen! Here’s how it happens:

 

  • Cholesterol enters the placenta and turns into pregnenolone
  • Pregnenolone is converted into DHEA in the adrenal gland and liver of the fetus
  • DHEA crosses back into the mother’s circulation
  • Mommy uses the enzyme aromatase to convert DHEA into estriol

Phew!! Now that’s teamwork!

 

What does estrogen do?

  • Develops breast tissue
  • Supports the lining of the uterus
  • Increases blood flow to the uterus – and everywhere else which can cause rashes and venous stasis
  • Stimulates fetal organ development
  • Relaxes smooth muscle – causing reflux and constipation
  • Closer to term, it stimulates prostaglandins to promote uterine contractions and helps ripen the cervix with the hormone DHEA

 

Progesterone

Compared to estrogen, progesterone production is easy! It is made entirely by the placenta. Mommy doesn’t have to do anything. Just like estrogen, progesterone is made from cholesterol. It is first converted to pregnenolone, and then it becomes progesterone.

 

What does progesterone do?

  • Allows for implantation of embryo – if you’ve gone through IVF you make take a progesterone supplement during your third trimester to ensure embryo stickiness!
  • Suppresses the maternal immune response – this prevents rejection of the fetus and can stabilize immune conditions like multiple sclerosis
  • Maintains the placenta
  • Supports the lining of the uterus
  • Prevents uterine contractions
  • Relaxes smooth muscle – causing reflux and constipation
  • Loosens pelvis ligaments to prepare for labour

 

Thyroid Hormone

There are two thyroid hormones to take note of during pregnancy. T4 is an inactive, precursor hormone. T3 is your active thyroid hormone, which is derived from T4. Elevated estrogen levels promote elevated T3 and T4 to help with metabolism and regulation of steroid hormones.

 

hPL

Human placental lactogen is secreted by the placenta in order to help mom break down fats and carbohydrates for the baby. Unfortunately, this hormone opposes insulin so it can lead to insulin resistance in mom; this is why you may be screened for gestational diabetes at the end of the second trimester.

 

Cortisol

Cortisol is your “stress” hormone. As you near 40 weeks of pregnancy, cortisol production from the baby’s adrenal glands increases. This increase makes the uterus more sensitive to contractions; it also increases estrogen in the circulation and decreases progesterone to allow for even more contractions! You may be familiar with Braxton Hicks contractions, which are false contractions that occur from pressure on the uterus, not from elevated estrogen.

 

Oxytocin

Get ready to push! Oxytocin is made by mommy and is responsible for dilating the cervix and stimulating strong uterine contractions for delivering baby. After delivery, oxytocin is stimulated by the baby suckling on the nipple and promotes milk let down.

 

Prolactin

Prolactin is the hormone that stimulates your breast tissue to make milk. Estrogen promotes prolactin secretion from mom’s pituitary gland to prepare for lactation, but you will not typically begin lactating until after birth because the high amounts of estrogen and progesterone inhibit prolactin from acting on the breast tissue. After delivery when the hormone levels decrease, prolactin can then promote lactation. When the baby sucks on the nipple, prolactin and oxytocin are secreted to produce milk. Prolactin can be a “natural birth control” if you produce enough of it and breastfeed frequently, this is because prolactin inhibits ovulation.

 

After Birth

Hormones begin to normalize immediately after the delivery of the placenta, and are back to pre-pregnancy levels by day five post-labour. That’s really quick! It is this spontaneous change in hormones that can lead to low mood in the post-partum period. Being more aware of the influence of these hormones on your body will help you understand what you’re feeling and hopefully help you cope with the symptoms.

 

Book an appointment with Dr. Sumner HERE. Learn more about her pregnancy services HERE

 

References

Kumar, P., & Magon, N. (2012). Hormones in pregnancy. Nigerian medical journal: journal of the Nigeria Medical Association53(4), 179.

Hendrick, V., Altshuler, L. L., & Suri, R. (1998). Hormonal changes in the postpartum and implications for postpartum depression. Psychosomatics39(2), 93-101.

C,L. S., PhD. (2014). Physiology (5th ed.). Wolters Kluwer.

Chakrabarti, S., Morton, J. S., & Davidge, S. T. (2014). Mechanisms of estrogen effects on the endothelium: an overview. Canadian Journal of cardiology30(7), 705-712.

Byrns, M. C. (2014). Regulation of progesterone signaling during pregnancy: implications for the use of progestins for the prevention of preterm birth. The Journal of steroid biochemistry and molecular biology139, 173-181.

The Ins & Outs of the DUTCH (dried urine test for comprehensive hormones)

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I’ve committed myself to learning all about dried urine hormone testing (aka DUTCH) and here is what I’ve learned so far (the good, the bad….and my exact results).

The purpose of any lab test is to give you more information than you already have. If having more information is not going to change the diagnosis, or your doctor’s treatment plan, then lab testing is unnecessary. If you have clear and understandable clinical symptoms that can guide diagnosis and treatment you likely do not need hormone testing. If you want to know more about individual hormonal pathways or have mysterious symptoms, then hormone testing may be for you! Keep in mind that the person is always more important than the numbers; naturopathic doctors always practice individualized medicine.

 

So what’s the DUTCH test and how is it completed?

DUTCH stands for dried urine test for comprehensive hormones. The test measures steroid hormones excreted in your urine (I will just be talking abut sex hormones in this blog).

In Canada, a naturopathic doctor can requisition this test for you from several different private lab companies. It’s a very simple test to perform. I used Rocky Mountain Analytical:

  • “Collection day” is 6-7 days before your expected menses- e.g. if you have a 28 day cycle you will be collecting urine on days 21-22 of your cycle
  • You’re given 4 sheets of laboratory paper for your samples
  • You are instructed to pee on the paper at 4 different times: once around dinner time, once before bed, once when you wake up, and once 2 hours after waking (I brought my pee paper with me to work, it’s the only way if your collection days don’t land on a weekend!)
  • You will be given specific instructions on how much water to drink as to not dilute the urine
  • You will fill out demographic information and answer questions about your menstrual cycle and corresponding symptoms
  • Then pack up all of the materials and send it to your lab and you’ll have the results within 3 weeks

 

How does the DUTCH test work?

Sex hormones exist in our bodies in many different forms. Inactive hormones are bound to proteins in the blood; active hormones are free in the blood. Hormone testing via blood measures both free and bound hormones. Urine testing measures free hormones. These free hormones are found in the urine as precursor hormones like estrone and estradiol, or in the form of free metabolites like 2-OH-E1. Estrogens for example, exist in their original forms: estradiol, estrone, and estriol, but they can also interconvert between their original forms or be converted by the liver into metabolites. I will discuss metabolite formation in detail, as it is one of the main “claims to fame” of the DUTCH test!

 

You may be wondering, well how do our hormones get into our urine?! And the answer is through liver processing!

In order for sex hormones to be excreted, they have to be processed by the liver. The liver is our main organ of detoxification, the goal of the liver is to take your hormones and make them more water-soluble so your body can excrete them in urine (and stool).

There are two phases to liver processing of hormones: aptly named phase 1 and phase 2:

Phase 1 takes your hormones and makes them more potent. It is during this phase that hormone metabolites are made through a process called hydroxylation. These metabolites can exert negative and positive effects in the body.

Phase 2 takes your hormones and tries really hard to get rid of them through a process called conjugation. Think of conjugation as tagging your hormones with a sticker that says “I don’t want this anymore”. Once hormones are conjugated they are ready to be excrete by your body. The hormones that are found in urine are conjugated with a sulfate or glucuronide group (now we’re getting fancy). After you’ve sent you urine samples to the lab, the lab has to break the conjugation bonds in order to measure your hormone levels.

Urine hormone testing measures free hormone levels only, because bound hormones are not metabolically active and thus are not broken down by the liver. Urine hormone testing allows you to get a picture of the active hormones in your body, not the bound and inactive hormones.

 

Oh but there’s more to hormone excretion- it’s called enterohepatic circulation!

After the liver detoxifies your hormones, the majority are excreted in the urine (and a small amount in the stool). However, pesky hormones can be reabsorbed by the gut before they make it to the urine through a process called enterohepatic recirculation. This is your body’s unfortunate way of storing hormones for later. If you don’t have a high fiber diet and lack healthy gut bacteria you are more prone to this recirculation. We don’t want this to happen, and supposedly measuring hormones in dried urine can help you measure this process. I’ll explain how as we go.

 

Now that we have a better understanding of how the DUTCH test works, I’ll explain the exciting part of INTERPRETING THE RESULTS!

Remember how I mentioned that the DUTCH test measures both “precursor” hormone levels and hormone metabolite levels? This is where interpretation gets interesting!

 

Here are the top 4 benefits of DUTCH testing:

  1. The DUTCH can demonstrate whether your body is efficient at turning “mother” hormones into “daughter” hormones

For example, androstenedione is a mother hormone that makes testosterone but it also makes androsterone, eticholanolone, and estrone. Elevation in androstenedione can be found in PCOS and can cause symptoms of acne and male pattern hair growth.

This is a photo from my personal DUTCH test. You will see that of the three “daughters” of androstenedione, the smallest daughter is testosterone and the highest daughter is androsterone. This is okay news for me. It shows that my body is converting androstenedione into androsterone instead of testosterone, which is an extremely weak androgen. (I owe this ability to certain enzymes I will save for another blog). This explains why I don’t have symptoms of hyperandrogenism, even though my androstenedione metabolites are extremely high! Sure serum blood tests measure androstenedione and testosterone, but they typically don’t measure androsterone…which turned out to be crucial information for me.

  1. The DUTCH measures estrogen metabolites, and certain metabolites are more harmful than others.

As I mentioned earlier, estrogen has many potential metabolites. The DUTCH test measures three estrogen metabolites: 16-OH-E1, 4-OH-E1, and 2-OH-E1.

2-OH-E1 is considered the healthiest and most protective form of estrogen. 16-OH-E1 and 4-OH-E1 are more potent and harmful and have been indicated in cancer risk. Here is the breakdown of my estrogen metabolites:

My production of 16-OH-E1 is low, which is good, however I’m not making much of the protective 2-OH-E1 estrogen either. Having this information is extremely valuable, because naturopathic medicine has the potential to alter the metabolism of estrogen in a more favourable way and preferentially metabolize estrogen into the protective and healthy 2-OH-E1. Both 2-OH-E1 and 4-OH-E1 can be methylated by an enzyme called COMT, and naturopathic medicine can support the function of specific enzymes! Pretty awesome!

  1. Speaking of methylation, the DUTCH measures the function of the COMT enzyme

    It measures the amount of methylated 2-OH-E1 in your urine. You want this enzyme in tip top shape to prevent DNA damage. Here’s my result: given the small amount of 2-OH-E1 I make, my body is doing a pretty good job with methylation.

  1. Can the DUTCH measure whether or not my body is adequately excreting hormones, and not just reabsorbing them in the gut?

    Remember that the DUTCH test is based on the urinary excretion of hormones, so you may be wondering “what if my body isn’t excreting the hormones properly, does that mean my hormone levels will look deceptively low?!?!” I’ve wondered the same thing!

The three estrogen metabolites all come from a form of estrogen called estrone, except for 16-OH-E1, which is produced from a number of reactions! Below you will find my estrone level. Next to the photo of estrone, are my metabolites. Now look at where all of the green arrows are pointing. My estrone level is midrange, however my metabolites are all low range. The makers of the DUTCH would like to see the arrows of the metabolites all pointing in the same direction as their precursors- meaning they are all in the same range. This is not to say that the metabolites should directly equal their precursors, hormone production is much more complicated than that! Given this information, my results indicate that I have high circulating levels of metabolites and I am not excreting efficiently. Do I buy this information? I’m not sure that I do! Estrogen metabolism is so interconnected that each form cannot be expected to be in the same range as another form at any given moment in time. If you have thoughts on this please comment!!!

Holy smokes?!?! I know that’s a lot of information to take in! I would like to leave you with a pros and cons summary of the DUTCH test so you can make the most informed decision possible when it comes to hormone testing.

The PROS:

It can easily be performed at home. The interpretation gives us information on metabolic pathways and enzyme function. It also gives as a greater picture of active hormones levels, compared to bound and inactive hormones in serum. It may potentially provide us with insight on hormone elimination and recirculation.

The CONS:

It is extremely new and still being validated. The creators have a lot more research ahead of them and gathering enough data to solidify reference ranges of urinary hormones. As more awareness is given to DUTCH testing, the references ranges for the hormone levels will change and there will be a greater pool of patient data to use. Many hormones, like progesterone, are not found in the urine so we rely on the metabolites of progesterone to measure overall levels. Furthermore, I mentioned that we cannot assume that metabolites are within the same range as their precursor hormones.

The CONS of ALL hormones testing:

The worst part of every hormonal test is that it’s not financially or physically feasible to test your hormone levels every day, twice a day. Given this barrier, there’s always a chance you miss something important if you do not test on the right day, or just have a weird cycle the moment you decided to test! Hormones are extremely dynamic, so testing in any medium has it’s flaws. If you’ve every used hormone testing you will see that the reference ranges for “normal” hormones are so massive that it’s almost impossible to catch abnormal hormonal levels. This is a direct reflection of the fact that hormones are extremely dynamic and don’t like to be pinned down!

 

Want to order the DUTCH? Book an appointment with Dr. Sumner HERE

 

If you want to learn about more specific labs offering DUTCH, check out the links below:

ZRT Lab: https://www.zrtlab.com/images/documents/Estrogen_Metabolites_Info_Guide.pdf

Rocky Mountain Analytical: http://rmalab.com/sites/default/files/tests/spec_sheets/20160317_pt_dutch.pdf

http://rmalab.com/sites/default/files/tests/collection_instructions/20150720_dutch_collx_0.pdf

Meridian Valley Lab: http://meridianvalleylab.com/wp-content/uploads/2016/06/Urine-Hormone-Interp-Guide.pdf

 

References:

Tsuchiya, Y., Nakajima, M., & Yokoi, T. (2005). Cytochrome P450-mediated metabolism of estrogens and its regulation in human. Cancer letters227(2), 115-124.

  1. Whirl-Carrillo, E.M. McDonagh, J. M. Hebert, L. Gong, K. Sangkuhl, C.F. Thorn, R.B. Altman and T.E. Klein. “Pharmacogenomics Knowledge for Personalized Medicine” Clinical Pharmacology & Therapeutics (2012) 92(4): 414-417.

Im A, Vogel VG, Ahrendt G, et al. Urinary estrogen metabolites in women at high risk for breast cancer. Carcinogenesis. 2009;30(9):1532-1535. doi:10.1093/carcin/bgp139.

Sanderson, J. T. (2006). The steroid hormone biosynthesis pathway as a target for endocrine-disrupting chemicals. Toxicological sciences94(1), 3-21.

Could your yeast infection actually be cytolytic vaginosis?

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We all know those tell tale signs, the itchiness, the redness, the agony; the instant you notice them you run to the nearest pharmacy and grab an over the counter pill and cream and go about your day waiting for the discomfit to pass. Then the next infection hits and you’re going through the same thing all over again. We just assume it truly was a yeast infection because the anti-fungal medication sort of works, and well, we really hope it’s not anything else! But, what about when it doesn’t work? What about when you keep getting them over again and no amount of Canesten or Monistat is doing the trick? In these cases the yeast infection you think you have may actually be cytolytic vaginosis.

It sounds scary, cytolytic vaginosis, but it really isn’t! It’s just an overgrowth of the normally occurring, protective bacteria in the vagina called lactobacilli. What’s the difference between this and a yeast infection? A yeast infection (candidiasis) is fungal overgrowth, but cytolytic vaginosis is bacterial overgrowth. Confusingly, the symptoms are exactly the same! When you have too many lactobacilli in the vagina they produce extra lactic acid and hydrogen peroxide, which cause the itchiness, redness, and white curdy discharge that look and feel exactly like a yeast infection!

 

Yeast Infection vs. Cytolytic Vaginosis

  • BOTH present with irritated and itchy vulva and vagina
  • BOTH present with profuse white and thick discharge that has no smell
  • BOTH present with a vulva that is red and swollen
  • BOTH present with a vaginal pH that is less than 4.5 (optimal vaginal pH is 3.8-4.5)
  • ONLY a yeast infection will present with a positive swab for candida, if you have cytolytic vaginosis the candida swab will be negative

Neither a yeast infection nor cytolytic vaginosis are sexually transmitted, meaning you don’t typically “catch” them from your partner, however sex can lead to imbalance in the vaginal and penile flora so both partners (same sex or opposite sex) can develop similar symptoms. Both the penis and vagina depend on steadily controlled, protective flora in order to stay healthy.

 

Here is a list of some of the factors that affect our flora and predispose us to developing vaginal infections:

  • Oral antibiotics – These can wipe out the healthy bacteria in the vagina
  • Unprotected sex (with a male partner) – Semen is acidic and can irritate the vaginal mucosa.
  • Protected sex (with a male partner) – But on the other hand, latex condoms and condoms with spermicides may irritate the vagina and eradicate good bacteria.
  • Oral sex – Saliva is not the most hygienic of lubricants, but it can also interfere with the pH of the vagina (which should be 3.8-4.5). I wouldn’t ever suggest taking this away from you; just take a little break if you’re prone to infections!
  • Low vitamin D – Vaginas need sunshine too!
  • Vaginal creams – The vagina is self-cleaning, that’s why you have daily discharge, so there’s no need to use any store bought cleaning products.
  • Scented toilet paper and tampons (and wearing daily pads for that matter) – Even though Tampax makes a pumpkin spice tampon it is not our friend!
  • Food sensitivities and too much sugar – Food intolerances affect the gut flora, which often translate to the vaginal flora. Sugar is also a motivating fuel source for pathogens.
  • Not letting the vagina breathe- G-strings and skinny jeans aren’t doing as any favours, but going commando at every opportunity will!

If you’re suffering from the symptoms of a yeast infection but the vaginal swab comes back negative, you should suspect cytolytic vaginosis.

Here’s what to do to get rid of it:

Twice daily baking soda sitz baths. Fill your bathtub (or a large bucket) with a small amount of warm water and add two tablespoons of baking soda per litre of water in the tub. Sit in the bath and read a book for at least 30 minutes. The purpose of this treatment is to decrease the acidity of your vagina and reduce the lactobacilli. You should be feeling better in no time!
Book an appointment with Dr. Sumner HERE

 

References

Sobel, J. D. (2016). Recurrent vulvovaginal candidiasis. American journal of obstetrics and gynecology214(1), 15-21.

Yang, S., Zhang, Y., Liu, Y., Wang, J., Chen, S., & Li, S. (2016). Clinical Significance and Characteristic Clinical Differences of Cytolytic Vaginosis in Recurrent Vulvovaginitis. Gynecologic and obstetric investigation.

Ahmad, A., & Khan, A. U. (2009). Prevalence of Candida species and potential risk factors for vulvovaginal candidiasis in Aligarh, India. European journal of obstetrics & gynecology and reproductive biology144(1), 68-71.

Suresh, A., Rajesh, A., Bhat, R. M., & Rai, Y. (2009). Cytolytic vaginosis: A review. Indian journal of sexually transmitted diseases30(1), 48.