Aviva Romm on Hormone Intelligence & Calming Hormone Chaos

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Katie: Hello, and welcome to the “Wellness Mama” podcast. I’m Katie from wellnessmama.com and wellnesse.com. That’s Wellnesse with an E on the end. And this episode is all about hormone intelligence and getting your hormones into actual balance and what that means. I’m here with Aviva Romm, who is a world-renowned midwife and herbalist who also happens to be a Yale-trained MD and a board-certified family physician. Her specialties are in integrative gynecology, obstetrics, and pediatrics. And she has a new book out called “Hormone Intelligence,” and it explores the impact of all the things that our modern world on our hormones and our health, and it brings a new paradigm of medicine for women that’s both holistic and natural, but also grounded in the best that science and medicine have to offer.

We go deep on a lot of topics and really address some of the reasons we are seeing such drastic hormone-related changes in every age group, including early puberty, including infertility issues in women, menopausal problems. We go into all of that today. I also wanna mention that you can get some really cool bonuses from her right now by going to avivaromm.com/book, and she’s got a lot of bonuses there when you get her book. But we also just go deep on so many topics in this episode. I can’t wait to share it with you. So let’s join Aviva. Aviva, welcome back.

Aviva: Katie, thank you so much for having me back. I’m really excited to chat with you today.

Katie: I’m excited to chat with you, too. You’re so much fun to talk to. And our other times that we’ve chatted, I’ve had amazing response. People love to hear from you. And I’m excited about your new work because I think it was timely anyway and now even more so with everything that’s happened in the last couple of years. And you talk about a hidden hormone epidemic in your new book. And I know I’m hearing from so many listeners and readers that are having all kinds of crazy hormonal struggles right now. It’s obviously no secret that we’re seeing an increase in stress and all kinds of problems. But walk us through why we’re seeing…why are these hormone problems increasingly prevalent right now?

Aviva: Yeah, so it’s funny, I had this term “hidden hormone epidemic” before the pandemic, and then certainly the pandemic has now escalated women’s experience of stress and how that shows up in our cycle. So, you know, really, we have had this evolutionary blueprint that we have lived by from time immemorial. What I mean by that is from the, you know, first woman on the planet to now, we have all had menstrual cycles that started at puberty. We get pregnant with the same hormonal background. We go through menopause. And this has been pretty consistent over time immemorial until, screeching halt, the last like 30 or so years.

So, what’s going on? Well, there were, first of all, no environmental chemicals when our grandmothers were kids or our great-grandmothers depending on how old we are. Our diets have changed drastically in the last 50, 60 years. And our stress levels have increased in the sense that, you know, human beings have always had stress, like being a mom of a bunch of kids and taking care of kids, and maybe working at a job. Of course, all the stressors that our grandmothers and our mothers had are still the same but now we’re doing it 24/7, right? The expectations on us as women, as mothers to just keep going, the demand of the electronic world where work never stops.

And then in addition to that, the fact that those electronics themselves have an impact on our hormonal production, our hormonal cycles. So just, for example, being exposed to blue light from your computer or your Kindle at 10:00 at night when you’re still surfing the internet or, you know, checking Instagram or catching up on work that you didn’t get done during the day, doing that last little thing, actually suppresses some of our hormones like melatonin, which then have an impact on fertility, ovulation, and all of that. So, this has been like this increasing escalation.

And, you know, back to these environmental toxins that I mentioned that our great-grandmothers and grandmothers really weren’t exposed to, we know that they’re having a measurable, huge impact on women’s health and we’re all exposed. I mean, no matter how clean and green your life is, we’re still all exposed. There’s a lot that we can do and we can talk about that. But one area that I find, sort of, highlights how dramatic these changes are is puberty in our daughters. So, in our great-grandmother’s and grandmother’s day, you could expect to get your first period, somewhere between 14 and 16, maybe as young as 12, and start getting pubertal development, so breast development, for example, and pubic hair development, maybe a year or so before that.

The new normal is actually considered 9 years old for getting your first period, and as young as 7 for breast development. And it’s putting our girls at risk physically because they’re exposed to a lot of estrogen that’s causing this early on. But it also exposes our girls to emotional and possibly even risk of physical trauma because they’re developing these mature female characteristics at an age where they’re too young to handle that. And we know that that is a direct result of these endocrine disruptors that are coming through herbicides and pesticides in our food, also body products that we’re using, our soap, our shampoo, lotions, things that are in our home environment through our cleaners. So not to be a Debbie Downer because I never wanna be like, “Oh, the sky is falling,” but we need to know these things so that we can change these things. And I know you’re also really committed to this greener lifestyle, healthier food, and it’s so important.

Katie: It is. And like you, I don’t ever wanna veer on the pessimistic side of it because like you said, the importance of knowing so that we can be proactive. And unfortunately, like, we’ve seen this change so quickly. I remember having conversations with my grandmother before she passed and she would be like, you know, “It shouldn’t be this hard to be healthy.” And she’s right, it shouldn’t. But we have so many more inputs. There’s more variables we’re having to figure out than our grandmothers did, or certainly our great-grandmothers. And so it’s not that we have to hide from those things, it’s just, we do need to be aware so we can be a little bit more proactive.

I see the word hormone balance thrown around a lot and a lot of products that claim to balance hormones. And I know some of those are just because the FDA limits what you can say related to any specific mechanism. But I think there’s even, like, some misconception or misunderstanding of what actually hormone balance means because, for men, their hormones change on more of a daily cycle, which ties in with those light patterns you mentioned, which makes it even more important. But for women, our hormones change, like, if you graph them, it’s almost like a roller coaster over the course of a month. And so there’s a little bit more that goes into hormone balance. And I think there’s also a negative connotation, like women get told they’re being hormonal if they’re, you know, being grumpy or whatever. There’s just so much that’s wrapped up in that word. So can you walk us through what it actually means to balance hormones when they’re constantly changing?

Aviva: Yeah, so I love this question. So, totally, our lives are, you know, estrogen, progesterone, estrogen, progesterone, estrogen, and then there’s the testosterone in there and, you know, thyroid hormone, and cortisol, and all these other hormones that really, there is no such thing as hormone balance, as if there’s this static, perfect place that we get to and everything is in a constant hum. So I think what we mean when we say…We all, kind of, know what we mean when we say hormone imbalance. Like if I were to say to you, “My hormones feel really imbalanced,” you’d probably know I was talking about a range of, like, either I’m tired or irritable or my cycles are off. And so that’s what we mean when we say my hormones feel unbalanced.

But when we talk about hormone balance, again, there’s no one perfect, like, you get to this place and you stay there because we’re meant to have ups and downs throughout our cycles of our hormones. That’s how we menstruate. That’s how we ovulate. That’s how we’re pregnant. That’s how we go into menopause. It’s those fluctuations. But within that, each woman has her own variation within a range of what is considered normal. So there is a normal range for estrogen, let’s say in the first half of your menstrual cycle, compared to the second half of your menstrual cycle. There’s a normal range for progesterone in the first half versus the second half. There’s a different normal range of those hormones during pregnancy. There’s a different normal range during perimenopause and menopause.

So what we’re really talking about is how do we feel and how does what we feel, kind of, compare to those lab numbers? And if we’re in those normal ranges, we usually know it because we feel fine. Like, we’re not experiencing…As you said, you know, your grandmother saying being healthy shouldn’t be so hard, in my new book, I talk about how…in my work how being a woman is not a diagnosis, right, this idea that we’re supposed to suffer, which kind of goes all the way back to Biblical times, you know, in so many ways, like this idea, you’re in a woman’s body, so suffering is just part of it. But that myth has also been perpetuated in the medical model.

So we get this idea from the medical model, also, like if you have period pain or you have heavy periods and you go to your doctor, and then they’re like, “Oh, well, that’s normal, because you’re a woman.” But we’re not meant to suffer. And so when we’re in those healthy ranges, things are going really well. And when we’re not feeling optimal throughout our cycles or we’re struggling with symptoms like period pain, or more significant conditions like PMS, or, you know, severe period pain, endometriosis, polycystic ovary syndrome, fertility challenges, that’s usually telling us that something’s going on with our hormones that are getting them out of those normal ranges.

Katie: That makes sense. And I love that line, that being female is not a diagnosis because I think we’re finally starting to have some awareness about this. But like you mentioned, in the medical world, tests are historically done on men, studies are done on men, reference ranges are pulled from studies on men. And the irony is it’s because they don’t have hormone fluctuations. So it’s much easier to control for variables. But it’s a disservice to women because we do have hormonal changes. So we’re taking medications that were designed for men. We’re being stuck on reference ranges of labs that were designed for men. And that does make things a little bit more complicated for us. But I think also now that we are aware of this, we’re seeing a lot of good information and data that is helpful.

And I think also, it’s really important, like you said, to unpack that word “normal” because I certainly heard that over and over when I was trying to figure out my thyroid condition. They’re like, “Oh, well, your lab…Your T3 is normal.” And there’s so much that goes into that as well, like, well, normal ranges are created from largely men, for one, but also from people who go in for thyroid testing. And, you know, young, optimally healthy people don’t just go in and randomly get testing. So the studies have been done on people who have some sort of potentially not normal range and then we’re trying to fit us all into that. But I remember how frustrating it was to be told, like, “Oh, that’s just normal,” or, “That’s normal after having a baby.” Or, “Of course you, like, can’t lose weight or your hair’s falling out, that happens after you have a baby.”

And so, I get really excited when people like you are really unpacking all of these things and giving tangible tools because I feel like I didn’t get answers from the medical community for so long. And it was so empowering to be able to, kind of, step into and understand this myself and start to put the pieces together, which I think a lot of women have that experience is we are our own primary healthcare provider and we start to really see a difference when we can have these tangible tools and start making the changes ourselves. I wanna circle back to, you mentioned about girls starting puberty so much earlier. And I have four daughters, and so this is something that’s been very top of mind for me. And thankfully, we’ve avoided early puberty so far with all of them. But for any moms or parents listening, what are some things we can do if we’ve got young ones that will help them have, hopefully, optimal hormone entry into puberty?

Aviva: Well, first of all, I just wanna say because I know, as a mom, you know, you can hear things and think, “Oh, my gosh, I didn’t do that. Now we’re doomed.” None of that. And then also no blaming ourselves. Like, there’s so much pressure on moms, as if, like, everything we do is what determines who our kids are. And now, I mean, as a mom of four grown kids and two grandkids, our kids have their own path. And part of our job is to just respond really well to their path. So no shame, no blame, none of that. But within that, actually starting in pregnancy, there are things that we can do, or even preconception. So a lot of what we get exposed to from environmental chemicals, so let’s just say the body lotion that we’re using, which we put all over our body, if it has something called pthalates in it, those are plasticizers, and we actually absorb them. Ditto with anything that we’re, kind of, like, putting all over our body or breathing it. And so a lot of the perfumes that we use, scented body products, scented household cleaners, air fresheners, all of those scents that we’re breathing in actually can shift our hormone balance.

And so starting in pregnancy, whatever we’re absorbing, we download to our babies through our, you know, circulation, through placenta to baby. So we know from studies done both by the Environmental Working Group, as well as other independent researchers, that babies are born with almost 350 chemicals already detectable in their umbilical cord blood, so at the time of birth. So going as far upstream as we can, you know, we’re doing everything you can to eat organic, use good clean body products, good clean household cleaners. Those are some really important basics that have been shown to make a huge difference in our blood levels of these chemicals. And then when you start feeding your…you know, when you’re breastfeeding, of course, the same thing. When you have a newborn, being mindful to use organic, unscented, or naturally scented, you know, essential oils, very minimal scent of any body products, soaps, all those kinds of things on baby.

And then as baby starts to eat, as much as you can, organic fruits and vegetables, organic, you know, antibiotic-free dairy, and then if they’re eating meat or getting any animal products additionally, make those organic, antibiotic-free, hormone-free, grass-fed. And, you know, I know that can also sound intimidating from a cost perspective. But I will say that I raised four kids on a school teacher’s salary, private school, you know, we were doing the $40,000 a year thing and then my midwifery income, which was, you know, back in the day when midwives got paid like $450 for all prenatal care and a birth. You can do it. It definitely takes more work to be mindful and thoughtful. But it’s easier now than ever. I mean, you can go to a Walmart even and find good organic food resources and a lot of home delivery services do organic.

So, back in the day, boy, we had to search out the healthful stuff, but now it’s doable and, you know, it’s one of those, yes, it is more work but, as a physician who cares for women and children, I do truly believe it’s a pay now pay later situation. It’s worth doing the work now because as you have healthier kids, it’s so much easier.

You know, helping kids to stay within a healthful weight is important. We’re seeing a lot more obesity in kids in the American population. And I’m like, I never wanna talk about weight in a way that’s shaming but we do know that estrogen is stored in fat tissue. So if we have a lot more fat tissue, then we’re more at risk for having more estrogen. And so that’s been one of the risk factors that I wouldn’t be doing my full job if I didn’t at least address. So if kids are really struggling with significant weight problems, you know, working with a nutritionist who has an integrative approach and also, like, a very positive approach to food and body size, if there are signs of early puberty can be helpful, too.

And if your child is showing signs of early puberty, so breast development, 6, 7, 8 years old, it is important to bring your little one to a pediatrician, because there are some risks with early puberty. When we go into puberty as young women, if we stop growing, our height stops, our bone growth stops within one to two years after that first menstrual cycle, which is why most of us achieve our adult woman height within a couple of years of our first period. But if that happens when you’re 6 or 7 or 8 or 9, you know, it can affect your stature, so your height. So working with a pediatrician, and making sure there are no other…You know, yes, endocrine disruptors can be a reason but there can be other issues that are happening medically that can cause this too.

Katie: That’s really good to know. I hadn’t heard that about height stopping, but it makes sense. And I’m glad that there are resources for that. What are the most common things you’re seeing in adult women in your practice right now related to hormone issues?

Aviva: You know, I see a lot of sleep problems across the board and especially women in perimenopause and menopause. I see a lot of polycystic ovary syndrome, a lot of endometriosis, and just a lot of PMS that’s really taking women out. And a shocking amount of women just really struggling with acne, not just in their teens, but 20s, 30s, 40s even, some of it with polycystic ovary syndrome, some not. And then a lot of fertility challenges. So just so many young women I know. In fact, some of my patients will come in and they’re like 32 and they’re struggling with fertility problems and they’re like, “I’m not even surprised because all of my girlfriends are struggling with this too.” And, you know, kind of, back to what you were saying, Katie, earlier, about how we accept certain things as normal. We’ve kind of gotten this belief that just because it’s common, it’s normal. So a lot of young women are like, “Oh, this polycystic ovary syndrome, this is just normal. Everybody has it. Fertility issues, it’s normal. Everybody has it.” But common and normal, not so much.

Katie: That’s a really important distinction. And I’m definitely hearing from a lot more people as well with PCOS and endometriosis and fertility struggles. It seems drastically on the rise much more than we should be seeing in the span of one generation. And I think a lot of women are hearing from their doctors that, A, these things are normal, or B, that there’s not really that much you can do to address them. And they go straight to, kind of, more extreme either surgical options, medication, etc. So, I’m curious for a woman coming to you with those problems, specifically, things like PCOS, endometriosis. what is your approach? I’m guessing you’re not diving straight into surgery. So, how are you guiding those women?

Aviva: Yeah, so I mean, surgery can be a really important option if you’re struggling with fibroids that are making your life miserable or you’ve done everything you can for endometriosis, and you’re just done with…you know, you’re just ready to have those lesions taken out. And I’m so supportive of that if you are. And ditto with PCOS, you know, if you’re just ready for the pill or you’re ready for Metformin, I really support that too. But there are so many things that we can do before that, that can make a huge difference and that can completely mitigate the need for those approaches, and that are safer. So, for me, I look at all the factors that are impacting a woman’s total health ecosystem. That’s what I call it. What is going on in our diet, our stress levels, our gut microbiome health? And I start unpacking that.

I always start with food first because it’s the lowest hanging fruit, no pun intended, doesn’t require any testing. You could just change your diet. And we know, for example, for women with PCOS, just shifting the ratio of what are called macronutrients, protein, carbohydrates, and fats, away from too many carbs to a higher protein diet, just that change alone can improve insulin resistance, reduced testosterone levels and improve symptoms, which are some of the underlying metabolic and biochemical issues that contribute to polycystic ovary syndrome. For women with endometriosis, we are told that it is a permanent condition. There’s nothing you can do. But actually, studies that look on laparoscopy, so, you know, looking in the belly to see what’s going on with the endometrial lesions, we find that they can go into remission. They may be there one month and they may not be in the same place the next month.

And so we know that can go into remission and we know a few things. For whatever reason, women who get more citrus in their diet, so women who eat one or two pieces of citrus a day are less likely to develop endometriosis and more likely to have remission in their lesions. Red meat, big contributor it seems, to endometriosis. So taking red meat, either completely out of the diet and leaning more into fish and more vegetables, which we know women who get more fish and more vegetables in their diet have less inflammation and reductions in their endometriosis symptoms. So knowing these different things for these different conditions, I look at each woman individually and say, “Okay, what are the universal things that we know make a difference, and then what’s going on for you specifically?”

So, we know, for example, that microbiome disruption, can lead to PCOS, can contribute to inflammation. And endometriosis is associated with fertility challenges and other conditions as well. So, has this person taken a lot of antibiotics? Did they have a trip to a country, you know, in Central America, or they go to India and they drink water and then got a gut infection, you know, gastroenteritis. And then after that, they’ve never been the same. So start looking at, well, what can we do for the gut? And some of that is supporting the gut with diet. We know that you can have a huge impact on gut health in even just a couple of weeks by shifting the diet away from the standard American diet into healthy fats, good fiber, more fruits, and vegetables, again, really can make a difference. So, that’s something I look at.

And then stress, you know, we hear…Like, even when we go to the doctor, right, like, you may have experienced this, Katie, when you were trying to sort out your thyroid, you know, issues. Oh, you know, she’s got three kids, four kids, five kids, it must just be stress. You’re just tired. It’s normal. And so we hear that stress can be a problem. But I think…And we know there’s a connection between stress and our health. And we’ve probably all experienced some point in our life where maybe we traveled or we got sick with the flu and we skipped a period or our period was late. So we know there’s a connection, like, on an experiential level. But when we really go into the science, the connection between stress and also not enough sleep in our hormones is actually astonishing.

So I really bring in mind-body practices, meditation, time in nature. And of course, I often hear from my women patients, especially the moms, “I don’t have time. I can’t do it.” And then I often find myself saying things like, well, I get that because I mean, I’m a mom too. And I know, like, sometimes you have to go into your closet to have some privacy, or to record a podcast, or to do meditation or anything, or your bathroom and shut the door. But I also feel like what we’re modeling to our children about how being a parent is really important. So, if we’re modeling to our children, our daughters, or our sons, that being a parent means you have no time for yourself, I don’t necessarily think that’s the best modeling either. Whereas by embracing I have a right, you know, as a human being to relax and to decompress and to get good sleep. And also, I’m teaching my children as part of their education and emotional self-management that these things are important. We can not only help heal our hormonal imbalances if you will, those symptoms that we’re experiencing our conditions, but we can also help to forestall some or prevent some of those challenges in our kids.

So those are some of the things I do. I work a lot with specific foods that support healthy hormone levels. So, just some of the core things we can do every day, getting flax seeds or chia seeds in our diet, pumpkin seeds, sunflower seeds, sesame seeds, lots and lots of leafy green vegetables. Making sure that you are getting enough fiber. Usually, if you’re getting 8 to 10 servings of fruits and vegetables every day, which, you know, one green juice and one big salad and a sweet potato will pretty much get you that amount. It sounds like a lot, but it’s really not that much. All of these little things that we can do make a huge difference.

So those are just some of the things that I start with. And then, of course, on an individual basis, I might be saying, “Oh, you know, how does this woman’s cortisol levels fit into this or how to do her thyroid hormone levels…right?” Because we know that if your thyroid function is slow, that can affect your periods. It can affect your ovulation. It can cause anxiety and depression. It can cause weight challenges. It can cause hair loss or hair breaking. So, looking at how that is also affecting menstrual health and ovulation and fertility is part of it.

Katie: So many important points there to unpack. And touching on the food thing, I think there’s so much information out there when it comes to diet and health, and especially so much of it is geared towards specifically weight loss. And when people ask me now, like, “What did you do?” I wish I had some glamorous answer to give them but the reality is, I got really careful about my life patterns and my sleep. So I’m a huge proponent of morning sunlight, which signals that whole cortisol pathway. It’s free. And that made a drastic difference for me. And also counter-intuitively to what I was doing for a long time with food, I learned I had to actually eat more. And I had to shift my mindset to hyper nourishing versus deprivation because I think society, kind of, gears us toward depriving ourselves of food or viewing food as bad because of the diet culture. And when I actually, sort of, kind of mapping it out, I was eating very clean, but I was not eating enough. And I specifically was not eating enough protein most days. And I had actually gone way too far and avoiding too many carbs. And so I had to learn to love things like sweet potatoes, and fruit, and vegetables again because those are actually important building blocks for hormones.

And I know this is a pretty complicated topic and very individualized when it comes to things like fasting and carb restriction in women and how it impacts our hormones. I think there is an element of we each have to, kind of, dial in what’s gonna work, what ratios work for us specifically. But for me, those keys were making sure I was getting enough micronutrients, make sure I was getting enough protein, and enough calories, and carbs, in general. But then, like you said, not pushing it over that line because too many carbs certainly can be very damaging for hormones, as well. But I like to bring that up just because I think a lot of women think like, “Oh, if I’m struggling with my weight, I just need to keep eating less and less and less and less.”

Aviva: And oh my gosh, Katie, I couldn’t agree with you more.

Katie: Yeah, you’re training your metabolism to operate more slowly by giving it less food, not that you should just start overeating but like…

Aviva: Well, you’re putting your brain into survival mode. So you’re actually triggering cortisol. And when your brain is in survival mode, it doesn’t know if there’s a four-alarm fire, if you’re being chased by a tiger, or if there’s a famine. And so your body actually goes into feast and famine mode and starts holding on to weight. And so, I couldn’t agree with you more. So, a huge tenet and, like, the whole first, sort of, like, therapeutic chapter, or support chapter of the book, if you will, after, like, the whole intro five chapters, is food. And I even started out by saying, “Okay, let’s talk about the D-word,” because I don’t wanna use the word diet, I really wanna talk about nourishment. So I call it the Hormone Intelligence Diet in my new book and also to how I talk with my patients and my students because diet really means how we eat. But the word diet has so many connotations. And I really want to focus deeply on nourishment and how are we nourishing ourselves?

And yes, I mean, we have to listen to our own bodies, right, and our own bodies throughout our life cycles. Where are we in our life? When we’re pregnant, we may need something different than when we’re breastfeeding than when we’re in perimenopause than when we’re, you know, in our 20s and paying attention to those shifts, but so many women under-eat, over-restrict. It does not serve weight and metabolism. But also things like carbs provide important building blocks for our neurotransmitters, things like serotonin that make us feel good. So one of my big prescriptions for women who are struggling with PMS, for example, is to make sure you’re eating carbs, and enough carbs, healthy carbs like sweet potatoes, squashes, like, winter squashes, brown rice, you know, whole grains, especially in that week before your period. It can make that complete shift from low mood to healthy mood and actually feeling excellent before, you know, your period comes.

So, I so agree and I love hearing your story. And, you know, just seeing you, I mean, I just see how transformed you are in so many ways. And we were talking about that before we started interviewing together but you are glowing. You’re absolutely glowing. Not that you weren’t before but there’s something new that I noticed was happening. So it’s working, girl.

Katie: Oh, thank you. And I love also in your book how you talk about, kind of, conventional methods that are used and also the more holistic alternative side, because I think we get the best results when we take the best of both worlds. So I’m curious your take on things like, is there a time and a place for, for instance, progesterone, supplemental progesterone, or, like, can these be helpful tools? And if so, how can we use them?

Aviva: Yeah, thank you for noticing that and bringing that up. So one of the things I wanted to make sure of with the book was that nobody felt like there was a polarization or that doing the conventional thing was judged or shamed. And I find, to me, I always lean into natural first, both in my personal life and as a physician, anytime I can. So I very rarely prescribe pharmaceuticals. But I don’t want someone who is taking the pill to feel like, “Oh, well, this program is not for me,” or, “I’m doing something wrong,” or you know, that there’s any shame. And I think that can happen sometimes in the wellness space. It’s very much either you’re doing it natural or if you have to resort, if you will, to the medication, somehow you failed, like you haven’t done the natural thing well enough. You haven’t taken the supplements right, or you haven’t done the diet hard enough, or you haven’t meditated enough. And it’s just not true.

The factors that are affecting all of us are beyond our control. And a lot of those factors were affecting us before we even knew about them or had agency. So I want us to be really, really self-compassionate about where we are and what we need. Within that, there are so many natural things that we can do before we ever get to the hormones or pharmaceutical treatments. But yes, there is definitely a time and place for them. So, I really feel like, you know, if you’ve been trying all the natural things and you’re still struggling with symptoms that are really impacting your quality of life or your well-being…I mean just, for example, I think about a patient I had who came to me a couple of months into COVID. And she has polycystic ovary syndrome. She’s young, she’s in her 20s. And her dad had gotten really sick, not from COVID, but another medical complication he had.

And she had to go and live in her hometown where her parents were. But she didn’t wanna live with her parents because of COVID. She was afraid to expose them and her dad was sick So she got an apartment with some other women and, you know, she says, “Look, I’m living with three women in their 20s. Like, it’s really hard for me to never have wine or to not eat the pasta dinner or the pizza.” And her acne, I mean, it was really flaring. It was making her really, really self-conscious and miserable. She was having a really hard time losing weight, Her hair was falling out. I mean, she was having a lot of pretty severe PCOS symptoms. And she’s like, “I’m so stressed with COVID. I’m so stressed with my dad being sick, I don’t have the bandwidth to do, like, a full-on natural program.” So, she really wanted to start a low progesterone pill. And she did. And it was a game-changer for her. And she felt so supported in that choice.

Similarly, sometimes I have women who come to me, you know, they’re in their late 40s or early 50s. They’re having crazy hot flashes that are waking them up at night, they’re not sleeping well. And yes, the natural stuff can be great, but it’s just not fully taking the edge off and a little bit of low dose, again, progesterone in the form of hormone replacement or bioidenticals makes them sleep, then they sleep better, they feel more nourished, then they’re not, like, hitting up the coffee in the morning and the sugar all day and then the glass of wine to unwind at night. So there’s definitely a time and a place. Fertility treatments sometimes can be hugely helpful. One of my closest friends has a baby that she had through IVF. And I got to be at her birth and it was a great experience. She was in her 40s, or just turning 40, and struggling for a couple of years to get pregnant. And it was a game-changer.

But here’s the thing, even within all of that, it’s still important, even if you take the progesterone for your sleep for menopause, even if you use the pill for your PCOS, even if you’re doing the IVF, there are a lot of natural therapies that can support and improve the outcomes with those treatments. And we still have to do the things that address the underlying causes because let’s say you use the pill for acne for PCOS, and it makes a huge difference, you still have to address the insulin resistance, the inflammation, and all those underlying things because they can show up in other ways either now or later, like pre-diabetes or sleep apnea. So there are risks that it’s never one or the other. It’s always let’s do all of it together if we’re doing the medical approach. It’s so important.

Katie: Yes, not either-or but both-and when those things are necessary.

Aviva: Yep.

Katie: You also have a really great concept in the book of the sixth vital sign. And I think this is really, really key. And I don’t hear this talked about at all. So can you explain…? Probably most people never heard this. So explain what that is and why it’s so important.

Aviva: Yeah, so in 2005-ish, the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists made a statement that when we look at menstrual health, and they were talking about in adolescence and teens, that the health of our menstrual cycles isn’t just this reproductive thing that happens every month, but it actually is a vital sign. So, like, our blood pressure, our temperature, our heart rate, our respiratory rate, and pain, those are considered the first five vital signs. Menstrual health is a sixth vital sign. And so what they were saying is that, “Look, if a teenager is having periods from hell, like she’s bent over in pain every month, we shouldn’t just be giving ibuprofen. We need to look under the hood and say, ‘Is there something else going on? Is there endometriosis?’” If a girl is having really severe irregular periods and acne, and she’s a teenager, should we just give her the pill? And the answer’s no. We should make sure that she doesn’t have something like polycystic ovary syndrome.

There are a couple of important things about this. The statement that was made is game-changing. The problem is, I never heard that in medical school. I don’t know a single doctor, other than the people that were on that panel or the few people, you know, maybe people I’ve taught about this or who randomly heard about it, know this. So there are no pediatricians. There are no gynecologists or obstetricians that if you were to ask them, “Have you heard about this idea of menstrual health as a sixth vital sign?” They would say no. They would not have heard of it. So that’s really unfortunate because it’s huge.

The second thing is they didn’t go under the hood far enough. So just saying that if, you know, you’re in your teens, 20s, 30s, and you’re having these problems, we should look under the hood and see if there’s a medical diagnosis. That’s important. Half of all women with PCOS don’t know they have it. It takes on average nine years for a woman with endometriosis to get a diagnosis and multiple different doctors. So if women were to get these diagnoses, instead of, like, you were with your thyroid, that’s the most under-diagnosed, missed condition of hormone condition for women, so just getting the diagnosis would be really helpful. But then we have to go under the hood even further. Like, they’re lifting the hood. We need to look at the engine. We need to look at the carburetor. We need to look at, like, all the stuff that’s going on in there and saying, “Well, what causes those things? Is there inflammation? Are there nutritional imbalances? Is there trauma? Is there stress? Is there microbiome…? What are all the things that lead to those things? Because it’s those things that are actually the cause of 85% of all the chronic illnesses that we’re facing when we get into our 50s and our 60s and so forth.

So, looking at the menstrual cycle as a vital sign throughout our entire lifecycles, even into menopause, cannot only set the stage. So, like, a healthier menstrual cycle in our 20s and 30s means probably healthier fertility, easier fertility. It also then means an easier time with menopause. It also then means greater health into our…We have, like, you know, ideally, hopefully, three or four decades, maybe five after menopause. And all that hormonal time, all those years set the tone for that. So, that’s what menstrual cycle as a sixth vital sign. Some people say fifth because they don’t count pain. It’s technically sixth vital sign. And it’s really fun because you can just basically start paying attention to your menstrual cycle. We can teach our girls to do this from their first periods, give them an app, or, you know, a tracker, or give them a chart. I started tracking my menstrual cycle when I was 15. So I’ve got charts that go from 1981 all the way to, like, 2002. And they’re beautiful. Like, I can look at the journey of my menstrual cycles over the course of my life.

So we look at how often are you having periods? You know, how many days in between? How long are they lasting? Are you having pain? Are you having premenstrual symptoms? How heavy is your bleeding or how light is your bleeding? And then there are, kind of, like, with hormone levels, like, we know there’s a normal range. There’s a normal range for all of those things. So, 26 to 34 days is a normal menstrual cycle. You know, from the first day of your period to the day before your next period, that’s normal. But if it’s less than that or more than that, or if it’s highly irregular from month to month, if you’re blowing through more than six or eight pads or tampons in a day, that’s heavy bleeding. So we can start to look at all these parameters.

But the other thing is we can start to use our menstrual cycle for some really interesting information. So here’s a weird fact. We are more likely to go on a spending spree that we then maybe have buyer’s remorse about after in those few days before our period. So, it may not…You know, like people say, “Don’t go shopping when you’re hungry because you’re more likely to buy a lot of things you don’t need.” Don’t go shopping on a couple of days before your period unless you, you know, really know what you want because you can end up putting a lot more on your credit card than you need. And so there’s lots of fun little facts that we can learn about our menstrual cycle that can help us be more insightful about our habits. We know that we tend to lean more into things like more active exercise and movement when we’re ovulating. And we tend to wanna do things that are more low-key movement, right, when we’re premenstrual.

So, if you’re beating yourself up because you don’t feel like going to SoulCycle two days before your period, maybe it’s because you don’t wanna go to SoulCycle. Maybe you actually would rather do some gentle yoga. But if you wanna start a really great new food plan or exercise plan or a business plan, whatever it is, starting that around ovulation, you may actually have more success with it. And maybe your motivation is more naturally aligned with that. It’s really interesting stuff.

Katie: Yeah, like you, I’ve tracked my cycle since probably high school. And now, like, it’s so much easier. We have these apps. I have the Oura Ring, which lets everything…I can see the body temperature rise and fall, which is…So I kind of know ahead of time when my period’s about to start, which is helpful.

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I’m curious, just a side question for personal reference, I would guess hormones have to start rising and falling for a little while before your period actually starts. Like, the body’s almost, like, gearing up. I just have a 13-year-old daughter. And I’ve noticed this of, like, a little bit mood swings once a month and I’ve started, kind of, keeping track. Does that happen for a while before a girl’s period will actually start?

Aviva: It totally does. So even for like a year or so before, we’re like, “Hmm, I noticed she’s really irritable or moody or acting what we would typically call teenagery.” And yeah, they’re starting to go through changes. So their brain starts to have these rhythms that start to release a chemical from the pituitary that stimulates the hypothalamus of the glands in our brain that are going to trigger the ovaries to start kicking into gear. So, absolutely. And interestingly, after menopause hits, we’re doing the same thing, but in the opposite direction. So, you know, in puberty right before the period starts that year or so, the cycles are happening but they’re subtle and they’re not accompanied by a period. But you will notice those, like, cyclical fluctuations. And they may be irregular. And it’s also normal, once a girl starts getting her period for those first few years for them to be irregular. And then in…Well, a couple of times this happened.

So, a lot of women will tell me when they’re doing extended breastfeeding that, you know, you know, “I’m 10 months out. I’m a year out. I’m 14 months out and I’m still breastfeeding, and I haven’t gotten my period back. But I’m noticing that I feel like I’m gonna get my period for a few months in a row.” And then they ultimately do. Like, they notice those, kind of, like, sensations in their mood or their body. And then with menopause, we experience cyclic sensations as well but with no period. So, it’s like our hormones are winding down in the opposite direction of the ramping up. It’s really interesting. So yes, you’re spot on. I love that you’re tracking your daughter’s cycle. Are you telling her, like, her moods…are you telling her this?

Katie: I haven’t because I don’t wanna have any, like, confirmation bias or project that on her. And it’s just…

Aviva: I love that.

Katie: Because she’s very much like, “I’m not gonna be a normal teenager. I’m not gonna wear crop tops and be moody.” I’m like, “You know what? That’s great. But also if you are moody, that’s fine, too. And I understand that I’m here no matter what your experience is. But that’s really good to know. I thought I was noticing that. I think also…

Aviva: I love that you’re talking with her about it and I love that you were tracking your cycle in high school. And it’s so wonderful, like, the legacy you’re now giving to your girls is beautiful.

Katie: Well, and to your point, it’s like we see that women have these hormone fluctuations that can put us at a disadvantage in some ways in the medical world because the studies are done on men. But if we reframe it, we also get a window into our health that men don’t get. And so if we, like, reframe our cycle that way, we can learn so much. I’m a data nerd. We get so much data from that. And we can then within the span of a month or two, see if something’s working. So, I think if we approach it that way, it’s a great source of data. And I think also, especially after this last year, we would be remiss if we didn’t delve a little bit into the sexual and libido side of hormones because I’m sure you’re seeing this as well. I’m hearing from a lot of women who have had cycle changes or hormone problems for the first time after everything in the past year-and-a-half, but also from so many women who seem to be experiencing low libido and sexual trouble they’ve never had before. So, what are some of the factors that are going into play with this?

Aviva: Yeah, so actually, I’ve been hearing it from women so much too that I ended up doing a blog and a podcast on what’s going on with our cycles vis-à-vis the pandemic, and I’m hearing a lot of things. So, women who have COVID, there definitely seems to be an impact. Whether you have long haul symptoms or not, there’s definitely, like, that first three to six months, a lot of women are reporting irregular menstrual cycles, maybe having more than one period in a month, maybe skipping periods. That seems to be the key theme with some irregularity. Women who have had COVID vaccine are also reporting that. I’m hearing a lot of like, “Wow, I just had my period before the vaccine and I just got it again and it wasn’t due for another two weeks,” or women saying they skipped a period after.

And so I think, with the menstrual cycles, two things are happening. One is just the very reality of the stress. You know, we’re sleeping differently. There’s been a lot of sleep disruption with COVID, just the stress of it. You know, it’s interesting, my daughter, my oldest daughter said, “You know, I wonder, Mom, you know, we’re not hanging out with our girlfriends the same way we used to. We’re not getting together physically. So I wonder if we’re also just not getting some of those pheromones and biological cues that help us start to have that more regular cycle.” But then we also know that for people who do get sick, whatever it is, the flu, you know, something more than a common cold but anytime you do get sick, it can throw off your cycle, and you know, creates inflammation. It creates stress. It affects your thyroid. That’s all normal for getting sick. And so, we may have some irregular periods.

And with COVID, particularly, we don’t know exactly, you know, all the manifestations that it causes. But there definitely seems to be something about it that is particularly affecting women’s menstrual cycles. A new report just came out, interestingly, that long haulers, so people who are having long haul COVID symptoms, are worse in women with polycystic ovary syndrome. So there’s something going on there that’s very real. When it comes to libido, I think there are a lot of factors going on. I mean, I know being home with our partners all day long can be really lovely, but it can feel like we’re all up in each other’s business. So that can affect your libido. If your kids are at home all the time, and by the end of the day, you’re just tapped out, that can affect your libido or, you know, they’re just home all the time,there’s no room or space to have sex or you’re trading off, you know, one of you guys is doing work during the day, one of you guys is taking the work night shifts so someone could be with the kids during the day, that’s had an impact. Again, just the stress of it, you know, the uncertainty, the anxiety that pulls some people together, but it also can push people apart.

And then here’s something really interesting. You know, we already knew before the pandemic that people in their 20s were having sex less often than any generation for the last 3 generations. And what it has been the one singular factor that has been associated with was using smart devices. So getting in bed and instead of being intimate with each other, we’re on Netflix or we’re on our smartphones and we’re scrolling through Instagram and, you know, just being distracted. And most everybody who has been home during the pandemic, who has been working from home is on electronics all day and all night right now. I mean, the number of Netflix shows or Hulu or whatever it is, all good. You know, it’s all fine. I’ve watched them too but that can have a huge impact on our libido. Not getting as much movement, not getting as much social stimulation, just in terms of like things…

I think people described that being home and the pandemic, especially in that first 8 or 10 months, as Groundhog’s Day. Did you hear people say that it feels like Groundhog’s Day? And without that variety being the spice of life in terms of, you know, just kind of having stimulation in our life, it can make things feel very emotionally flatlined, and that can affect our libido as well. So so many little factors together. On the other hand, the at-home pleasure device business has exploded in the past year for people living alone who don’t have partners. So, I think people are finding ways to create pleasure too. So, that’s a good thing.

Katie: Can there be also, like, nutrient deficiencies or specific hormone imbalances if people are seeing, like, a change in libido that’s uncommon for them or, like, would there be things that they would, like, maybe wanna ask their doctor for testing or supplements or things food-wise, anything that would be helpful maybe addressing that?

Aviva: Well, I would definitely start with common things being common. So, we know that for a lot of people this year has created a lot of anxiety and depression. So just jumping, you know, into testing, for example, might not be the place that I would start. But absolutely, if people aren’t eating as well, you know, you can get your iron checked, your vitamin B12 checked, I think vitamin D is a really important nutrient right now. You know, in all of COVID, it’s been the only nutrient or supplement, if you will, that even conventional medicine and substantial research around the world has said, “We don’t know if taking vitamin D is going to reduce your risk of COVID. And it doesn’t seem to do anything once you have COVID if you do get sick, but it does seem that people with lower vitamin D levels were more susceptible to getting very sick. We also know that we need vitamin D, you know, from our sunlight and our diet, but most of us are still not getting enough. And low vitamin D can affect your hormones and it can affect your mood. It can make you more depressed. So, you know, I think taking the multivitamin during this time and vitamin D, 2,000 units a day for most people is a really safe bet. It’s a great option.

But if your libido is low and it’s a new thing for you, and it’s kind of persistent, I would get tested at least for thyroid. You know, that’s a really important contributing factor to low libido. you can get your cortisol checked. Sometimes high levels of stress will often impact libido. So, getting your cortisol checked has value. And if you’ve seen substantial and persistent changes in your menstrual cycle, then getting a basic hormone panel is not a bad idea. So just testosterone, estrogen, and progesterone, and something called sex hormone-binding globulin, SHBG, along with the TSH and free T3 and free T4, all of that that comes along with thyroid testing.

Katie: And we touched on it a little bit, and I know we’re gonna get close to the end of our time, but when it comes to birth control specifically, I feel like this is something that we don’t talk about enough from the perspective of we’re taking supplemental artificial hormones and this is happening on a wide scale. So, what are some of those myths that you would like women to understand when it comes to birth control and what direction do you point women in when they come in to see you?

Aviva: Yeah, so, first of all, more than half of women taking the pill aren’t even taking it for birth control, which is, kind of, astonishing. They’re taking it for hormone imbalances. But if you are taking the pill, first of all, making sure that you know your own risk factors. You know, do you have migraines with aura? Do you have high blood pressure? Are you a smoker and you’re over 35? Things that your doctor should be asking but often isn’t asking. And it’s unfortunate we have to, kind of, become our own doctors. I mean, I’m all about us being our own healers, but we shouldn’t have to also be our own doctor any more than we should know how to fix our own car or, you know, wire or something electronically. There’s people that are supposed to be experts. And we’re supposed to ask these things, but we don’t. So, there’s this belief…I think it’s just, sort of, the way it’s given out so commonly and so easily by doctors gives this impression that there are no risks. So making sure that you know your risks, talking about those with whoever’s prescribing the pill for you, critically important. And if you have any of those risks, either finding another form of contraception or a form of the pill that isn’t gonna add to your risk. So, you know, estrogen-based pills, for example, can often add that but progesterone ones can contribute too.

Another myth is that doctors will often say, “Oh, no, you know, the pill can’t change your mood or can’t cause depression.” That is absolutely not true. We know from large studies of tens of thousands of people done in Europe that taking the pill can cause not only minor mood changes but significant depression, so much so that it was upwards of 20% of women, including teenagers and women in their 20s, who had never had depression before, went on the pill and got significant depression, a large portion of those substantial enough to warrant getting a diagnosis of depression and put on an antidepressant medication just because of the hormones in the pill.

So, one, be prepared for that possibility, not to psych you out. Like, we don’t wanna create, as you said, Katie, confirmation bias or self-fulfilling prophecy. But if you go on the pill and you’re not feeling like yourself, and it’s really affecting you, and it’s not a trade-off that you want because it is affecting you, and you go to your primary care provider or your OB-GYN and they’re like, “Oh no, that can’t be true,” let them know that that is true and that there’s really strong data and that you need, you know, something else for your birth control or another form of the pill.

And then it’s really important to be knowledgeable about the symptoms that can happen, headaches, activation of autoimmune diseases. If you have inflammatory bowel disease, like ulcerative colitis or Crohn’s disease, if you have lupus or rheumatoid arthritis, some forms for the pill can actually make that worse. So you wanna be aware that might not be for you or you might need a form that’s right for you. And then finally, I would say, you know, know that there are other forms of birth control that you can use, an IUD. You can learn natural family planning or fertility awareness method. You can use that in combination with condoms. And finally, is just that if you are taking the pill for non-birth control reasons, if you’re taking it for any hormone imbalances, keep in mind that it’s not healing the problem. It’s suppressing your hormones and creating a certain hormone state so that even though that you’re feeling better and your symptoms are better, you still also need to address those underlying causes that we’ve been talking about together.

Katie: Perfect. I’ve been taking notes. And as we get close to the end, two final questions, if there’s one piece of advice or thing that you would love women to know when it comes to all the things we’ve talked about, what would be that piece of advice you wish you could get across to all women?

Aviva: I would say maybe to value your sleep, you know, really, really deeply value that time, that hour before bed as a beautiful time to wind down. Try to get seven or eight hours of sleep every night. And then value that time when you first wake up in the morning. Like, give yourself 10 minutes to ease into your day, to do some deep breathing to think of something you’re grateful for or something you’re looking forward to in that day before you just, like, jump onto Instagram or jump onto, you know, your to-do list for the day. That would be my big takeaway.

Katie: And lastly, is there a book or a number of books that have had a profound impact on your life that you would recommend? And if so, what are they and why?

Aviva: So, you know, from a personal perspective on, kind of, what set my life in motion, “Spiritual Midwifery” was a huge influence for me. You know, it set my path as a midwife and what I wanted to do. It’s a very hippy crunchy book by Ina May Gaskin, but that was transformative for me. If you don’t like the hippie crunchy, she’s got “Ina May’s Birth” book, which is great too. But from a, sort of, lifestyle perspective and mindset perspective, I would say the book “Mindset” by Carol Dweck is probably the single most influential book. It’s all about how we experience life, either as a learner with a growth mindset, or a judger. And when I can remember to stay in that framework, it is a powerful, powerful gift to approach life as everything is about learning and growing. There’s no failure. There are no mistakes, and how harshly we can really judge ourselves about so many things, about where we think we should be, how we think we should…The word should comes in a lot with the judger. So, if I would recommend any book, that would be it.

Katie: I love it. I will link to those both in the show notes. That’s at wellnessmama.fm for you guys listening. And I know that you are a busy physician, and mom, and grandma, and in the middle of a book launch, so I’m gonna respect your time. But thank you so much for being here today. I would love to do another round with you sometime soon and to stay in touch.

Aviva: Thanks, Katie. Katie, can I tell your listeners where to go if they do get my book because there are some pretty amazing gifts that I would love to make sure that they have access to getting?

Katie: Absolutely. And I’ll make sure those links are in the show notes as well.

Aviva: Perfect. Simply go to avivaromm.com/book, and you’ll have access through June 8th if you preorder to a 28-day gut reset. And then through the month of June to a replay of an event that I’m doing where Ricki Lake is interviewing me about my book, and I have some amazing teachers who are just doing great work in women’s hormonal health. And so that’s all free with one book purchase.

Katie: Amazing. I’ll make sure that link is included as well. Thank you so much for your time.

Aviva: Thank you for having me, Katie.

Katie: And thanks as always to you guys for listening, for sharing your most valuable resources, your time, and your energy with both of us today. We’re so grateful that you did, and I hope that you will join me again on the next episode of the “Wellness Mama” podcast.

If you’re enjoying these interviews, would you please take two minutes to leave a rating or review on iTunes for me? Doing this helps more people to find the podcast, which means even more moms and families could benefit from the information. I really appreciate your time, and thanks as always for listening.