Endometriosis, PMDD and Fibroids with Suzanne Fenske

INTRO: 
This week on The Less Stressed Life Podcast, I am joined by Suzanne Fenske, MD of TārāMD. We talk about the conditions that can arise from hormonal imbalances, like Endometriosis, PMDD, and Fibroids.

KEY TAKEAWAYS:

• Endometriosis, symptoms, diagnosis, and management
• What endometriosis looks like in perimenopause
• PMDD, symptoms, diagnosis, and treatments
• Different types of  fibroids, why & who gets fibroids, and common symptoms

GUEST SHARED HELPFUL TIPS ON:

• Supplements, HRT, and Lifestyle recommendations for hormonal estrogen imbalances.

ABOUT GUEST:
Dr. Fenske is a native of the New York area board cert in ob and gynecology. and cert NA MenoPause society provider.

Dr. Fenske felt that her robust academic education did not provide her patients the comprehensive, whole-person care she felt they deserved. At this point, she applied and was accepted to the University of Arizona Andrew Weil Center for Integrative Medicine fellowship with a scholarship and became board-certified in Integrative medicine. She then took a deeper dive into root cause analysis and trained in functional medicine with the Institute of Functional Medicine.

With this unique combination of training, she started TārāMD with a focus on treating complex conditions such as hormonal imbalances, polycystic ovarian syndrome, perimenopause, menopause, chronic pelvic pain, endometriosis, fibroids, recurrent infections, sexual dysfunction as well as optimizing women’s health and wellbeing during their annual examinations.

Dr. Fenske has been invited to speak at national conferences and contributed to many magazines, news articles and peer-reviewed studies. She consistently strives for growth, offering both her patients and colleagues her expertise and readiness to help solve the most complex challenges facing women’s health today.

“Live life to the fullest: use your talents and skills to create a difference, laugh every day, love with all your heart, and surround yourself with like-minded and spirited people.”- Suzanne Fenske

 TRANSCRIPT

Suzanne (00:00):
<Affirmative>. If you are missing days of your life during your period, meaning that you are not going to work, you are not going to school, you are not going out with your friends or doing, you know, the hobbies that you like to do or the things you like to do during your period because your period is that uncomfortable and painful, then you have to start thinking for yourself and advocating for yourself that there's a potential endometriosis.

Christa (00:23):
Stress is the inflammation that robs us of life, energy, and happiness. Our typical solutions for gut health and hormone balance have let a lot of us down we're overmedicated and underserved at the Less Stressed Life. We are a community of health savvy women exploring solutions outside of our traditional Western medicine toolbox and training to raise the bar and change our stories. Each week, our hope is that you leave our sessions inspired to learn, grow, and share these stories to raise the bar in your life and home.

Christa (01:05):
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Christa (01:52):
Rupa is a lab concierge, so they send the lab invoices on your behalf of a client, pays for their own labs. They help them get set up with a lab draw, navigate testing questions, and they provide the requisition forms. It's literally a dream go sign up for free to help streamline your practice and simplify ordering labs for your clients@ rupahealth.com. That's rupahealth.com And let them know I sent you when you sign up. You can also check out the show notes for this episode for a short video walkthrough of how I use Rupa Health in my own practice. All right. Today in the less stressed life I have Dr. Suzanne Fensky. She's a native of the New York area and is double board certified in Obstetrics and Gynecology. She's certified by the North American Menopause Society as a provider. And there's a little bit more of a fun background job.

Christa (02:36):
Let her tell us if she wants to. She got accepted to an accelerated medical program, did some training, I dunno if it was Mount Sinai. Either way. She did all of her middle school school training and found that even though she went to school for all of those years, it didn't really provide her patience with the way she wanted to practice in this comprehensive whole person care that she felt that they really deserved. And so it was at that point she applied and I was accepted to Andrew Wild Center for Integrative Medicine Fellowship and then became board certified integrative medicine. And then she took a deeper dive into root cause analysis and trained and functional medicine with the Institute of Functional Medicine. So with this unique combo of training, she started Tara MD with a focus on treating complex conditions like hormone balances, polycystic ovarian syndrome or p o s, perimenopause, menopause, chronic public pain, endometriosis, fibroids, recurrent infections, sexual dysfunction, as well as optimizing women's health and wellbeing during their annual exams. Welcome Dr. Fisk.

Suzanne (03:32):
Thank you.

Christa (03:34):
So you started in New York and you traveled and you came back to New York. I love your story in the bio, but I want to hear your story a little bit more. And I always have this conversation when clients or if there's some doctor blaming that happens in the world, right? And it's like, well, no one wants to see 10, 20, 30 patients a day. Right? It's not really like a great model if someone's got a complex issue going on. Like how do you even approach that? So tell me how this kind of came to be for you, or if you even had some of your own journey that helped you kind of delve a little bit. What I think my real question is why were you open to training and integrative and functional medicine?

Suzanne (04:10):
I think a lot of people in our world tend to be kind of driven by their own personal medical issues or their journey along the way, issues they faced. I actually was not driven by my own issues. I've always been driven by my patients. So for me, I always wanted the most amount of knowledge as possible to be able to do the best amount of care as possible. I'm definitely obviously a type A personality, a meditated type a personality. So, you know, along the way when I had great opportunities, great training and did my ob gyn residency and then did a two year laparoscopic robotic surgery fellowship at Mount Sinai and then stayed on actually as a faculty at Mount Sinai for many years and was really kind of fell into this niche of taking care of women who had chronic pelvic pain, endometriosis, sexual dysfunction, sexual pain, and did a lot of surgery and felt that, you know, I think that I felt what patients were feeling right, that the care is sort of really fragmented and very just sort of some symptom based and medicate surgery for the symptom.

Suzanne (05:15):
And that's basically it. And felt that there was more to it than that, which is how I kind of meandered into Dr. Andrew Wild's fellowship and did that to be able to provide more integrative management to my patients, to be able to approach it, whole person, whole lifestyle approach and evidence based modalities from mind body, from botanical supplements and so on. And then as you dive deeper and deeper into it, right, kind of going down that rabbit hole, I felt that I wanted more of a root cause analysis too, to be able to really link everything together. I think what really drove me into looking at functional medicine was more knowledge and regarding the gut microbiome.

Christa (05:55):
Mm-Hmm. <Affirmative>, how long was your fellowship with Andrew? We center for integrative medicine, because you've already been in school for many, many years before this and then you're essentially joining this fellowship. So I'm wondering how long that was and if that felt like drinking from a fire hose or if it just kind of brought everything together as you wanted it to be.

Suzanne (06:11):
Yeah, I mean I think that I've spent most of my life in school, probably <laugh>, I have spent most of my life in school. So I did the two years in laparoscopic robotic, and then Andrew Wees was two years. And you know, I, I went into that for learning more from my patients, but to be very honest, it turned out to be a real awakening to myself. That actually was what changed how I was in my own personal healthcare too. So that was two years. And then ifm functional medicine can take anywhere from two to three to plus years depending on kind of how you orchestrate it. It's, it's more controls in how you wanna, how long fast you wanna do it, right. So my type A is a little bit faster with functional medicine a year and a half. Mm-Hmm.

Christa (06:54):
<Affirmative>. Yeah, for sure. Cruise right through that. So here we are. And so now you're working with these, these complex cases and I wanna dive in a little bit into an area that doesn't get, I feel a lot of really great options and kind of, which is endometriosis and then the things that sometimes go along with it or have similar common denominators like pmdd. And so let's start with end endometriosis and because this is a big area that you help women with and this is a very challenging, painful, can't go to work, et cetera situation. So first of all, let's talk about what it is diagnosis. Is it getting missed? I would say essentially what does that clinical picture look like when someone's presenting to you with endometriosis? And then we can get into what you do with it.

Suzanne (07:39):
Yeah, so endometriosis, just, just so we start from kind of square one, endometriosis is basically a disease in which the tissue that lines the inside of the uterus, the endometrium is found in places outside of the uterus. So it can be found on the ovaries, the Philippian tubes. There's a layer of tissue called parone, and that lines are abdominal cavity and endometriosis can be found anywhere in our bodies, right? I mean, I've had patients who have had monthly nose bleeds and that was their endometriosis. I've had patients who've had monthly lung collapses due to blood collection and lungs and that was their endometriosis. But basically it's when that tissue, which should really only be inside the uterus, is found somewhere else. But when you get back down to the pathophysiology of what endometriosis is, it's really a disease of estrogen and inflammation. So we know what the cure for endometriosis is.

Suzanne (08:29):
The cure for endometriosis is, you know, menopause because of a lack of estrogen. So it really is a disease of estrogen and inflammation. What's really amazing about endometriosis is that, you know, we've known about it for so long and there is research done in many aspects of it, but ultimately we still don't know the cause of it. We know that's probably multifactorial, that there's definitely a genetic component to it. And we see that with a lot of first degree relatives, you know, know both have having endometriosis, but that in and of itself is not enough. Right? So the variable expression, right? Some women will have very advanced endometriosis and minimal symptoms, but just sort of incidentally find that along their journey with infertility and get this diagnosis of endometriosis. And some women have what seems to be very minimal endometriosis and very, very intense symptoms.

Suzanne (09:20):
So then you have to factor into play that basically with endometriosis there's a lot that comes into the picture, much more so than just genetics and just estrogen and inflammation. Right? Yeah. And you touched on something really wonderful in that yes, it is, on average it takes seven to 10 years before women gets her diagnosis of endometriosis. And that's a lot of years of pain, a lot of years of issues and pain and just not being heard and women thinking that it's in their head and that or that this is normal. Right. And you know, on average we know that women have to see three to five providers before somebody diagnoses them with endometriosis. We know that it affects 10% of women, but that's probably a huge underestimation on how many women it actually really affects.

Christa (10:05):
Well I didn't know that. Monthly nose bleeds, lung issues. And in this essentially the tissue that should be in the uterus found anywhere could be endometriosis. I just thought it was thickened uterine lining of the uterus. So that makes me think that it would be difficult to diagnose if it's someone with nose bleeds. Right? Yeah. Does for example, if it's someone who's got monthly nose bleeds, what is the diagnostic criteria for endometriosis? What are you doing for diagnosis endometriosis, and how do you then go to I have monthly nose bleeds. And how do you figure out that that's also endometriosis And do they also have thick uterine lining at the same time? Or maybe it just depends. That could be one or the other.

Suzanne (10:42):
Yeah, yeah. So the definitive way to diagnose endometriosis is, you know, the gold standard, I should say in the medical world is doing a laparoscopy and seeing the endometriosis presence in the abdomen. And there's kind of classic ways our ability to visually detect endometriosis is only about 60%. So even with a good surgeon, an experienced endometriosis surgeon, they can take a look around in the abdominal cavity, take a look at the most common places that you find endometriosis and everything looks fine. Right? And they can miss diagnosis of endometriosis. For me, I always did biopsies, surgical biopsies of the most common areas. If everything looked completely normal and a woman came in with a history that really sounds like endometriosis and I'll touch on that in a minute, then what I would always do is regardless of appearance, you biopsies, because those biopsies are sent off to pathology and a pathologist will analyze and look for endometriosis and that's the best way to do it.

Suzanne (11:40):
I will say that even though that's the gold standard for diagnosis, somebody who's experience with endometriosis can usually diagnose it, you know, very close to a hundred percent will say 90 plus percent based on just symptomatology and examination actually. Right. So there's a couple of things that I always say to women, and I think that it's really important if you are missing days of your life during your period, meaning that you are not going to work, you are not going to school, you are not going out with your friends or doing, you know, the hobbies that you like to do or the things you like to do during your period because your period is that uncomfortable and painful, then you have to start thinking for yourself and advocating for yourself that there's a potential endometriosis.

Christa (12:23):
Hmm. Yeah. That's a really great pearl for them. And although the laparoscopic is, or that essentially like minimally invasive surgery is still invasive and expensive really Yeah. For the diagnosis. So it makes sense that it would not be the automatic thing that happens and I, when we know how that, how that people can get kind of tossed around depending on their access to medical care as well. With that, let's talk about the symptoms of endometriosis and how you might diagnose someone with just symptoms and exam.

Suzanne (12:52):
Yeah, it look like this can be variable. The most common usually is pain with your period like on pain. That's really not just, you know, I have some cramping, I took some Advil or some NSAID and felt better, but significant pain with period, or we call it the medical world Dysmenorrhea. Okay. And that's a classic side and symptom of it. But also along the same minds is that women can have just non clic pain, just generalized pelvic pain that they feel at other times of the month unrelated to their period. And then another symptom that can come into factor in is pain with sex and usually pain from endometriosis is pain with penetrative sex and usually deep felt more deep on deep penetration. Yeah, there's different things to consider from a gynecological etiology on pain with penetrative intercourse on insertion at the entrance versus deep.

Suzanne (13:43):
But if you have penetrative intercourse and it's pain with deep, then that's another sign or symptom of endometriosis. Got it. An examination, a gynecologist can do an examination and feel that the exam completely normal. Right. But there are things, you can also feel an exam, you can actually sometimes feel the scarring and then the uterus and the ovaries are less mobile on examination. You can actually sometimes feel the nodularity or these hardened tissues that you feel in the most common areas where you see endometriosis, which can be kind of behind the uterus and between the uterus and the rectum, which is called the posterior cul-de-sac or between the bladder and the uterus, which is called the anterior cul-de-sac. So there's classic areas that you can kind of feel some thickening and with endometriosis often too.

Christa (14:29):
So if someone's having these signif, significant paino period or disin and more specifically they're missing work or school or or, or social activities because it is so significant and they don't have a diagnosis or no one's brought up endometriosis, that might be time to see, ask the provider or potentially ask for a referral to another provider or look for another provider that is maybe a little more skilled and endo for that potential diagnosis. And then once they know that this is an issue, what is classically done here? And then what are some things that you do with a broader training?

Suzanne (15:03):
Yeah. So classically in the medical world, the endometriosis is managed in two ways. Either kind of with suppression of the extra estrogen that's floating around in the body with hormonal therapy, usually the birth control pill is really, really commonly used. And or surgery. And the surgery, like you had mentioned, is a laparoscopy. Usually it's not an open surgery, but a minimally invasive surgery with small incisions in a camera where you look around and remove any of the endometriosis. The thing for me that was different with all of this is that that's, you know, that's definitely an option with the birth control pills. You're managing the estrogen component of things. These are kind of bandaids in a way, right? I can't say that we're gonna be able to cure endometriosis necessarily, but getting back down to kind of the root cause analysis of it and really approaching more of the full lifestyle approach.

Suzanne (15:53):
And that's how I do things, right? I don't just put bandaids on things with a birth control pill or a surgery, but you wanna look at the, a diet and nutrition, incredibly important, right? As we mentioned before, it's, it's a disease of estrogen and inflammation. So you wanna approach these factors, what affects inflammation in the body, right? And whether it's nutrition and what you're putting in your body. And there's, you know, there's a couple of studies that have been done over the years looking at nutrition and endometriosis and there was one looking at like gluten free diet and endometriosis and these are all small, tiny little studies. It would be great to have, you know, much bigger or large scale study looking at nutrition and endometriosis in the impact. But even taking that and pushing it forward and looking at basically approaching nutrition from an anti-inflammatory standpoint, right?

Suzanne (16:34):
So looking at the most common things and you of all people will know this, and the most common factors in diet that cause inflammation and, and considering on your own actually trying to do your own kind of modified elimination diet and eliminating out the most common things like gluten, like dairy, the significant high omega six to omega3 ratio foods and seeing whether or not that can affect the inflammatory component, but also looking at lifestyle, right? So exercise we know can help with it too. There are certain definite forms of exercise that are even better for, for endometriosis and, and pelvic pain disorders in general like yoga and being able to really kind of work in the pelvic floor area with yoga. Strengthening the core with Pilates is also really helpful. Mind body therapies, we know reduce stress, reduce inflammation. And then also looking at these women who are really recalcitrant, who are doing everything possible, who have, you know, approached this the right way but still are facing really uncontrolled pain. Then I actually would really look at the gut microbiome too and see if there's leaky gut and things like that that are quad inflammation.

Christa (17:40):
And I think when you have pain, when you're in this, it's not as obvious, but when you have pain, this is like just sending stress signals to the brain like crazy. It makes me think about someone that had some undiagnosed, essentially pelvic pain and it took her a while to get her into an OB that could diagnose it properly and then she was able to receive treatment. It was fine, but it was causing a lot of stress, which caused a lot of mineral loss. It infected of course, or gut microbiome. It was just, it was preventing us from closing the loop <laugh> Yeah. Of correction when you have pain. So if we can reduce pain as soon as possible, then that's great. The tricky thing. So diet is amazing, but always the tricky thing about anything that has to do with our cycle is that it can be immediate and it may be you may have to compound it over a couple of months sometimes to really see changes, I feel anyway.

Christa (18:29):
Yeah. Like it can be right now, but it can be, you know, up to two, three months where you start to continue to see that really take shape. There's a lot of pieces as you said, right? It's toxic burden, microbiome, stress, food, all the things that are contributing to the inflammation bucket overall. Yeah. since this is an, can be an estrogen or is an estrogen issue, I guess, you know, at the core, do you look at serum estrogen levels? Do you look at estrogen metabolism dash testing? If you get a endo diagnosis, what are some then tools you use to help maybe focus your treatment? Cause the thing about it is there's a lot of options. I think this is good, but sometimes people find that overwhelming. It's like, oh, there's a lot of pieces here you can put together and create a better treatment protocol. You know, because suppression and then surgical removal, while surgical removal might remove pain at that moment, alls I can think about is, well then that will just grow back because we didn't really manage the estrogen anyway. Right? So you almost have to move, right? If you're not gonna, if you're not gonna suppress your hormones, you know, and you actually want them to be metabolized properly, you've gotta do something else, you know? Right. What are some things that you do to help focus on what you're gonna do next?

Suzanne (19:37):
No, I think it's a great point. I mean, a lot of women have come to me after having had five laparoscopic surgeries and being in their early thirties. Mm-Hmm. <Affirmative>, something's not right with that. Right? Like, that should resonate <laugh> that something's not right. So yeah, I always personalize things, you know, I don't have like this kind of set formula that I do for every person, but if I have someone who's, you know, recal trend to treatment modalities, I think that the Dutch test is a fantastic test because the question that has to come into play, and this is kind of a deeper dive into the Dutch test and so on, is actually looking at, you know, the phase one, phase two metabolism and seeing whether or not that's an issue, right? We know that if a woman is metabolizing inappropriately with, you know, and breaking it down into too much of 16 oh age, right?

Suzanne (20:23):
Then you're gonna have more active metabolites of estrogen in the body. So in, in addition to estradiol, tron, riol, you're also gonna have more of this 16 oh age, which is also acting as an active metabolite as well. And then you have to think about more long term risks, right? Like we know that endometriosis can cause even more serious conditions later on in life like ovarian cancer. So you do wonder also about four oh H and whether if you're metabolizing down into too much of four oh H and having more of that DNA damage that's occurring. So I do think it's important if you have somebody who's not responding to the lifestyle modifications or the things traditionally done, I mean, for some women I actually do a completely natural approach to endometriosis and manage it with supplements and lifestyle and that's it. There is no hormonal activation in any way, but you have to look and think about what else is going on. Does it come down to the gut microbiome? Does it come down to how this woman is metabolizing her estrogens? And is that the issue? Is that the underlying issue?

Christa (21:25):
There's a lot of options and I, I wanna talk about what endo can look like and perimenopause next.

Suzanne (21:31):
Yeah.

Christa (21:32):
But before we get to that, you just brought up a 30 year old five surgeries. So from my hormone mentors, you know, what I had learned was that hey, we would not wanna just give hormone, progesterone, for example, to someone that can create hormones on their own. However, in this more severe scenario, while you're working on other things and if you're having issues with those being responsive, do you ever use progesterone, even in young women to help balance that estrogen progesterone overall? Because usually when estrogen is high, progesterone is kind of suppressed. So does that ever help as part of treatment?

Suzanne (22:04):
Absolutely. I mean, absolutely. An option is using a bio identical, even, you know, FDA approved progesterone that's it's readily covered by their insurance, which is very helpful to a lot of women. True. And using that just to mediate, you know, there's a lot of common denominators, and this is more sort of my working theory on things, right? There's a term that's used very frequently in this space that I don't love the term, but it's still a true issue in which basically there's higher amounts of estrogen versus progesterone in a woman's body. And this is kind of a similar thing that we see with endometriosis, with fibroids, and even with, you know, pmdd, right? That these are all kind of conditions where you have relatively speaking higher amounts of estrogen to progesterone that's creating. So if you can either normalize that more so, and again, endometriosis is a little bit more difficult, it's a little, a little bit more severe in the symptomatology, but if you can normalize those hormones, either you know, ideally naturally with a certain supplement regimens, or if you have to cycle back some of a, I prefer biodentical progesterone into a woman to help her normalize it herself, then absolutely modalities that I would use.

Christa (23:14):
Yeah, there's again, there's just a lot of options and that's not meant to be overwhelming, it's just that there's much more than birth control and removing some lining and scar tissue. It's just more, Yeah,

Suzanne (23:24):
I, that's, I think that's the key point. I think that's the key point that it, that I think it's always really important. Unfortunately in the medical world, and I'm, I'm sure this is the experience for a lot of listeners that you have, is that it sometimes can be a very patriarchal type of field where you walk in and you're told that this is what you're going to do. You're either going to take this pill or do this surgery. And I think it's just important to know in general that that might be the right option for you. But alternatively, there are still many ways of managing it and you should feel in control of managing the disease that you're the one who's battling. Right, <laugh>. Yeah,

Christa (23:55):
For sure. I wanna come back to fibroids and pmd D because like you said, there are common denominators in this estrogen dominant or

Suzanne (24:03):
Estrogen metabolism

Christa (24:04):
Conversation. But before we do that, I like to think about, you know, we go, this is a condition of a cycling woman and then we can drop into perimenopause for up to eight years right before going into menopause. And I think we're coming into menopause awareness month, so we'll give a little lip service to this conversation. But my experience or mentorship has said that, you know, perimenopause is not as graceful when your hormones are kind of like cattywampus, <laugh>. Like you have, like you have a lot of estrogen. And so what does endometriosis look like in perimenopause? Do you see things decrease or do you actually see some of those issues with like low progesterone stores, et cetera, just kind of exacerbating and it doesn't actually look better and it just feels kind of sucky for

Suzanne (24:48):
The clients. Yeah. No, I love that you brought this up because I actually commonly see women fibroids and endometriosis all of a sudden having a diagnosis right in their forties, which is pretty atypical, right? Because we know that endometriosis is a condition, fibroids is different, but endometriosis is a condition that's gone on, you know, probably well before that, I'm sure that probably we're having symptomatology of it or actual signs of it in their twenties. Mm-Hmm. <Affirmative>, but we're asymptomatic at that point. But with the fluctuations and hormones that happen with perimenopause, we know that there's different stages of perimenopause, right? So the first thing that happens with our hormones is that in our thirties we know that testosterone starts to decline, but it's more of a gradual decline. We know that later thirties, forties, all of a sudden there's a much more drastic decline in progesterone.

Suzanne (25:32):
And then you have this state, right, where there's higher amounts of estrogen, lower amounts of progesterone, then you take a woman who has fibroids pm d d, right? One of the classic signs of early perimenopause is worsening PMs and endometriosis. And you already have that situation where these are disorders that are characterized by too much estrogen or woman's own estrogen. And then you compounded by now she's an early perimenopause where her progesterone levels are even lower than they were. And so, yeah, I've had many, many times women come in all of a sudden having a diagnosis of endometriosis in their early forties, which has been matched up until this point, or very commonly, is to have a lot of women in their forties experience significant fibroid problems again, because they have all of this estrogen that's not being balanced out by progesterone because their natural stores are progesterone have now gone down. Yeah. What's more classic and late perimenopause, which is kind of the perimenopause that everyone really traditionally thinks about is estrogen deficiency. So now your estrogen has dropped down and now you have the brain fog and the hot flashes and the night sweats and the vaginal dryness, the things that are more classically thought of a perimenopause. But what you brought to light is that there is this earlier stage of perimenopause and that's more classically characterized by lower levels of progesterone and higher levels of estrogen.

Christa (26:53):
Well, you just mentioned that a classic symptom of early menopause is worsening pmdd. And so I wanna talk about pmdd because you know, if we thought that endometriosis or clients with endometriosis ever had gas lighting issues where they're like, It's fine, you're not really in that much pain, I would expect PMDD to almost be worse because I feel like it's mostly emotionally presented. Can we talk about, first let's just classify what's pmdd. Let's talk about why it's related, which you have already touched on a little bit, and kind of how you diagnose that, you know, just again, the issues of estrogen when it's not, when it's kind of uncontrolled.

Suzanne (27:32):
Yeah, so PMDD is premenstrual dysphoric disorder and it's, you know, a worsening case of basically PMs, premenstrual syndrome. And there's multiple symptoms that fall into this. But examples of symptoms can be, you know, mood, mood is a significant one. So depression, anger, rage, irritability, anxiety, bouts of crying that are just spontaneous bouts of crying. And then you have more of the physical symptoms too, which is the bloating, the breast tenderness, the water weight, retention, fatigue. And there's just, you know, a myriad of symptoms basically. And pm d d by sort of checking in boxes and having a certain number of symptoms in each category gives you this technical diagnosis of pmdd, right? Basically what happens, and, and what I had touched on was that it's very common that we, you know, estrogen is a wonderful hormone, does lots of beautiful things. The way that our bodies work is that you want this balance, right?

Suzanne (28:25):
So anything in excess, anything in too little is always gonna be sort of a bad thing, right? So progesterone, I always call sort of the great balancing hormone, your natural harmonizer basically, and it works in concert with estrogen and balances out estrogen. When you have too much of this estrogen in your body relative to the amount of progesterone in your body, then these are classic signs and symptoms that you're gonna experience if you time it with the cycle, right? So our natural cycle is that the second part of our cycle ovulation up until our menstruation is more dominated by progesterone, right? So your progesterone is supposed to rise with ovulation and balance out the estrogen at that point. What happens with PMs pm D D is that you know, you're not getting that appropriate rise in your progesterone to help balance out your estrogen. And then here you are a week before your period or a few days before your period with these classic too much estrogen symptoms. Mm-Hmm. <Affirmative>. So irritability, rage, anger, bouts of crying bouts of hysteria, feeling uncontrolled. And this is, I agree with you with the gas lighting because this significantly impacts, right? Women's life significantly impacts you cannot function the way that you normally function. You cannot function in your, your relationships, in your work, in your personal life with your family in general. So it really does take over completely, and again, this is one that's marked more, very much so by not enough progesterone.

Christa (29:55):
So in theory, this could quote unquote come out of nowhere to a woman who is simply just like living life and didn't have that much progesterone in the first place. And then she's dropping that as she's like getting into her late thirties potentially, or early forties. And it drops more. And it's not balancing, I'm just kind of reiterating it's not balancing out that estrogen. And so then around ovulation or around or right before the cycle, these symptoms can feel like they came outta nowhere, they're really severe and then they can kind of ebb and flow and go away and then they come back again two weeks later and they're crazy again. Right?

Suzanne (30:30):
Yeah.

Christa (30:31):
So that would be a case where that woman may really, she might have a life change if she had some progesterone at that moment.

Suzanne (30:38):
Yes, probably, you know,

Christa (30:39):
Yeah. Whether topical or oral or whatever, depending on that person, if someone was, you know, what you said with diagnosis, it was really, it's categories of symptoms. That's it. So there's no testing that's required for pmt.

Suzanne (30:52):
No, no.

Christa (30:53):
That's interesting. Which also tells me, I have strong feelings about this, but it's just my perception from working with clients that it, I don't think it's very common to test our serum hormone levels either like our estrogen or progesterone. Would you, like you could probably offer a lot more <laugh> around that, being trained in both places. Is that true? And and why is that, do you think? Why do we not just look at

Suzanne (31:13):
That? Well, yeah, I mean our serum testing when we do check for serum, where first of all it comes down to timing it appropriately in the cycle, right? You wanna make sure you're, you're having your blood work, if you're gonna have a blood work done, you wanna make sure it's being done during the right time of your cycle. And that's really dependent on, you know, how long your cycle is. You always hear this tint, this classic number that you wanna check your day 21 progesterone and kind of estrogen look at that way. But that really also depends on how long your cycle is. That's great day 21, if you have a classic 28 day cycle. But if your cycle's much longer or more shorter, that's not gonna be the ideal time to do it either. The issue with serum testing for your hormones is that, well the only hormone, the only estrogen serum testing looks at is estradiol, which is E two.

Suzanne (31:56):
It does not generally look at estro E one or Estriol E three. Mm-Hmm <affirmative>. And those are those, we actually as women make three different estrogens, ESTRO and estradiol and riol actually during the fetal time period. We also have aste E four circulating in the body too. But the three hormone, three estrogens that we make generally are estro and estradiol and riol. And that's one limiting factor with doing serum testing is that you're not getting the full picture. Mm-Hmm. <Affirmative> also progesterone progesterone's really hard. It doesn't come through very well on serum testing. It unfortunately comes through much more so with, you know, saliva and urine testing and just not as accurate to do with serum testing, which becomes a, a limiting factor also with it.

Christa (32:38):
Totally. Because I, I don't think, I don't feel like saliva urine testing would be very common in a conventional practice for

Suzanne (32:43):
It is not, no. Yeah, it is not

Christa (32:45):
<Laugh>. So our testing just kind of sucks in general <laugh> it does for it, you know,

Suzanne (32:50):
Percent right. <Laugh> and

Christa (32:51):
So you're not gonna even be able to find it. So it's very possible that when someone's having, so this is great, I make, I need to make sure I title this episode correctly so the bright people see it. Because if you feel like you're having this rage or anxiety coming out of nowhere and you're in maybe your late thirties and it actually times shortly before your cycle and maybe it's paired with breast tenderness or something that you didn't have for a while and now it's there, you know what, maybe progesterones declining, you can't balance that estrogen and it's coming out like this, which is like you said, significantly affecting your life. Like that's not a way to live. How did we handle this in the before we knew about it? I have no idea. I'm not, oh

Suzanne (33:27):
My gosh, how do we handle it? We handled it with antidepressant medications, anti-anxiety medication, <laugh>. Yeah, I guess so. How it's still traditionally handled

Christa (33:34):
<Laugh>, I True. That's sad, true statement. I think about when we think about the big picture of estrogen excess and I think about, and we don't have to make, I, I take like a very like non frightened approach. I'm like why don't we live in a world that's like full of endocrine disruptors? So you know, it's possible that all this stuff has climbed. I was actually pondering and wondering if we have any metrics or numbers around some of these estrogen conditions, Endo or any of them compared to other parts of the world. Mm-Hmm <affirmative>, I don't think we can compare it to history cuz like unfortunately the thing with history is that it feels like this is something we never really identified very well and we still are not identifying it very well. So I don't think historically even really matters. And I could be wrong, but internationally is, Americans have more issue with this. I mean Europeans and Americans are kind of similar honestly from health status, but maybe anyway, do you have any, do you have any knowledge of the <laugh>? Do we have any stats like that?

Suzanne (34:27):
I would love to know about that. Actually I look at the studies, I have to imagine just extrapolating that given the sad diet, right, the standard American diet, that we probably have more symptomatic endometriosis and inflammatory conditions in general because what we're putting in our body tends to be very inflammatory.

Christa (34:42):
Yeah, that's tricky cuz the standard American diet is really starting to be into almost any culture. You mean when you travel?

Suzanne (34:50):
That's true actually you're right. Traveled everywhere now. <Laugh>. Yeah, you

Christa (34:53):
Kinda see it when you travel. You're like, oh there's no garbage. I remember going to Central America in college and like, oh, there's no garbage system here. When everything was biodegradable that was no problem. And now on the side of the road there's like soda and chip stands and like you can see the garbage problem since the, you know, we have this non biodegradable stuff. Anyway, total random side notes. Speaking of random side note, you brought up that there's a different kind of estrogen while you're having like when you're pregnant, is that correct? Mm-Hmm. <affirmative>. Mm-Hmm. <Affirmative>. Yeah. And is that, so estrogen's a growth hormone? Is that, is this just special estrogen for growing babies?

Suzanne (35:26):
We don't really know the purpose of STE, but we know that it's produced by the fetal liver. So you know, it produ, it's circulates when during gestation and so obviously a woman's exposed to it during while she's carrying a pregnancy. And then also, but I would assume you're right, it's probably linked towards being, you know, growth related and that's what it is because it's only during that time period of life.

Christa (35:47):
Interesting. Just curious.

Suzanne (35:47):
It's actually interesting now because there happens to be, you know, E four s being used. I'm sure you know now there's actually a new birth control pill that came out with E four also. I

Christa (35:58):
Dunno. Yeah. Interesting. Very interesting. Another topic for another day, let's make sure we get to fibroids. So the other condition of, of a lot of estrogen, let's talk about fibroids, what that looks like. And will you differentiate fibroids and then pen that present as fibrocystic breasts as well? Is that like the same mechanism?

Suzanne (36:18):
Interesting one. So fibrocystic breasts and fibroids are different entities, but both of them could be very well related to, you know, again the too much estrogen relative to progesterone phenomenon that we kind of touched on already. Fibroids are basically this disease in which that you grow these benign, non-cancerous soft muscle tumors basically in the uterus. So the uterus is is basically a huge muscle, very strong muscle. Obviously you can give birth to human beings. So very strong muscle and fibroids are tumors that created in the muscle itself. It is again, multifactorial on why and who gets fibroids. We know that there's huge genetic component too. We know that there are certain ethnicities that are, have more of a propensity for developing fibroids and we have to actually start thinking, which I don't think anyone does at looking at metabolism. Estrogen doesn't come into play also with fibroids as well.

Suzanne (37:14):
And when I say fibroids there's multiple different types of fibroids, right? Fibroids is not just one type of tumor, depending on where it is in the uterus, it kind of gets a different classification. So if the fibroid is sort of attached to the outside of the uterus, it's called a subserosal fibroid. If it's in the wall of the uterus, it's an intramural. And the really pesky ones are the ones that actually grow into the cavity of the uterus. They're called subcool and that causes really heavy, heavy, heavy bleeding. And they have different symptoms too. You know, being the location of them is important to know, not just kind of from an academic standpoint, but knowing about the symptoms that go along with it. So 60% of women have fibroids, it's more common in African Americans and we know that, we see it basically with the symptoms associated with it can be really heavy bleeding, like I mentioned with your period.

Suzanne (37:59):
Those tend to be the fibroids that are either in the cavity of the uterus called subcostal or ones that are in the wall of the uterus intramural, but pushing up against the cavity of the uterus. Mm. The ones that are not having any interaction with the cavity of the uterus do not cause heavy bleeding, but if they get big and fibroids can get very, very big. And in the medical world we like to allow you to understand your fibroids by comparing them to different fruit. I'm not sure where that came into play, but that's what we do. So you have a plum size, you have an orange size, you have a cancel lope size.

Christa (38:32):
Holy moly, those are huge

Suzanne (38:34):
<Laugh>. Yeah, they get very big and unfortunately that's where the other symptoms associated with fibroids come into play. And those are what we call the bulk symptoms. So urinary frequency, pelvic pain, pressure looking and feeling kind of like you're pregnant, right? Seeing it in a enlarging abdomen, difficulty having bowel movements, constipation, pain with intercourse, penetrative intercourse again when you see the mass of these fibroids really pushing down on the pelvic floor.

Christa (39:03):
Mm. That's really fascinating to imagine a plum or an orange. I was not imagining fibroids being that size before. I would imagine that, and I don't know that you brought this up, but would imagine that the ultrasound would be a very useful tool for assessing and diagnosing whether you have fibro. Yeah. Is that kind of the main thing or the least?

Suzanne (39:24):
Yeah, the main way usually is, yeah, usually it's not you diagnose it with an ultrasound.

Christa (39:29):
Okay. So if someone's having, we should maybe like re-list that list of things they should maybe go in and ask about that and potentially probe for an ultrasound to look for fibroids. And if it first course they don't find it, maybe they should look again. But urinary air frequency, pelvic pre pressure, enlarged abdomen, that would be consistent. Constipation, pain with intercourse. That's all I wrote down. <Laugh>, what else did it?

Suzanne (39:51):
Heavy bleeding heavy men. Yeah.

Christa (39:54):
Which is tricky. We should actually just mention what normal bleeding is. It's actually not a crazy amount, isn't it?

Suzanne (40:02):
No. So you know technically, right? If you wanna get done it's, it's 80 milliliters of over the course of what normal bleeding is for the course of the whole entire cycle is 80 milliliters. So more than that's gonna be heavy bleeding. We know that the traditional right, we know that anywhere between 21 and 35 days is a normal menstrual cycle. Mm-Hmm <affirmative> and that usually period lasting up to seven days is normal.

Christa (40:27):
So since fibroids seem pretty invasive, depending on how, what size they are, and I would just imagine that these could go right next to endometriosis. If you have endometriosis, why wouldn't you have fibroids? I mean how often do you see those coexisting?

Suzanne (40:39):
I do see them coexisting frequently, yes. But you also see, you know, fibroids independently without any endometriosis

Christa (40:46):
For sure. Yeah. That would be much more common I would imagine. How common are fibroids?

Suzanne (40:50):
I'm sorry? How common? Uncommon? Well again, they say 60% of women have fibroids. 60.

Christa (40:54):
Okay. That's a lot. Yeah. So good. Let's talk about this fibroids. So my functional training was like enzymes and different things which people ask me, but fibroid questions. Like I don't, I'm not a fibroid expert. I feel like go to Suzanne <laugh>, please go to Suzanne. What do people usually do for fibroids? What's the conventional and the integrative or functional approach for fibroids?

Suzanne (41:15):
Yeah, so the more conventional modalities are depending on the symptomatology associated with fibroids. So if the bulk symptoms or what exists then either you look at how old a woman is, right? If she is close to menopause and conventional medicine, the options are either to use medication that puts her into menopause essentially by lowering her hormones. Yep. And bridging her to menopause surgery is another <laugh> surgery is another option and there's multiple different surgeries. Obviously the most definitive management for fibroids is a hysterectomy removal of the uterus with the fibroids and or myectomy, which is removal of just the fibroids themselves. Or in the more functional integrated medicine space, again, you're gonna kind get down to the root cause analysis again and look and see whether there's another etiology for the growth of these fibroids. So you kind of wanna look again at estrogen metabolism and see what's going on.

Suzanne (42:07):
So I actually worked on a study looking at vitamin D and fibroids and then there's actually a neuron model, also a mouse study that also looked at vitamin D and fibroids. And they found that low levels of vitamin D was linked to fibroid growth. So who isn't affected by low levels of vitamin D I'm up in the northeast <laugh>, it's very common to have vitamin D deficiency and insufficiency. Mm-Hmm <affirmative>. So these are things that can definitely impact fibroids and should be approached it. There's some studies that looked at actually eeg CG and it's impact also on fibroids as well. And I think that in the more, you know, integrative and functional medicine space, you're gonna look at these things and try to employ them as well into your management and not just approach it by simply putting them into, you know, medical menopause, doing a hysterectomy. Yeah.

Christa (42:54):
Well I think the challenge is is that it's painful. It's probably grown somewhat slowly since it's in a massive tissue ourselves. Right? But yet trying to reverse that or correct, you know, you gotta deal with the orange or a plum that's there, that's there at that time. So sometimes I talk about this from a perspective of every issue you can look through the lens of like is it structural thing and emotional or whatever, and then nutritional piece. And so if I was gonna do things in my nutritional realm, I still think there needs to be a structural intervention depending on the size of that, right? Where they need to be seen someone like Dr. Fiske or someone who can help refer them to the right resources to potentially have that rem, I cannot imagine a very large fibroid if you don't remove that, how that is not like really challenging for your life. Like I just don't see how that, I don't see how that equates like, this is in the wrong spot, <laugh>, this does not belong here. It's impairing things significantly. And I would guess, I mean, man, 60% of people with having this, I would guess that this gets missed a lot or overlooked a lot as a potential cause of a lot of like quite a mess of symptoms. A lot of, a lot of, I have a lot of empathy for these fibroids

Suzanne (44:02):
<Laugh>. Yes. But not everyone is growing cantal LOBs and apples and oranges. Yes. Thank God some people are just growing blueberries, thankfully. Yeah. Yes. When you have, you always have to take into, you know, consideration the emergency of the situation. There are some women who have really, really, really heavy bleeding requiring multiple blood transfusions for management of their fibroids. True. And that needs immediate attention and needs to be immediately dealt with. Yeah. And then 100%, I've seen so many women over the course of my years working that had really large fibroids and you can still manage things, again, other realms and other modalities, but you still have to take care of the fact that there is this antelope growing in their belly that's very symptomatic for them and you know, as much as we can do. Right? That's, that's the one key facets to integrative is really combining together these alternative modalities and traditional modalities and really tailoring 'em to the person is that you're right, that needs to be dealt with and likely surgically. Mm-Hmm. <Affirmative>. There is other modalities too that are more minimally invasive, like uterine fibroid embolization, which is procedure usually done by interventional radiologists where they're able to really kind of target the blood supply to the fibroids themselves and block those blood supplies and then basically allowing the fibroids to Nero or die off and shrink in size.

Christa (45:20):
Mm. I wonder if there's pain and what the symptoms look like after that. I would expect maybe some

Suzanne (45:25):
Bleed. There is, yeah, there's a lot of pain. There's, you know, still recovery time, definitely one week at least, you know, kind of out of work to deal with pain management and sometimes you do need to spend a night in the hospital because of the pain that's associated with it. Mm-Hmm. <Affirmative>. And then the other side effect that could be seen is just, you know, abnormal vaginal discharge afterwards as the fibroid is necrosing and dying and laying out all that extra tissue.

Christa (45:48):
Hmm. Yeah. So much to think about here that affects most people. Oh man. All right. Well we've covered a lot. We've covered a lot. We covered, we did a nice little 1 0 1 on endometriosis, brought that to light and then covered some pm d d, which also not well recognized all the time. Hopefully really helpful to some women that are entering into that para menopause state that feel like their emotions are a little funky right now. That it may not be pmdd, but it may just be a decline in those overall hormones. And if they're really out of range it could be quite significant. And then lastly with fibroids, so such a wealth of knowledge. You are, Thank you so much. I had one more question. You brought up different ethnicities had maybe a greater predisposition to more fibroids, but could mean anything here. You know, is there actually a difference genetically in other ethnicities in like detox genes or mechanisms that would cause this? Or does it seem to be more of like a, so that would be nature or is it a nurture thing where it's like, I mean I think it's probably both, but is there like an actual science? Like is there something different inside, certain in the genetics of different ethnicities that allow for estrogen issues to become a bigger issue?

Suzanne (47:04):
Yeah, I think it comes down to, it's definitely both and it's definitely multifactorial, right? So we know that there is genetics that are, they're chromosomal abnormalities and genes associated with these conditions with fibroids, with endometriosis, which tends to come into play more so in certain populations. And then definitely there's you know, nurture as well as as, as you're saying where that come into play with lifestyle that can affect and impact these things as well. I think it's actually would be really curious to look at, really focus in on metabolism of your estrogens across different ethnicities and see if we see patterns associated with that. Mm-Hmm.

Christa (47:42):
<Affirmative>. Yeah. We'll set it to the people in research.

Suzanne (47:44):
Yeah. Yeah. That has not been looked at, but that actually would be really interesting to see if, you know, certain ethnicities have more of an issue with whether it's phase one, phase two, Yeah. Or phase three metabolism.

Christa (47:54):
Yeah. So definitely curious and we could do, because that would affect their ability to metabolize drugs and everything else, so mm-hmm. <Affirmative>, Well, Dr. Fenski, where can people find you online, your practice, which has telehealth and in person and you teach classes, where can people find you?

Suzanne (48:09):
Yeah, so ww do tara md.com <laugh>

Christa (48:13):
And where did that, Yeah, where did that name come from?

Suzanne (48:16):
So are you familiar with Buddhism?

Christa (48:18):
Well, not to where I would know what Tara is and Buddhism. Yeah.

Suzanne (48:22):
So I wanted these strange people actually that double majored in college in obviously the premedical sciences. But then my other major was religion. I don't know why my parents were quite nervous and curious as to what I was gonna do with it, but I just thought it was really fascinating to understand people from different religions. So I was really intrigued by Buddhism. I've always been really intrigued by Buddhism. I'm ethnically Jewish, but <laugh>. But I like to say I'm Judas and Tara is like, you know, the, the dedi, the, the wonderful goddess Tara in Buddhism and she represents so many different forms in Buddhism. And I like to think about that when I'm approaching women that everything's really personalized and so many different forms and that, you know, Tara in Buddhism is just this amazing de de, she's linked to nurturing, she's linked to health and that's what we should be linked to, right? As a medical practice.

Christa (49:15):
Yeah. I like it's fun to hear about that because one, we'll remember you more for that and two, it's like a nice guiding mission and light and principles by which to go from. So. Very cool. Well, I look forward to our next conversation. Thanks so much for coming on and talking all about estrogen and the things that are actively causing issues for people and hopefully this episode's very helpful for

Suzanne (49:34):
Them. Thank you. Have a wonderful, wonderful day.

Christa (49:37):
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