On the Women's Series today Tahnee has the pleasure of chatting with returning guest Dr. Lara Briden, author of the game-changing book for women's health, Period Repair Manual and soon to be released Hormone Repair Manual. A naturopathic doctor with 25 years of clinical practice to her name, Dr. Lara is somewhat of a women's health activist on a mission to help women achieve healthy natural menstrual cycles (without hormonal birth control). This conversation is brimming with goodness as the ladies delve into the distinct differences between PCOS and Hypothalamic Amenorrhea, two conditions quite prevalent among women of varied ages and commonly misdiagnosed. As always, Dr. Lara ignites a sense of empowerment in femininity and reminds us of the plainspoken truth that a woman's period is not only a sign of good health but a creator of good health!
Tahnee and Lara discuss:
- The concept of gynecological age.
- Post contraceptive pill hormonal effects.
- The benefits of the menstrual cycles; how to utilise it.
- Why insulin resistance is a distinctive feature of PCOS?
- Different reasons why a woman's period may be missing.
- Recovering from hypothalamic amenorrhea; Dr. Lara's advice.
- What is the difference between hypothalamic amenorrhea and PCOS?
- Why is Hypothalamic amenorrhea it so commonly misdiagnosed as PCOS?
- What are the correct testing procedures for hypothalamic amenorrhea and PCOS?
- Pregnancy and its protective health benefits, due to the natural hormone surge.
- How exposure to hormones from the natural menstrual cycle helps women live longer.
- How the female body works and what women need, in terms of food and carbohydrate intake.
- The assumption that contraceptive drugs give the same benefits as menstrual cycle hormones.
- Bone health and how the health of this living tissue is directly related to the menstrual cycle.
- Zinc for good health; Why Dr. Lara can't recommend this nutrient for women enough.
Who is Lara Briden?
Dr. Lara Briden is a naturopathic doctor and the period revolutionary, leading the change to better periods. Informed by a strong science background and 25 years of clinical practice under her belt, Lara is a passionate communicator about women's health and alternatives to hormonal birth control. Her book Period Repair Manual is a proclamation full of natural treatment for better hormones and better periods and provides practical solutions using nutrition, supplements, and natural hormones. The book is now in its second edition and has become an underground sensation, helping so many women to reclaim their menstrual health. Lara has a second book coming out in February 2021, Hormone Repair Manual, a book that reframes perimenopause and menopause, looking at all its benefits through the lens of evolutionary biology.
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Check Out The Transcript Here:
Hi, everybody, and welcome to the SuperFeast Podcast. I'm here today with Lara Briden, which is exciting, because this is our second time chatting with her. She's incredible. I hope you listen to her first podcast, if you haven't, we'll put a link in the show notes to that. But she's also the author of Period Repair Manual, which is very popular in the SuperFeast community. And my copy is never in the office, someone's always got it, which is awesome. And she's an awesome practitioner, who is based out of New Zealand. And she normally travels, but obviously due to our current circumstances, she's home.
So I'm really grateful to have you here, Lara, thank you so much.
Lara Briden: (00:38)
Hi, Tahnee. Thanks for having me again.
Yeah, so exciting. So we wanted to really hone in on some topics today. You're such an expert on all of these matters related to menstrual wellbeing, but in particular hypothalamic amenorrhea. I keep worrying that I'm going to stuff up that pronunciation. So far so good.
And just because it's something that we hear a lot from our community around concerns around PCOS and just the period disappearing at certain phases in a woman's life. Sometimes related to diet, sometimes related to lifestyle, sometimes related to mysterious hormonal factors. I'm so excited to delve into this with you, because I feel like there's a lot to learn. I'm just curious as to, in your clinical work, is it something that you see a lot as well, this sort of bleed stopping for various reasons or is it less common, or more common, than maybe we would imagine, based on our feedback?
Lara Briden: (01:36)
It's becoming more common. That's something I'd like to start with. So I've been in clinical practise for 25 years. That's a lot of-
That is a lot of [crosstalk 00:01:46].
Lara Briden: (01:46)
... two and a half decades of seeing young women, and hearing about their periods, and I would say the last five to ten years, there's been what I see as quite a big uptick in women losing their periods to undereating, which is essentially hypothalamic amenorrhea. There's a little bit more to it than just undereating, but usually undereating is the main factor.
Lara Briden: (02:11)
Is there a particular demographic that you see? Is it younger women typically? Because I'm just thinking that also correlates to the rise of social media, which...
Lara Briden: (02:48)
Well, the reason it's younger women in particular, it's probably a few factors. It could be they're more exposed to social media, but part of it is just, physiologically, with younger women are more likely to lose their period.
Lara Briden: (03:02)
So older women, especially if we've had quite a few years of cycling, menstrual cycling under our belt, then it's what's called a more robust menstrual cycle. It's less likely to get wobbly or go off the rails with undereating, it's just more solid. That's what the research shows. That's to do with something called gynaecological age, which I really quite like this concept. Your gynaecological age is the number of years that you've been having natural menstrual cycles.
Lara Briden: (03:33)
So that doesn't count being on the pill, of course, because pill bleeds are not periods. So let's say for example, if you got your period at 13, then it takes about 12 years to fully mature the menstrual cycle. So, by 25, if you didn't go on the pill and you didn't lose your period to undereating, and everything was going well, by about the average age of 25, most women should have a pretty strong menstrual cycle, good levels of progesterone, and they're less vulnerable in that situation to losing their period. But of course, we know that's not the case. Women will spend years on the period and so they could be in their 20s, even 30s, in quite an immature state with the menstrual cycle, which is more vulnerable to undereating.
That brings up a question for me around our evolutionary menstruation, because when I was in university, I studied science and biology. And one of our lecturers got up on the podium and said, "All of you young women should go on the pill and not bleed, because your ancestors had babies from the age of 14, and they didn't have periods, and they are healthier than we were, so [crosstalk 00:04:41]-"
Lara Briden: (04:40)
That argument is total BS.
Lara Briden: (04:44)
So I have a blog post about that, we'll put it in the show notes, called Do Women Need Periods? So I just have to blast that.
Please, blast away.
Lara Briden: (04:52)
It is so sexist. Well, I don't know if your lecturer was a man or a woman, but even if it was-
It was a man, yeah. Of course it was a man.
Lara Briden: (04:58)
... even women. I address this briefly in Period Repair Manual. But basically, yes, we are different than our ancestors, there's no question. They were pregnant a lot of the time, and were breastfeeding a lot of the time. So it is true that they had fewer menstrual cycles and fewer ovulations, but... it's a big but, the contraceptive drugs do not mimic that situation.
Lara Briden: (05:28)
So this, for me, a lot of it comes down to our exposure to our own beneficial hormones. So, as you can imagine, as you know, during pregnancy, women are exposed to a huge amount of real oestrogen and real progesterone, beneficial hormones. That's one of the reasons pregnancy has protective effects on health.
Lara Briden: (05:48)
Now, for women who don't want to have 10 pregnancies, then . In fact, there was a brand new study from the British Medical Journal a few weeks ago came out that confirmed that years of ovulatory natural menstrual cycle helps women to live longer. That's exposure to hormones.
Lara Briden: (06:12)
So where your lecturer's logic completely breaks down is this assumption that the contraceptive drugs and the pill will give the same benefits as the hormones from pregnancy or menstrual cycles. And they don't, because contraceptive drugs do not have the same effects, and in many cases have opposite effects.
Lara Briden: (06:31)
So, yeah, that's really one of my pet peeves, actually.
Shut that one down.
Lara Briden: (06:38)
That argument is so... there's no easy answer, right? We're not going to go back to having continuous pregnancies like our ancestors did, so we have to just... this is our reality as modern women. We don't have as many pregnancies, so we instead harness the benefits of our menstrual cycles.
And I think that's something... when you look at the opportunity that... so many of my friends, anecdotally, have said that, after pregnancy, their cycle improves dramatically. And I guess it's sort of like a megadose of all of these natural hormones, and just the process of shedding so much of our lining. All those things.
Lara Briden: (07:15)
Yeah. I would agree, pregnancy does seem to have... and, obviously delivery, the whole process, the hypothalamus, the part of the brain that controls the menstrual cycle, that communication between the brain and the ovaries does seem to also mature with pregnancy. I don't think we know a lot about the mechanisms of why that happens, but certainly I've seen that clinically, that periods can be better after pregnancy. Not always though, there's no guarantee. And certainly, I just have to push back a bit on the idea that... because some doctors, especially for a condition called endometriosis, which we won't go into today, I don't think. We'll have to talk about that in a future episode.
Lara Briden: (07:50)
But sometimes there's this push from doctors to have pregnancy as almost a fix for that, and I don't think... that's not a reason to have a pregnancy.
Lara Briden: (08:03)
Have a pregnancy if you want a baby. There's other ways to fix the menstrual cycle that are not pregnancy.
Yeah, for sure. I guess I'm not advocating for...
Lara Briden: (08:15)
No, I know you weren't. You certainly weren't saying that, but I hear that sometimes. Women have been told that. They come away from their doctor's rooms, they're like, "Well, you can either go on the pill or you can become pregnant." It's like, "What? Wait." There's other options.
That's a wild solution. I guess, just on the topic of losing the bleed, and that's something that happens postpartum, is that related to the same... I guess, from a Chinese medicine perspective, when we lose our period, it's because the liver blood is being converted into breast milk, and that doesn't really correlate easily across to a Western paradigm.
But I'm curious, if we're talking about losing the bleed through diet and all these other things, is that a similar thing that happens postpartum, or is that a completely different thing?
Lara Briden: (09:05)
It's really different. Well, again, it's an area we don't have a lot of research. We don't have a lot of knowledge. But different things are going on during breastfeeding. There's high prolactin, obviously there's high oxytocin. There's a different state happening. And so obviously amenorrhea is normal, can be normal during breastfeeding. That's not something we have to try to correct or fix, but it's not equivalent to the amenorrhea. Well, amenorrhea just means no periods. It's not equivalent to the amenorrhea of undereating.
Lara Briden: (09:36)
The amenorrhea of undereating is actually really quite problematic for the body. So we'll go into [crosstalk 00:09:42]-
Just the fact that there's a hypothalamic implies that there's a hormonal thing [crosstalk 00:09:47]-
Lara Briden: (09:47)
Yeah. To say at the outset, there's lots of different ways to lose your period, of course.
Lara Briden: (09:57)
Having a healthy menstrual cycle, all women are kind of the same in that picture, but in terms of once you've lost your menstrual cycle, there are potentially several different explanations for that. And all those different explanations are different in terms of their negative health effects.
Lara Briden: (10:13)
Hypothalamic amenorrhea, the term, like many things in women's health, I think it needs a new name, because it sounds a bit more medical or complicated than it really is. It's really just saying that the part of the brain, the hypothalamus, that controls the menstrual cycle, has made the strategic decision to shut down menstruation, temporarily. It's not a malfunction. It's the brain doing exactly what it should do in the face of usually caloric deficiency.
Lara Briden: (10:51)
Because the brain knows... it's trying to protect the body and protect the situation. It doesn't want to make the mistake of embarking on a pregnancy when there isn't going to be enough food to support that pregnancy. The pregnancy might not go to term, that's bad for the baby, that's also bad for the woman to try to do that and not succeed. So it's something that evolved. Humans, even compared to other animals, compared to other mammals, we have quite a sensitive trigger, in terms of the hypothalamus shutting down menstruation, we're more likely to do that than other animals. Young women are even more likely to do that.
Lara Briden: (11:35)
So that's what the term hypothalamic amenorrhea means. It's not a disorder. Basically what it means is other problems have been ruled out. And, especially in the context of undereating, we can see that that's what's happened.
Lara Briden: (11:50)
It's associated with some pretty clear features on blood tests, which we can go into, which helps to differentiate it from another totally separate condition called PCOS or polycystic ovary syndrome, which is unfortunately a lot of women with hypothalamic amenorrhea are mistakenly given the diagnosis of PCOS, which is a big problem, because it then means they're not able to understand what treatment they need. Because obviously, in many cases, a lot of the messaging around PCOS is you have to eat less. So if you are already in a situation of eating too little and you're mistakenly told PCOS, and you then go to eat less, then it's really a problem.
Yeah, okay. So in terms of Markers... that's something I've heard a lot, again anecdotally, from people that I've talked to in the community. They go down this PCOS rabbit hole for ages, and then turns out, actually, they don't have that. And they've actually probably been doing diets and fasts under the guise of health, which is I think one of the more dangerous things that's happened in the last 10 years is it's not a diet anymore it's a wellness programme or something.
But yeah, what would we be looking for if we're working with a practitioner, how are we looking to self-educate so that we can better understand what might be going on?
Lara Briden: (13:12)
So let's try to talk through this kind of systematically here.
Lara Briden: (13:18)
It's a big conversation. Not a complicated one, we're just going to go through this... and I would also direct listeners to my blog post called Is it PCOS or Hypothalamic Amenorrhea?
[crosstalk 00:13:33] sorry, yeah.
Lara Briden: (13:33)
There I break it down a little bit more.
Lara Briden: (13:35)
So the first thing is when you lose your period or you don't get a period when you stop the pill, because pill bleeds were not periods. So when your real period does not start up after stopping the pill, or if you lose it, then the first step is the doctor's, so they can rule out all various things, including something called high prolactin, or thyroid problems, or in rare cases, early menopause, which is only about one in 100 women, it's unlikely, but it needs to be ruled out.
Lara Briden: (14:11)
So all of those tests need to be done. And then, at the end of all that, usually the most common is going to be either PCOS or hypothalamic amenorrhea, and they have a lot of similar features in that they can both present with no periods or irregular periods, either or. They can both present with polycystic ovaries on ultrasound. This is going to be the takeaway for your listeners today. That ultrasound finding of polycystic ovaries means nothing.
It's not good enough.
Lara Briden: (14:51)
It means zero. I'll try to explain that. Certainly there is a reason to have... having an ultrasound can be very helpful because it can pick up other things. It can pick up ovarian cysts, which are a completely separate issue to this. It can pick up, for example, a thickening of the uterine lining, which can occur with PCOS, which is important for the doctor to know about. There's no thickening of the uterine lining with hypothalamic amenorrhea, that's one area where the two conditions are quite different.
Lara Briden: (15:24)
So there can be a reason to do an ultrasound, that's not what I'm saying, but what I'm saying is the finding of polycystic ovaries means nothing. It's not specific to PCOS. It doesn't differentiate between the conditions. It can't diagnose PCOS. It's really just saying, at the time of this scan, your ovary had quite a few eggs and had not ovulated. There was no what's called a dominant follicle in that cycle. It doesn't mean that you're never going to ovulate or it's always going to look like that, because the ovaries change every month.
Lara Briden: (15:59)
It's really just telling the story that ovulation did not happen, which, if you're not having periods, you know anyway. So it's not adding anything to the conversation at all.
To the story, yeah.
Lara Briden: (16:10)
And, in fact, another thing just to understand is that they're not cysts, they're follicles, which are eggs, which are normal for the ovary. Which, again, I'll just say, is different from an ovarian cyst, a large, abnormal ovarian cyst, which is a totally separate issue. But all the multiple small follicles, that's also more likely if you're younger, because women have more eggs when they're younger. Most people know that. So that's why even the most conservative experts now agree the ultrasound finding of polycystic ovaries means nothing in women under 20. I would argue it means nothing anytime really, in general.
Lara Briden: (16:48)
The flip side is women in their 40s can have PCOS, but often don't show polycystic ovaries, because they have fewer eggs by their 40s. So you can kind of miss it. It can go either way. So having a finding of polycystic ovaries doesn't mean PCOS, and conversely, not having polycystic ovaries doesn't mean you don't have PCOS. If that makes sense.
Lara Briden: (17:13)
I might just define what PCOS is for the listeners. So PCOS, despite the name, polycystic being in the name, which is problematic-
It sounds like it needs a new name.
Lara Briden: (17:24)
It totally needs a new name.
Okay, that's what I'm hearing.
Lara Briden: (17:28)
Yeah. PCOS is the situation of high male hormones, excess androgens or male hormones, when all other causes of that have been ruled out. So there are other causes of high androgens, like something called adrenal hypoplasia. High prolactin is a hormone, can cause higher androgens. So the doctor needs to have ruled out is there any other reason for these high androgens? And, if not, basically you're left with the diagnosis of PCOS, which is not one thing, but rather just what's left over when everything else has been ruled out.
Lara Briden: (18:05)
And the kind of confusing thing about this is that it's not impossible to have symptoms of androgens, mainly acne or even a bit of mild facial hair, with hypothalamic amenorrhea. So you see what I mean? There's a lot of overlap between them.
Yeah. [crosstalk 00:18:25] one symptom, really.
Lara Briden: (18:26)
Yeah. So the main difference between hypothalamic amenorrhea and PCOS is that hypothalamic amenorrhea is caused by undereating. And so the typical hormone pattern with that is definitely not insulin resistance, the opposite really. Quite a low fasting insulin, that's a blood test that I would order quite often. The hormone insulin, not glucose, but the hormone insulin.
Lara Briden: (18:54)
And, with hypothalamic amenorrhea, the other feature is quite low levels of LH or luteinising hormone, which is a pituitary hormone, which I test pretty routinely. I find this really helpful to distinguish between hypothalamic amenorrhea and PCOS, because with PCOS, it's a pretty strong feature to usually have higher levels of LH, or higher baseline levels of LH, which means either... early in the cycle, if there's any kind of cycle, or random day if there's no cycle. Keeping in mind... I always have to mention this, but LH, it is normal for LH to spike up really quite high for a couple of days with ovulation. So you don't want to look at an ovulation LH and then think, "Oh, that confirms PCOS." You can't do that. You have to think about was that ovulation? Which means was that test taken two weeks before you got a period?
Lara Briden: (19:53)
So hopefully that's not adding too much-
If you're not bleeding-
Lara Briden: (19:56)
Well, I'm just curious. If you're not bleeding, can you still ovulate? Because I know, with breastfeeding, that's true. Is it unlikely with HA and PCOS?
Lara Briden: (20:05)
No, really it's not really possible to ovulate but then not bleed. No, with breastfeeding... you can ovulate and then fall pregnant the first time you ovulate, and never see a bleed. So there's that.
Right, I see, okay.
Lara Briden: (20:22)
You can get fertile mucus and not ovulate. So you can have fertile mucus but no bleeds, but the way the body works is once ovulation has occurred, you're either pregnant or you get a period two weeks later.
Lara Briden: (20:39)
So in the case if there's no periods at all and you test LH, what you have to do is just wait two weeks to make sure you don't get a period two weeks later, and then if you don't, then it's not an ovulation LH, then it's a valid baseline reading. If that makes sense.
Lara Briden: (21:03)
In terms of differentiating, I would start to think about context. Is there undereating or insulin resistance? Is there a low carb diet which might have explained the lack of periods, which is then the diagnosis of hypothalamic amenorrhea. And, if you're really, really stuck, look at LH. I have in my blog post that I referenced and in a few places I've shared it, a compare and contrast between PCOS and hypothalamic amenorrhea table.
Lara Briden: (21:33)
And the other thing that's really usually a pretty good giveaway is, with PCOS, the doctor will be able to induce a withdrawal bleed, with either a course of a progestin drug or even you could use real progesterone for that. Some of your listeners might have had that, where they do a challenge, like a progesterone challenge. They give it to you for like a week, and then they wait a week and see if you get a withdrawal bleed. If you do get a withdrawal bleed, that's usually a sign that it's more in the PCOS camp, because you have a thickened uterine lining. If you don't get a withdrawal bleed, that's usually hypothalamic amenorrhea or undereating.
Mm-hmm (affirmative). The thickened uterine lining is the endometrium has not shed for some reason? Is that basically what a PCOS is pointing toward?
Lara Briden: (22:23)
Oestrogen causes a thickening of the uterine lining. So, with PCOS, there is a low level of oestrogen happening, but no progesterone kicking in to-
Make it shed.
Lara Briden: (22:33)
... normalise the lining and then make it shed. Whereas, with hypothalamic amenorrhea, there's no oestrogen, temporarily.
Lara Briden: (22:41)
Just as long as you're in the condition. Which is why hypothalamic amenorrhea is so much more dangerous for bone health.
I saw that in your table that there's bone loss, which is not great.
Lara Briden: (22:53)
Yeah, because there's no oestrogen. There will be oestrogen as soon as you eat enough to get ovulation to kick back in. So it's not a permanent situation, but it's not good, and you don't want that to go on for too long, because you can... you probably know, our bones are a long-term project. We're supposed to achieve what's called peak bone density by about 30 years old, and then we're on a downward slope. It sounds bad, but from then, from that point, we're just losing bone until we're 80. So you want to bank that up, build as much bone as you can. You can't afford to lose years of building bone.
I think one thing that people don't appreciate is how much of a living tissue bone is and how it's being constantly broken down and recycled, and rebuilt. That's actually where we get the calcium from is that recycling process. Not even from our diet necessarily.
It's just something I remember learning that about 10 years ago in yoga training, and I was like, "Wow." I just had so much more respect for my bones after that. I think we mentally just visualise them as this sort of skeleton-
Lara Briden: (24:00)
Yeah. Like in a science lab or something.
Lara Briden: (24:06)
I've got a new book coming out next year. You'll have to have me back to talk about perimenopause if you want to, but my perimenopause book is coming out in March. And I've got a section called Bone is Living Tissue, where I talk about exactly what you're talking about. And I talk about the hormones that bone makes, and how it actually turns out now, which from a TCM perspective makes sense, bone is involved in the nervous system, HPA access, adrenal response, stress response system. It makes hormones that are part of that.
And that's the kidney energy in Chinese medicine.
Lara Briden: (24:37)
Yeah, it's also very involved with the immune system. Bone cells are immune cells basically. So there's a lot going on. And it is true that, big picture, keeping your bones healthy is about keeping everything healthy. But definitely giving your bones the decades of oestrogen that they're expecting, and progesterone is beneficial for bones as well.
Yeah, so just a general healthy cycle is going to be, for bones, positive. It sounds to me like hypothalamic amenorrhea is really... I hope I'm not oversimplifying it, but it's easy to treat in terms of you look at what's going on with diet and lifestyle, and then address that through increasing calorie intake. Is that as simple as that?
Lara Briden: (25:24)
Or is there more going on?
Lara Briden: (25:26)
It is, but what's not easy about it is the lag time, because you have to... it's one of those things with health where unfortunately you have to go all-in, commit to eating more, and sometimes it's a lot more. Probably for recovery from hypothalamic amenorrhea it might require 2,500 calories a day and 200 grammes of starch a day. And commit to that for like six months before you even see a period. Which is-
So it's not going to turn around overnight.
Lara Briden: (25:55)
No, which you can't just try eating more for a few weeks and see if that works. Unfortunately you just really have to go for it. And it's hard. I get that it's hard. If you're not sure which direction you're supposed to be going. Because basically we're in a situation, a crossroads, of no period. Okay, do I restrict my diet or do I double my intake? Do I do one or the other?
Lara Briden: (26:17)
So you have to be pretty clear what you're doing. Put it this way, I think restricting the diet is... it's about understanding if there is insulin resistance or not, not just assuming there is because someone said PCOS. How much do your listeners know of what insulin resistance is-
Well, I was going to say, if you could flesh that out and maybe explain the testing for that, because I think that's something that you're saying with the glucose testing, I think sometimes people don't really understand the implications of insulin resistance. I see it bandied around a lot in the paleo, keto community, but sometimes I read it and I'm like, "I'm not sure that actually makes sense." Anyway, if you wanted to explain that relative to this PCOS stuff, I think that'd be awesome.
Lara Briden: (27:03)
Yeah. To be fair, insulin resistance is pretty common, so we don't want to minimise it, because it definitely is a key feature of PCOS, if it's the correct diagnosis. But that said, not every woman who qualifies for a PCOS diagnosis has insulin resistance either. So it's very important to test for it. It's quite easy to test, but you unfortunately have to ask specifically or self order, because in Australia and New Zealand, and I'm sure your listeners know, especially in Australia, it's very easy to order the test for insulin resistance.
Lara Briden: (27:38)
The one I use is either fasting insulin, so that's at one point in time test, the hormone insulin in the fasting state, which is different than glucose in the fasting state. And then the other more sensitive test is doing the glucose tolerance test, which is that test where you take a fasting sample and then they give you a sweet drink, and then you sit there and they test again at one and two hours. If you're going to do that test, please, please have the doctor or order it yourself test insulin as well as glucose, because then you're getting a better picture.
Lara Briden: (28:17)
So, with insulin resistance, the condition insulin resistance, which is a pre-diabetic, pre-type 2 diabetes condition, it's metabolic dysfunction. It's real. With that condition, insulin is higher than normal, it's too high. It's too high either fasting and/or either the one or the two hour mark, which is in stark contrast to hypothalamic amenorrhea where insulin is quite low, in fact below what I would consider a cutoff for a normal fasting insulin.
Lara Briden: (28:50)
So it's not like insulin is bad. Insulin is actually really important, and it's a beneficial hormone. And having enough of it is in a part of having a menstrual cycle is beneficial for the menstrual cycle. But having too much of it is a problem.
Lara Briden: (29:06)
So, if you do have insulin resistance, then yeah, you're looking at changing the diet, but not just necessarily just eating less. I don't know that that's... that can be part of it, but if there is insulin resistance, the thing I look at with my patients is having a serious look at high dose fructose, which means desserts...
Lara Briden: (29:31)
Not fruit necessarily. Not whole fruit. Because there's actually relatively low dose-
[crosstalk 00:29:36] fruit, because I've heard people talk about how they can really affect...
Lara Briden: (29:41)
Yeah, with my patients, I tend to just not worry about whole fruit. I don't want them having fruit as a meal, like just having only fruit. But if you're having fruit at the end of a meal, I'm not worried about fruit. But what I am worried about is fruit juice or soft drinks, or dried fruit, including date balls and so-called protein balls, which a lot of them are just dates. That kind of thing, dessert type things. Agave syrup. A lot of those so-called natural sweeteners are really just high dose fructose.
Lara Briden: (30:10)
So, through my lens, there's growing evidence that all those dessert type foods, in a person who is genetically susceptible and has other risk factors, can be pushed into insulin resistance due to that. And therefore, by removing those, getting off sugar, getting off desserts, can do quite a lot for reversing insulin resistance. Insulin resistance is always a reversible state. It's not a permanent thing.
I have kind of a curious question. Because I just recently interviewed someone who's a prenatal and pregnancy nutrition expert dietician lady, and she was saying there's naturally a kind of insulin resistant state at the end of pregnancy.
Lara Briden: (30:56)
And we were also chatting about that. But that reminded me of this thing I read a while ago based on evolutionary biology, which was talking about how we would naturally alternate between periods of access to a lot of sugar and thus an insulin resistant state, and then a more ketogenic style diet, I guess over a winter time or when there's more scarcity. I was curious if you've ever seen that it's healthy to alternate between those states, or if you prefer people to just be a bit more stable in terms of their diet? It's just a curiosity more than anything. It was an interesting thing, I was like, oh.
Lara Briden: (31:32)
Well, big picture, I certainly... it depends who you are too. I think if we're looking at people who are tending more to insulin resistance, especially into perimenopause and past menopause. If we're not specifically talking about young women, men, then I think there's a role for in and out of ketosis. The thing is we actually go in and out of ketosis anyway all the time, like overnight and when we're exercising.
Yeah, not eating.
Lara Briden: (31:58)
That's something called promoting metabolic flexibility, which is maintaining your body's ability to burn ketones. So I'm supportive in general of intermittent fasting and different lower carb techniques, and maybe even cycling them with the season. I'm not opposed to that at all.
Lara Briden: (32:18)
And certainly, insulin resistance is interesting, from an evolutionary perspective, if we're going to get into that, because it's a functional state. We have, during adolescence, we're naturally a little bit insulin resistant. Females are, as part of maturing the menstrual cycle. Most 11, 12-year-old girls would kind of officially be PCOS, because they're high androgens, a bit insulin resistance, they're not ovulating yet, but then the idea is you grow out of that, and then your cycles kick in and your oestrogen and progesterone kick in, which both help to resolve the insulin resistance.
Lara Briden: (32:56)
There can also be insulin resistance during the final stages of pregnancy. Just, from a total big picture... this is really [inaudible 00:33:05]a tangent now, but I love bears. I'm from Canada.
I love bears too.
Lara Briden: (33:10)
I grew up around bears. I'm from Canada, we have grizzly bears in our back garden sometimes. I'm scared of them but I also love them. They're one of many hibernating animals. They use insulin resistance strategically.
Well that was what this was talking about, yeah. To hibernate.
Lara Briden: (33:27)
In the autumn when they're gorging on berries and stuff, they become insulin resistant and then they get super fat from that, which is good for them. That's not a bad thing.
Lara Briden: (33:37)
It is true that big, big picture, insulin sensitivity fluctuates for lots of reasons. But, for a human, you don't want to be chronically in the state of insulin resistance. No, that's going to have downstream problems.
Lara Briden: (33:54)
But yeah, it's good to put it in that perspective.
I liked in one of your blog posts, I think you talk about if you have this, and you have this, and you have this, and you have this. And I think that's good for people to remember that it sort of stacks on top.
Because another factor for PCOS is inflammation, which doesn't really show up in HA, right?
Lara Briden: (34:13)
Correct. I would say hypothalamic amenorrhea is not a state of chronic inflammation. Again, because one of the big differences is that PCOS is an abnormal state, whatever the underlying driver is, whether it's inflammation or insulin resistance. Whereas hypothalamic amenorrhea, it's not abnormal but it's also not good at the same time. It's the body making a normal, healthy decision, in the context of undereating. But you can't let that go on, because that will, over time, have negative effects on bones, in particular, and other things too.
Lara Briden: (34:51)
So yeah, if that helps. Someone could be actually quite healthy-
Yeah, in terms of it's a healthful response. You're [inaudible 00:35:00] protecting its functions through not allowing you to menstruate, which is saying, "Hey, let's save this resources for ourselves and not a baby."
Lara Briden: (35:10)
Yeah. And then it can all just be switched back on. So recovering from hypothalamic amenorrhea, we've said a couple of times earlier, it's really just about eating a lot more, but there's nothing broken that has to be fixed. Not that I like to apply the word broken to anything, but PCOS is a bit different, in that that's not a normal situation. It's reversible and it's fixable, but there could be things going on.
So normally, if you're looking at inflammatory things, are we talking food sensitivities then histamine problems? Are we talking about [crosstalk 00:35:47] activity?
Lara Briden: (35:50)
What you referred to in my book, that flowchart I provide for the different, what I call, functional types of PCOS. You're looking for the underlying, what I call, driver of the miscommunication between the brain and the ovaries.
Lara Briden: (36:07)
And underlying that, there's always going to be a genetic susceptibility or just an epigenetic, something that happened in utero, you were exposed to. There's a lot of growing evidence now that exposure to in utero, as a foetus yourself, exposure to androgens in some form can set you up for a PCOS state later in life or a vulnerability to PCOS.
Lara Briden: (36:32)
So that could be just if your mom had PCOS or if you're exposed to environmental toxins that have an androgen effect or potentially even if your mom was using contraceptive drugs that are androgenic, which a lot of them are. So that's a bit of a tangent as well, but acknowledging women... it's not always something they've been doing something wrong. They have potentially had some exposure to some genetic susceptibility to having this with PCOS, this non-communication between the brain and the ovaries.
Lara Briden: (37:06)
On top of that, then you've always got the driver... the more proximate, the more immediate thing that's driving the problem that you can reverse and try to fix. So insulin resistance, in many cases if you can reverse insulin resistance, you can restore the normal functioning of that communication in the inflammatory scenario, what I call the inflammation type. It's about reducing inflammation maybe coming from the gut, for example, from food sensitivities, which could include histamine. And once you lower all that inflammation, then that can, with some other supportive things, help reestablish the normal communication between the brain and the ovaries.
So the four functional versions of PCOS, I guess, you're talking about there's an inflammatory version and an insulin resistant version, and an androgenic version, is that-
Lara Briden: (38:01)
The four types I provide... and there's different ways to interpret this, but I talk about the insulin resistant type, which is the most common. It's about 70% of women who end up with a PCOS diagnosis have insulin resistance. So it's a pretty key feature.
Lara Briden: (38:15)
If there is insulin resistance, that really does become the priority of trying to fix that. That's where you want to focus. If there's not insulin resistance and there's some evidence of inflammation, including maybe autoimmune inflammation like thyroid, autoimmune thyroid, then the focus is to reduce that inflammation, fix the gut.
Lara Briden: (38:36)
The other type I talked about is post-pill, which is really more of a temporary androgen surge that happens when you try to come off the contraceptive drugs, either Yasmin or Diana. So it's either drospirenone or the progestin [syptarone 00:38:56] which is really only used in Australia and New Zealand as far as I can tell, even women in the States aren't subjected to that drug, but it's a common pill down here. It's an anti-androgen drug that, when you stop it, seems to cause this-
Lara Briden: (39:12)
... temporary, usually for a year or two, this surge of androgens from both, usually from the ovaries, but the ovaries and the adrenal gland.
Lara Briden: (39:18)
So, with the post-pill, it's just recognising that it's probably going to be temporary, which can help, because then you can just have faith, get through the couple years of post-pill acne or whatever it is, knowing that, once your... again, I'll just say, once oestrogen and progesterone kick in with a natural menstrual cycle, they have beneficial anti-androgen effects. So they help to establish, counteract the PCOS state.
That's a good one. I just want to stop on that quickly, because I'm thinking about a lot of things I've seen around post-pill acne, [inaudible 00:40:00] Vitex and things, but really you're looking at... because, for me, the thing that worked best was a product called estro-blocker, which is a DIM supplement. And I think that idea of trying to... your oestrogen and progesterone are almost offline, is that what you're saying? And it's the androgens are just really bumped up on account of having been suppressed for so long. Is that...
Lara Briden: (40:22)
Yeah. I think there's an up-regulation of androgen projection because of the... well, in the case of post-pill, because of those drugs. Yes. Down-regulating androgen production, so then the body responds to that.
Lara Briden: (40:37)
I prescribe DIM. It can help with skin, for sure. It's to do with its anti-androgen effect. But again, it's usually something you only need for six months or something until your own anti-androgen hormones kick in. The other supplement, if we're going to talk about supplements, the one that really should at least be considered is zinc, my favourite.
Mm-hmm (affirmative). Yeah, [crosstalk 00:41:00].
Lara Briden: (40:59)
And with zinc, it's obviously, as anyone who follows my work knows, I talk about zinc for almost everything. But it's really beneficial. If you're going to take it, you need to have a decent quality, like either capsule or a liquid, something you're going to absorb, because some of those tablets just don't absorb. And it needs to be at least 30 milligrammes, and you probably need to take it with food or you could feel sick. It's all these [inaudible 00:41:23].
Lara Briden: (41:25)
If you're anyone who's listening is on a plant-based diet, then 100% zinc. There's not enough zinc in a plant-based diet to do really anything that you need. So zinc is an absolute [crosstalk 00:41:37]-
So why do you love zinc so much? What is it doing for you that... Why are we lacking at it? Is it just not enough in our diets these days?
Lara Briden: (41:50)
Yeah, well one thing about the nutrient is we don't store it at all, so we have to have it. Whatever we have in our bodies is what we've consumed over the past couple of days.
Like vitamin C as well.
Lara Briden: (41:59)
Yeah. It just leaves the body. So there's that, I think. And the main dietary source of zinc is animal products. So meat, oyster, seafood is quite high. So I think anyone who's not having animal products is, just by definition, going to be deficient. There's a little bit of zinc in some plant foods, but not a lot.
Lara Briden: (42:19)
And, just therapeutically, it does seem to be beneficial, even for women who should be having enough from diet. It's anti-inflammatory. The immune system loves it. It's really good for tissue integrity.
Lara Briden: (42:40)
I have a blog post called... what did I call it? Seven Ways Zinc Rescues Your Hormones. The body just really loves it. The brain loves it in particular. It's quite good for anxiety. It supports a part of the brain called the hippocampus, which helps to regulate the stress response. The ovaries seem to love it. It has anti-androgen effects. I don't know, I take it myself.
It's sounding pretty good.
Lara Briden: (43:04)
I always feel like I'm doing an infomercial for some of these [crosstalk 00:43:07]. The great thing about zinc is it's not expensive. There's a lot of good brands. You don't have to stick with a particular brand with it, but I would just say again, try to get at least a capsule rather than tablet, usually, or liquid can be even better. And if you get a liquid, you're going to have to aim for 30 milligrammes. Some of the Australian liquids, their recommended dose... one of the popular brands... I like a lot of the Australian liquid brands, but one of them, the recommended dose on the label is only five milligrammes, it's like well that's not going to be enough.
[crosstalk 00:43:40] not therapeutic. Okay. So you're saying 30 grammes, 30 milligrammes?
Lara Briden: (43:42)
Yeah, 30 milligrammes, not 30 grammes. 30 milligrammes.
Yeah, I was just going to say, hang on a second. I always took zinc picolinate, is that... do you recommend anything?
Lara Briden: (43:53)
Yeah, I think zinc picolinate, zinc citrate, there's a few other ones out now, glycinate. So those [inaudible 00:44:01] those are just zinc bonded to another molecule that helps absorption. I think any of those are good.
Yeah, great. I feel like we've covered a lot of territory here. If I'm in one of these states and I'm not sure, I'm going to my doctor, I'm getting checked out, I'm making sure that I've ruled out any potential other things that might be going on. And then, if I'm really noticing, okay... some of the women I've spoken to are models that have this amenorrhea, and that's pretty obviously going to be a diet related thing unfortunately for them, and we've spoken about that, the people I've talked to who've reached out to us about that.
But, if your nutrition is up there and you're eating a high amount of calories, and you're okay, then you're looking at your insulin resistance, you're looking at your androgens. So are we testing all of these things, are we getting a big panel done? What's the approach [crosstalk 00:45:02]-
Lara Briden: (45:02)
I guess it would go like this. Go to the doctor, say I'm not getting my period. That's obviously an abnormal situation. What's going on? So, in the background, the doctor hopefully will have tested thyroid prolactin... or coeliac, a strong gluten sensitivity is another way to lose a period that has nothing to do with either hypothalamic amenorrhea or PCOS. But hopefully you shouldn't have to coach the doctor through all those steps. Hopefully they do all of that.
Lara Briden: (45:33)
And then the next step is if the doctor says, "Okay, you've got PCOS." The next question is "What is that diagnosis based on?" Say to the doctor. "Just so I can understand why are you saying that? Do I have high androgens?" Because, if not... by high androgens, I mean either male hormones measurable on blood tests or a pretty significant degree of facial hair or jawline acne. If that's not there, and yet you're being told PCOS, I would really question that diagnosis. If you say, "On what is that diagnosis based?" And if they say, "Well, there's ultrasound and lack of periods," then say, "Actually, I've heard that, according to the Androgen Excess Society..." Who have I would say a more reliable set of criteria for diagnosis. "According to some criteria, I understand that doesn't qualify me for the diagnosis of PCOS. Is it possible that this is undereating?"
Lara Briden: (46:36)
You can just say that to the doctor. "Is it possible, from what you're seeing on the blood test here, that this could be a situation of undereating? Because I've been restricting my diet." I know sometimes women don't like to talk about that, especially if there's any degree of eating disorder, but it's best to be as honest with your doctor as you can. And unfortunately, undereating or hypothalamic amenorrhea is, from my experience, often not as much on their radar as it should be. And partly because they've only got five minutes with you, so if you say, "Well, actually, is it possible? I started a low carb diet like six months ago, could that be having an effect?" Hopefully the doctor might say yes, if that's the case.
Lara Briden: (47:20)
So it's about questions like that. And also just understand if they say, "Well, your diagnosis is based on ultrasound." And if you say, "Well, I think that's not valid." And if they insist that it is, "I would get a second opinion." To be honest.
Yeah, I was going to say, one thing people need to remember is you're [crosstalk 00:47:38] served by this, so if you're not getting the answers you want, [crosstalk 00:47:41].
Because that was my biggest regret. I was told, "This is just normal, just bear with it." I was [inaudible 00:47:48] post-pill, so obviously like you're saying, there's an element of waiting it out, but just not understanding, not being explained the actual I thought was happening and why it was happening. And just to be told it was normal, go away. [crosstalk 00:48:00].
Lara Briden: (48:00)
So, Tahnee, if you feel like sharing, was your situation undereating then?
I was on the Yasmin pill for a really long time, I guess about 10 years, and I was actually doing some of the stuff originally suggested by my science professor. So taking the pill consistently to not have the withdrawal bleeds and things.
And then I stopped it cold turkey and just that was it. I just didn't get a bleed for... off the top of my head, it was close to a couple of years, but then I got really bad acne. And I never really even had acne as a teenager. I maybe would get a pimple. But yeah, I got the whole jawline acne and everything that you've talked about. I went back to the doctor who prescribed me the pill over the time I'd lived in that city, and he just was like, "Oh, it's normal." And I was just like, "What?"
So then I started seeing naturopaths and things, and they just put me on low inflammation diets. It was great, in hindsight, in that it really triggered me into my own deeper understanding of my body, and hormones, and things. But to feel very lost in that and not understand what was happening is not super pleasant.
Lara Briden: (49:12)
So then do you have a clear sense of what finally brought your period back, or do you think it was just being off contraceptive drugs for long enough [crosstalk 00:49:19]?
I actually think it was a combination of herbs for stress, and increasing my calories, and taking DIM. I think the DIM helped clear up the acne probably more than actually bring my period back. But I was a vegetarian as well, so probably... and probably eating a lower calorie diet than I needed, in hindsight. Hindsight is 20/20.
So yeah, it was a combination of things. And it took a bit of time to really work it out. But yeah, definitely for me, herbs, Chinese herbs really helped. That was a massive change when I started taking them.
Lara Briden: (49:56)
Yeah, definitely have a medicine cabinet, no question, can help to regulate the communication between the brain and the ovaries. That situation, that's definitely a post-pill... post-pill acne, for sure, because drospirenone, that's the drug you were trying to come off, is anti-androgen. So you get that androgen surge, which you just said yourself, you never had before. It's not like you were high androgens going into this.
Lara Briden: (50:19)
Now, officially, the way PCOS is diagnosed these days, because it's just, by definition, PCOS is high androgens, because you had the jawline acne, you do temporarily fit under the diagnostic umbrella of PCOS, even though you also probably had undereating going on at the same time. So it was probably a combination of a temporary post-pill PCOS with underlying undereating.
So the curiosity I have is if PCOS is androgen excess but with all the other causes ruled out, would you diagnostically look at someone who is coming off the pill and say, "All right, well that's, for now, a temporary explanation, and we'll sort of ride it out and see," or would you also continue delving in?
Lara Briden: (51:02)
Well, that's exactly what I say. In a patient like in your situation, I would probably say something like, "Okay, well clearly you have symptoms of androgens, which in your case seemed likely to be from coming off the pill. So that's temporary. So we're not going to attach the label. We're not going to get too attached to the label of PCOS. We're just going to put that on the back-burner. Whether you officially qualify for that diagnosis or not, it doesn't matter. We'll just deal with what's actually going on, which is you're trying to recover from the withdrawal symptoms from that drug. And, at the same time, make sure every other box is ticked for getting a healthy period, which in your case could have been reducing stress, potentially putting [crosstalk 00:51:44] in place, eating enough."
Lara Briden: (51:46)
Constantly with my patients, I have a little checklist in my brain, which sometimes I say to them, sometimes not. But I'm like, is she eating enough? Bottom line, is she eating enough? And sometimes it's really obvious that someone is eating enough. Well, okay, that's not the problem. But if I have any uncertainty, then I dig into that a little bit more.
I'm curious on that, because I've had an eating disorder, and I am in a community of younger women where I can see how there's still a real lack of acceptance that women have fat, and especially in this area, there's a lot of people who are making their money through their looks, and their body, and things, and it's a tricky one to really impress... I know, for me, I've really had to accept that a womanly figure is my norm.
It's interesting when you're talking about that early, pre-menstrual time being high androgen. I was very skinny and very tall as a younger woman. And the moment I hit into my stride of puberty, which was probably around 18, 19, I started to get hips and boobs. Now, with a lot of education and hindsight, I can see that's a good thing. And I had a really easy pregnancy and all of those things. I probably am lucky that my body has easily adapted back to a natural cycle and those kinds of things.
But yeah, it's something I see so much, where even friends who are like, "Oh, look how skinny I used to be, and now I'm bigger." But it's like, to me, you look really healthy.
Apart from obviously therapy and work like that, is there a marker for how many calories you want to see women eating? How much body fat do you see as normal? It's more than we think probably, right?
Lara Briden: (53:35)
The period is the marker. The period is the report card, what I call the monthly report card. Basically, if you're in that situation of hypothalamic amenorrhea, you need to eat enough to get a period. That's your marker. It's going to be a bit different for everyone, what that amount looks like.
Lara Briden: (53:50)
But one thing that might be helpful is to distinguish between... just to talk a little bit about fat deposition patterns. So hip, bum, breast weight is normal and healthy for women, especially younger women. It's very, very different from belly weight, which is actually like that apple-shaped weight gain is more... that's what happens with androgens and insulin resistance.
Lara Briden: (54:25)
If that helps people to understand, well, if you're gaining weight on your hips, and thighs, and bum, from a hormonal perspective, that's really beneficial weight usually. If you're gaining around the middle, that can be a sign that something is not quite right in terms of insulin resistance.
Lara Briden: (54:41)
But one thing I need to say there... because I've had so many patients who think, "Oh, I'm gaining weight around the middle," but what they're actually experiencing is digestive bloating that's making them sometimes feel distended and bloated in their stomach. That's not abdominal weight gain, that's actually just digestive problems that need to be addressed.
Are you talking subcutaneous fat or you're talking more even the visceral fat, around-
Lara Briden: (55:04)
It's the visceral.
So if someone has like a belly roll, they're not freaking out, but if someone-
Lara Briden: (55:08)
No, exactly. [inaudible 00:55:12] the bellybutton, a little... no. Of course there's going to be some subcutaneous fat around the belly, too. That's allowed. No, I'm talking about the more visceral... and actually, the group that you're speaking about, I guess the demographic mainly that we're speaking to today are unlikely to actually be in that apple-shaped obesity, insulin resistant state. [crosstalk 00:55:33].
And you're really looking, there's not going to be a lot of waist definition. There's going to be quite a round middle. Is that sort of what we're looking [crosstalk 00:55:40]-
Lara Briden: (55:40)
I guess the classic example of apple-shaped obesity would be probably more looking even at the different age groups... it can happen to younger women too, but looking more to women in their 40s and 50s. You can start to see that shift to be more apple-shaped. That's the kind of weight that, I guess, when people talk about weight being unhealthy, that's... I'm hoping this is helpful. I don't want to be [crosstalk 00:56:01].
Lara Briden: (56:01)
What I'm trying to actually distinguish is that the hip, and bum, and breast weight is good. So to not be afraid of that, and just to understand everyone has a different... some women are just naturally slimmer and don't have as much bum weight, just because genetically that's how they are. But some women, their default or their set point would be to have a fair amount of thigh, and bum... that's normal and healthy.
Yeah. And so not to compare what your... if you're looking at your body and your menstrual cycle, and it's healthy, then that's a good weight for you, and you feel comfortable [crosstalk 00:56:37] stick with it. And if you start losing and you're losing your period, well that's a sign that your body doesn't want to sustain that weight long-term.
Lara Briden: (56:44)
Exactly. Losing your period is an unmistakable sign that something is wrong.
Yeah. Too far.
Lara Briden: (56:52)
Awesome. Well, is there anything else you wanted to add? I think we've covered a lot of subjects.
Lara Briden: (56:55)
I think we've covered it. I hope that's given some clarity. And also, just to end with the message that your period is a good thing. It's both a sign of health, which is very important, and it's a creator of health as well, because it gives you the oestrogen and progesterone you need to stay healthy.
Healthy bones, healthy you.
Lara Briden: (57:17)
Yeah, healthy brain, healthy heart.
Yeah, for sure. All right, well thank you so much, Lara, again. Amazing conversation, and you're so interesting. I could talk to you all day.
So tell me about this new book. Is that coming out next year?
Lara Briden: (57:32)
Lara Briden: (57:33)
It's coming in March.
Lara Briden: (57:36)
So it's for women, 40-plus, which is a lot of women.
Yeah, I'm so excited, because perimenopause and menopause are questions we get asked about all the time, and I feel like [crosstalk 00:57:46]-
Lara Briden: (57:45)
Yeah, it's difficult to find experts who want to talk about it.
Lara Briden: (57:50)
I am super passionate about it right now, because I will be 51 in a couple of months, so I'm-
Happy [crosstalk 00:57:56].
Lara Briden: (57:56)
... right in the crosshairs of all of that. That's all happening. And so I've found a way to reframe that through the lens of evolutionary biology and think about all the big picture benefits of menopause, really, from an evolutionary perspective.
Lara Briden: (58:14)
As much as I love menstrual cycles, I also think, when our reproductive years are done, then moving into menopause is also normal and healthy.
Yeah. And exciting that we're one of the few mammals that actually have a menopause, so there's got to be a meaning there, right?
Lara Briden: (58:30)
There is. We can go into that when you have me back on next year.
Okay, we'll talk to you next year.
Lara Briden: (58:36)
Because then people can, after they hear the whole... they can get all fired up and excited about perimenopause and then go buy my new book.
Yeah. I'm really excited for that one. Okay, great. Also I'll link to your website. It's larabriden.com. Lara is also on social media, so we'll link to all of those. And her book, The Period Repair Manual is literally one of those books that we get written-to every week about how good it is. I think, even in our team, a couple of the girls have just found it to be super helpful in managing their own health. So yeah, thank you for creating such an awesome reference for us all, and thanks for being here today.
Lara Briden: (59:15)
Yeah, thank you for having me, and for just everything. It's great to chat with you as always, and see what you guys are doing.
Thank you, Lara. All right, take care.
Lara Briden: (59:25)