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Birth Control and Female Athletic Performance | Victoria Felkar

Episode 52, duration 1 hr and 25 mins
Episode 52

Birth Control and Female Athletic Performance | Victoria Felkar

Victoria Felkar is a doctoral candidate conducting interdisciplinary research on women’s health, reproductive function, and pharmaceutical steroid hormones. Her work offers a novel and critical perspective into the use of drugs for health and performance purposes within the female athlete population. Victoria’s research has achieved international awards and accolades within the academic field. Beyond academia, Victoria is an internationally respected educator and consultant within the fitness, bodybuilding, and strength sector. Her unique multidisciplinary background has provided the perfect platform for pioneering work in athlete-centered coaching methods, integrated health-performance methods, and female athlete health. For the past 12 years, she has worked with a wide range of individuals and organizations, including top-level athletes and competitors, special populations, health professionals, and strength coaches, and has lectured at events worldwide.


In this episode we discuss:
– Why humans are horrible for research.
– The major issues with birth control & contraceptives.
– What causes menstrual dysfunction?
– Why banned substances in sports is a joke.

00:00:00 Introduction

00:02:16 Starting in On Women’s Health and Sport

00:06:06 Hormones & Female Athlete Performance?

00:13:36 Estrogens and Progestins in Sport

00:24:18 Optimal Hormone Levels

00:26:13 Oral Contraceptives

00:34:16 Basal Temperature Tracking

00:40:13 How is Progesterone Made?

00:42:21 Ovulation and Health

00:49:20 Chronic Ovulation Dysrhythmia

00:56:22 Estradiol

00:59:08 Synthetic Hormones in Sports

01:09:57 Unfair Restrictions for Athletes

01:14:14 Alternative Contraception

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Victoria Felkar, Dr. Gabrielle Lyon

Dr. Gabrielle Lyon [0:00:01]

Welcome to the Dr. Gabrielle Lyon Show where I believe a healthy world is based on transparent conversations. In today’s episode of The Dr. Gabrielle Lyon Show, I sit down with a beautiful and articulate Victoria Felkar. She is an instructor, an internationally renowned Junior scholar, which she is currently completing her doctoral studies at the University of British Columbia. Why did I have Victoria on? Because she holds a very unique position in the space. She is a social and cultural sport historian with a special interest in physical cultural performance enhancement, and her research has achieved international publication and award. Essentially, Victoria combines the history of what we are talking about as it relates to male-female hormonal manipulation, and the study of social ethics. She combines them, which makes the podcast so fascinating to hear the scientific aspect as well as the social-cultural aspect. We discuss, should women take oral contraceptives? What have we gotten wrong about the use of female hormones? And finally, strategies to optimize hormones for athletic performance.

I strongly suggest that you take a moment to rate and subscribe to the podcast. If you love this episode, share it. I’d love to highlight that with the new availability to pre order my book, Forever Strong, you can get it on Amazon, you can go to my website, that there are communities that we have put in place for you so that you can actually be involved in Q&A with experts like Victoria. Head on over to Amazon or my website to pre order the book, Forever Strong, which goes on sale October 17th. Within that pre order, there will be a ton of free bonuses for you to interface with the best of the best. Let’s get started.

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Victoria Felkar, thank you so much for coming on the show. I’m really excited to talk to you all about women’s health hormones, oral contraceptives, all of the things as it relates to sport performance. One of the reasons I’m so excited to have you on is you are just about finished with your PhD, and your research is incredibly unique. Again, with this podcast, we like to bring in individuals that are in the trenches, and those that are changing the conversation, having innovative conversations. I would love for you to share a little bit about your particular research.

Victoria Felkar [0:05:24]

Thank you so much for having me. It’s honestly such an honor. I’ve seen all the rock stars that you’ve had on here, and I am so excited to be a part of it. My work specifically looks at the use of pharmaceutical estrogens and progesterones in the athletic female population. I have to start off at just the name itself, because that throws some people off because it’s not a common way to refer to a very commonly used group of pharmaceuticals. when I use the term, pharmaceutical estrogens and progesterones, this includes anything from HRT, or hormone replacement therapy, all the way to hormonal contraceptives, all the way to the mono use of both pharmaceutical estrogens and progesterone.

The name for me is really important, because it actually is a big part of the story about these drugs, and that it is this huge umbrella of drugs that often does get brought down to only just talking about HRT, or hormone contraceptives, when the reality is there’s a ton of different compounds underneath those umbrellas, and each of those different compounds interact with the body differently. That’s a big piece of the puzzle that when we look at the athletic female population hasn’t always been observed properly within sport, both by those studying on more of the sport science realm, but then also within sport medicine, and those that are prescribing that there has definitely been, and as my work has  teased apart this long drawn-out history that I have to say when I first got into it, I did not know existed at all. I was so ambivalent to it and naive and that I had my own story, which really interacted with me being a young female athlete put on the pill at a very young age and having health consequences as a result of it.

I thought, I was like, oh, it’s just one and done. I was like, no, actually, this is a big story that really within both the hard sciences as well as more of the humanities hadn’t been discussed before. When we were talking earlier, I said in my message, one of the big things is I just don’t understand why. To me, it’s right there. So my work really is trying to bring attention to it, both from that hard science standpoint, but then also from the more social side of it as well, the sociology, the anthropology, because I sit in the middle. I’m an interdisciplinary researcher.

Dr. Gabrielle Lyon [0:08:00]

Which is so unusual. It’s very unusual, especially when I have guests on, it seems as if it’s really divisive in terms of what their area of specialty is. Either they are clinicians or PhDs, and typically science, PhDs and/or real-life experience in the trenches, individuals that have excelled or have been in a particular situation and  going forth. What’s so beautiful about you, and I do want to talk about the place in which we are now as it relates to the use of hormones and the athletic population or again, I’m sitting here across from you thinking is hormones the right word? Is it a steroid hormone? Is it oral contraceptive use? How do we reframe this conversation, and what can the listeners get from this? Because you do bridge both quite in a fascinating way the historical aspect, which by understanding the history, we can understand where we’re going. The historical aspect, as well as you are a scientist.

That’s a long story to say, please, if you could, bring us up to speed as to where we are now, where some of the misconceptions are, what we are doing as it relates to the athletic population. You and I have sent numerous papers back and forth, and within the current thinking, people will say the current evidence shows no influence of women’s menstrual cycle phase on strength and performance and adaptation to resistance training. Other people will say, well, absolutely. We should train for our cycles. Where are we, and what is happening?

Victoria Felkar [0:09:55]

That’s a great question. One of the most fascinating things is that when we actually look at the body of research on the female athlete, there is very little research. Then you peel back another, and you go, is the research that’s there solid? Are our methodologies where they need to be? Are we accounting for certain variables? You scrape off all of that paper, and you’re left with very little to look from. You’re left with a very small pool, which when you think about it, we’re in 2023. It really sheds light to the fact that this is a really complex topic. The history, as you mentioned, it’s really embedded in our current everyday practices. I think that’s one thing that really fascinated me was that I kept asking questions like, why, how, where did we come from? Why are people thinking about it? As a result, that led me down that history route. But if we just go back to today, so where are we today?

There are a ton of varying opinions about how female menstrual cycle influences performance, and then also how performance influences the menstrual cycle and overall female athlete health. I think of it almost as like a bi-directional. That has existed since mid-1800s to 1900s. It’s been a long saga of this discussion of, how does the menstrual cycle influence how we perform? Does it impact our endurance or our strength at different phases of the cycle? Also, how does performance, particularly high performance, influence female athlete health and the menstrual cycle reproductive capacity? In the 1980s, women were not allowed to run the marathon for perceptions around how strenuous and dangerous it was for their reproductive capacity and their menstrual cycle. So it’s not that long ago, and I would argue that today, we’re still seeing people having these archaic ideas around how performance impacts the menstrual cycle in a female athlete body. But I’m sure we’re going to get into that, so I don’t want to skip ahead.

There are lots of different opinions and different ideas. there are people that do ascribe to the idea that yes, indeed, menstruation has a massive impact on performance, and we need to be training around it, really titrating our activity or even our utilization of a certain dietary strategies around the menstrual cycle. Then there’s the other camp of people that go, wait a second. When you actually look at the science, we might not actually be getting this right. There might be a lot more to this. Maybe we don’t have the actual scientific evidence to give us that straightforward, clear-cut perspective of yes, indeed, there is this direct link between, let’s just say the follicular phase, which is that first half of the menstrual cycle, having blank impact on athletic performance. I would say I fall into camp number two, because when you do look at the data itself, and when you really claw at it, you see that there has been just so much misunderstanding in not only sports sciences, but also I think, within many sciences, and particularly, biomedical and medical sciences, around what it is a woman’s menstrual cycle is, what it is not, what are the hormones involved, how do these hormones differ, and more importantly, how the individual is really important to this conversation.

Back when I used to teach in undergraduate and graduate classes, I always used to say to my students that the human body is terrible to do research off of. It’s terrible, because if we think about just basic scientific method and trying to control variables, there’s so much difference between me and you and our cycles and our hormones and our life course that led up to this point today. Even if we were doing twin studies, there is just so much difference between humans. That’s what really gets this conversation starts to tease it apart as if we just start to really think about who are we studying, and how are we studying them? The reality is that within the female athlete population, there’s just insufficient evidence. The evidence by and large, and this doesn’t mean everybody, but by and large, the evidence that does exist is very limited. There’s a lot of research that has been based on either poor research practices or misunderstanding or even just really sexist stereotypes around the female body or around hormones themselves that don’t necessarily reflect what we now know today.

When it comes to even the conversation around hormonal drugs, I always use the term steroidal hormones because I get really picky about that stuff. But for me, personally, it matters big that we need to call a spade a spade, and that when we talk about steroid hormones, I refer to it as like the big three family being androgens, estrogens, and then progesterone, and then your metabolites of progesterone. But those are the big three. I don’t refer to them as sex steroids. I don’t refer to them as even reproductive steroids. I might slip up every now and again, but I try not to because I really want to try to get into, specifically the sporting world, that we have to get away from that very limited idea that these drugs or these hormones themselves are only related to reproductive function in both the male and female body, that they’re only related to, quote, sex, when we know that that’s not true at all. When you look back into history, you really see that starting to come out. But unfortunately, sports science, or medicine really, has not accommodated for these changes in actually what these drugs are or what these hormones are and how they do vary across individuals, and just the massive amount of pharmaceuticals that exist in those umbrellas.

Dr. Gabrielle Lyon [0:16:03]

That is so interesting. I noticed that when you were talking about estrogen, you didn’t say estrogen. You said estrogen. I was reading one of these papers, and it said that it’s not a particular hormone, but it’s a class of compounds, common, endogenous hormones from the class of estrogens, including estradiol estrone, estriol. Then of course, there’s synthetic estrogens not endogenous to animals, like phytoestrogens, all these different things. What I’m hearing you say is while we’ve typically thought about estrogens, progestins, testosterone as it relates to reproduction, how do these relate to sport? What do we know? What have we potentially gotten wrong? I would say why don’t we start with potentially what we’ve gotten wrong, because that allows us to shift the conversation to what can we now build upon?

 Victoria Felkar [0:17:05]

Yeah, absolutely. First and foremost, at the crux of seven years of research here, but we have done a very good job at creating what’s called biological dualism or binary thinking around the sexes. In 2023, we know that it’s way more complicated than that. But nonetheless, when the whole concept of sex was attached to hormones, it wasn’t actually that long ago. It was 1905, 1908 was when the research really was picking up. It was associated right away that hormones were with the gonadal organ. They thought that hey, testes, testicles, that’s where testosterone is from. That’s what it’s named for that. Then we have estrogen. They only had one back in the day that they knew of at the time, and then progesterone didn’t get named, or they really weren’t sure. They called it the yellow hormone right away, which, another story for another day.

So right away, they started naming these things. Estrogen is named eustress. It’s directly related to ideas around the female body. They thought these drugs only existed in the female body. By drugs, I mean hormones as well, and that testosterone and androgens only existed in the male body, so they named them as a result of that. We have this perception that testosterone and other androgens are inherently good and needed and positive for athleticism. They are needed for strength. They are needed for endurance. They are needed to get big, run fast, jump high, and that it’s the androgens. If we actually start scraping at that research, what we find is that really goes back to these really archaic and historical ideas around the male and female body. Women were not allowed to participate in sport. We didn’t connect their bodies, their hormones, their reproductive function, or their ovaries with physical activity or prowess or vitality. It was the opposite. It was the eternally wounded woman, the one who was always sick, particularly around menstruation.

There were these really tough, negative stereotypes applied to the female body, and these more positive-based ones applied to the male body. Those got reinforced within understandings of hormones. Unfortunately, if we think of today, we still associate sport with testosterone. The best example I can use, which is, for me, just was a mind-blowing thing when I started actually looking at it was the fact that, when I say to people, why aren’t anabolic steroids banned in sport? They’re like, that’s because they boost performance. I can’t believe you’re asking me that. I’m like, but do they for everybody? Do they work the same for everybody? What about estrogen and progesterone? People actually laugh. I’ve been laughed at academic conferences before when I’ve made that statement of why aren’t we thinking about estrogens and progesterones as being positive for sport performance?

When you start looking at the literature, you just see how little actually exists that studied systematically how estrogens and progesterones affect human performance. The research that does exist, there’s some animal studies, there’s some mouse models that have been done, but overall, just very limited. There’s other research that’s been done, but not very good. But nonetheless, we just have to be really open to the idea that, in my opinion, professionally from looking at the research, we really can’t label testosterone as being just inherently good for sport without also thinking about estrogen and progesterone. There is enough research that exists in other worlds outside of sport that talks about the importance of progesterone for our nervous system. We know sport has an impact on our nervous system up regulation. Why wouldn’t something like progesterone be beneficial for especially female athletes to have? That just to me goes like this.

It’s the same thing with muscle development. There has been some really great studies done on estrogen, not necessarily the impact of it, but what happens when you don’t have it for muscle mass? What happens when you don’t have progesterone? In that menopausal, postmenopausal cohort of individuals, why are we reducing muscle mass at such a rapid rate? Androgens do play a role in this as well, which blows my mind that they’ve completely forgotten that part in the research. But nonetheless, they have shown that our hormones are so important. It’s the balance. It’s where receptors are. There’s just so much there. The thing, I think, if I could dilute it down to one basic statement, it would be that steroid hormones matter for human performance, but it’s in how much, in whose body, and for how long. It’s not just levels. It’s also receptors and metabolism. It’s a much bigger system that we have to think about. We really need to open our eyes up to see that there’s a harmony and a serendipitous network of different interactions that have to occur to be able to create the most optimal levels of human performance.

Dr. Gabrielle Lyon [0:22:34]

How far away are we from figuring out those levels? Do you think that we’re ever going to be able to understand what level of estrogens that we need to optimize a particular performance, or what blood levels of progesterone we’re going to need? You do make a very insightful statement in that it’s not just the amount that we’re getting, but also the receptors and the clearance. Where do you think it’s going to go in the future? How can we start to look at potentially, athletes, individuals, blood labs and target treatment?

Victoria Felkar [0:23:12]

I think it has to come back to the individual. I really think we have to look at the individual. If we look at an example of a female athlete, and we think of, let’s just make a little case study here. We have a female athlete–

Dr. Gabrielle Lyon [0:23:27]

We do have a case study, but maybe we won’t talk about it. She can remain nameless if she wants. I’m sure she wouldn’t want to, but we’ll leave her nameless for now.

Victoria Felkar [0:23:39]

Okay. I don’t think it’s the same one we’re talking about, but for our purposes, for this little example, let’s say we have a female high-performance athlete that had her first menses at age 13, so very average onset of menses. You actually have an influx of particular steroid hormones even before that first bleed. Estradiol, typically it’s about one year, but it varies across individuals. You’re seeing dione, which is an androgen. It increases for about that first year, but it varies across individuals. But let’s just say that she got put on a hormonal contraceptive about six months or maybe four bleeds after the first bleed. She was on a hormonal contraceptive from the time that she was 13 and a half all the way to 28. Then she goes off, and through various means is able to, over time, regain a ovulatory menstrual cycle.

In this example, a couple of important things to take out is one, that individual did not have exposure to progesterone. We know that in that first, about seven to 10 years after menarche or the first bleed, that it’s very likely that we’re going to have a high fluctuation rate. It’s the roller coaster of hormones and that you’re more likely to have anovulatory menstrual cycles as your body’s really learning and adapting and figuring out how to develop this really complex system in terms of how it relates to internal and external factors. But when you’re on a hormonal contraceptive, you stop the ability to ovulate, so you’re exposed to a synthetic progestin, so it’s spelled totally different than progesterone. The molecule does not look the same, and it doesn’t act the same. Moreover, there’s some newer formulas of contraceptives that are now using more of a bioidentical estradiol, but by and large, ethinylestradiol is the number one synthetic estrogen that’s used in contraceptives. That has been shown to be quite a bit more potent than what our bodies naturally make. We have this individual who never had the opportunity to make and get exposed to natural endogenous levels of estradiol, estrone, estriol, and all those metabolites, and also didn’t get the exposure to progesterone. Then she comes off. It’s going to take a little bit for her body to get used to not only making but receiving, metabolizing her own endogenous hormones because they look different. They act different. There’s a beautiful body of literature, especially within neuroscience, that has looked at just how different the synthetics used in contraceptives are compared to our own natural endogenous hormones.

But long story short, one thing that we can take away from this is that individual may have a different, let’s say, muscular response to a synthetic hormone than in bioidentical what her own body is making hormone. This could massively impact performance outcomes. So it’s really hard to study then how optimal levels might be because in a case like that, she might feel particularly, and I don’t know if you’ve seen this in your own practice, I’ve seen this in my own work, though, where you see people that are trying to make hormones again after they’ve been really deficient for a while, and that they do have more of a magnified  somatic response as their body is getting used to making progesterone again, or making estradiol again. Even if you test serum levels, even if you do a very robust once a week lab tests for LH, FSH, estradiol, you’ll see that even at low levels on serum testing, they will reflect with higher symptomatic of elevated estradiol levels because their body’s just not used to it. That individual might feel great on sub-optimal levels initially, and then as her body gets used to it, things get back into flow, she might then feel much better at what we would consider to be like more optimal levels.

Long story short, I don’t think we can define these really rigid ranges. I truly don’t because there’s just way too much individual variance. Particularly when we look at that female population, just recognizing the amount of individuals that probably do have regular anovulatory cycles, they’re going to feel different on very low levels of progesterone than what they would be getting if they actually ovulated, that 600 and up range. No, I don’t think we can. I think they’re going to keep trying and keep not being successful.

Dr. Gabrielle Lyon [0:28:42]

What you’re saying is when a young athlete goes on oral contraceptives, it shuts down their natural ability to produce hormones, which, while they’re still getting a regular cycle, per se, regular from an external perspective, from the patient’s perspective, physiologically, it’s not exactly the same. It’s not the same, quote, natural cycle. The hormone flexes the body’s ability to make and maintain their own hormones are different. You’re also saying that it potentially impacts performance or potentially impacts musculature from a young age. Am I hearing you correctly?

Victoria Felkar [0:29:21]

Absolutely. What’s been interesting is it’s not just musculature. It’s also adiposity and fat free mass or fat mass. There, we’ve also seen substrate utilization be different. It varies actually with different forms of contraceptives. There are certain progestins particularly that are more pro-metabolic or anti-metabolic. It varies how long an individual is exposed to them, what their reproductive state was before initiating, how long they were on and at what dose. That’s where it makes studying them so complicated because there are so many different variables involved. Even for muscle recovery, they’ve seen higher rates of C-reactive protein after exercise in elite athletes that were on hormonal contraceptives. They’ve seen alterations with different bone structures depending on the type of contraceptive and when it was initiated. These are all variables that will alter and change how somebody’s performance, how we’re able to optimize it when we actually start looking at what is affected.


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Would you over would you overarching say that you don’t recommend young athletes or athletes in general to go on oral contraceptives, that there are potentially better ways to manage symptoms, pregnancy, all the things?

Victoria Felkar [0:33:34]

At the end of the day, I’m a feminist, and I believe in women’s rights. I believe in access to birth control. I don’t agree with blindly giving individuals a pharmaceutical that could potentially change their life without talking about the risks and without educating them so that individual can make their own decision. I think informed consent is an incredibly important part of this conversation that has been completely left out, in part due to just this incestuous relationship between researchers and pharmaceutical companies and everything else. I do believe that there are better forms of contraceptives. Yes, absolutely. I do agree that there are better forms of, let’s say, managing a menstrual cycle that is maybe not optimal or symptom free for an individual. We have to ask why before just going on a substance.

The thing about contraceptives is that there is very easy access to them. Individuals may go on them because they’re just not educated that there might be a better option for them. Or they might think that it’s just for now. It’s not going to be forever, not recognizing that, hey, depending on all the other things that make up who you are, there may be more long-term implications, particularly maybe if you haven’t had a regular ovulatory cycle prior to going on or if you started too young. I do agree that the age of onset needs to be pushed. If you look back, and again, going back to some of the historical stuff, if you look back in time, there was never intended to be a drug for young girls and women. It was actually 18 was the initial cut off depending on where people live.

Dr. Gabrielle Lyon [0:35:17]        

Meaning the cut off of starting?

Victoria Felkar [0:35:21]

You had to be over the age of 18. In other countries, it was even as high as 22 years old. Initially, it also was only intended to be used for about six months or so, and they kept just pushing that time even when there were voices speaking out against it, just like with some of the issues with long-term sterility or infertility post use. There were people pushing back about that, but they got definitely suppressed unfortunately, within the literature, and you just see that age. You see the indications going up, too. Initially, they were intended actually for, and it’s just stranger than fiction and the craziest truth to how contraceptives developed, hiding that they were anti-ovulatory. Marketers made a very strategic move because ovulation in the 1950s, ‘40s, and even into ‘30s are the idea about having a bleed. That was such an important part to womanhood, and so they essentially hid it. There are many doctors out there, and even today, research has shown, that don’t actually know that contraceptives completely blunt ovulation, and that there could be potential implications for fertility afterwards.

I shake my head because it’s just the craziest story when you actually started going like, they did what? This is a time before clinical trials were what they are today. This is a time before the FDA had the rules that they have today. So they got away with a lot, and nobody’s taken that question today and asking, what? Are you sure young girls should be going on these? Are you sure that we should be having women on them for 30 some odd years, and then just letting them go off in mid-40s and say, see you later, good luck, and not talk to them about implications for bone density? Or there might be implications for brain health. Those aren’t conversations we’re seeing happen, and that, to me, is really upsetting. It’s dangerous. It’s upsetting. It keeps me up at night. It’s why I’ve gone into the spread of research because it’s just, in my opinion, not okay.

Dr. Gabrielle Lyon [0:37:32]

Well, we’re definitely going to get your experience out there in this podcast. We had Stacy Sims on, and we do get a lot of questions about female health, oral contraceptives, female hormones, sport performance, weight loss, all the things. Having these conversations that are well thought out are critically important so that people can make decisions. I also will say that the young girls, the athletes, or many women are going to say, I don’t want to get pregnant. Oral contraceptives are what has been offered to me. What are some other alternative options that potentially have limited impact on body composition and sport performance?

Victoria Felkar [0:38:18]

I believe, all of me believes, tracking is so important. Basal temperature tracking is so important to be able to understand whether or not you ovulate because if you’re not ovulating, we have a problem.

Dr. Gabrielle Lyon [0:38:40]

Can we explain that for the listener?

Victoria Felkar [0:38:48]

Progesterone, such a cool hormone, love it, is thermogenic. It increases your body temperature. You create progesterone if you have an ovulatory cycle, which not all bleeds are ovulatory and not all bleeds have sufficient amounts of progesterone produced. Particularly when we’re talking about the female athlete population, there are some studies that have shown that they are more likely to have anovulatory or shortened luteal phases, which is that second half of the menstrual cycle when you are producing progesterone, and as a result are not producing sufficient amounts of progesterone. Progesterone, because it’s thermogenic, if an individual ovulates, their body temperature should rise in that second half of the cycle. Through tracking not just things like length of bleed, cramping occurrences, mood changes, fluid retention changes, but also your temperature, you can actually see whether or not your body has potentially ovulated.

This is also a really great tool to be able to say hey, I’m bleeding, but I’m not ovulating and then to be able to pursue why that might be the case. Are you in a stressful period of life? Are you in a period where you’re going through very tumultuous changes? Are you not sleeping sufficiently? Are you not overall eating enough? Are you having any other types of health indications that may be influencing this? That ability to ovulate is a superpower. It is so important. Through tracking, we’re actually not only able to find out whether or not we’re ovulating, but also find out how long our follicular and luteal phase links are to see that we’re making enough progesterone and then also to be able to test for it. If you just go in on day three of your cycle and get lab work done for progesterone, it’s probably going to tell you that you’re low because that’s not when progesterone has been produced. That’s going to be at the tail end. If it’s null, then typically, that tells us that either you didn’t produce enough or you didn’t produce it. That’s typically what research has shown at this point.

The third thing to know about basal temperature is that you can use it for fertility awareness method. It’s called FAM. You can calculate when are you most likely to conceive in your cycle if you have intercourse that’s unprotected. If you calculate it, and it’s going to be different depending on what your cycle is, but there’s lots of different amazing resources online to help women understand this, that you can be able to then use protection. I always say to create a buffer, too. If it says these five days, you’re more likely to conceive, create a buffer, maybe seven or eight days, and use protection during that time. That is a way that you can not only help with fertility, but also help with your health. Progesterone production is such an important and critical part of female health that has been just absolutely forgotten by not only the medical community, but the lay population. There are so many women when I go to speak at events or do consulting work or after podcasts that go like, I didn’t know what that was. No, I didn’t know that you might not make progesterone. I didn’t know that I’m supposed to.

There’s also misunderstanding on the big difference between a synthetic progestin and progesterone. As I’ve mentioned, in the female athlete population, there is a great concern that athletes aren’t producing enough progesterone or at least not sufficient levels for long enough because of just what sport is asking us to do. Sport is asking us to push our bodies, particularly if we’re in a competition season, or we’re doing a weight cut, or we’re tapering into six weeks where you’re going to track meets every weekend. Your body is going to go through higher levels of stress that you may not have the resources physiologically, psychologically, socially, and emotionally to be able to actually cope with those demands. We know from research that it’s not just about body fat in athletes. It’s not just about your body fat, not at all. Our mental health plays such a big role.

There has been an amazing research by an individual called Sarah Berga and a couple of her research team that have shown that just thinking negatively about your body, just having body dissatisfaction can induce anovulatory cycles in otherwise regular women. That’s big. That means that not even exercising, not even diet, that we can stop ourselves from having this really important physiological process, and not just for fertility. I’ve got lots of athletes going, I don’t want to get pregnant. I don’t want to have kids. No, progesterone is so much more important than just fertility. It’s for brain health, bone health, cardiovascular health, neurological health, thyroid health, I can keep going. It’s just such an important hormone that we’ve just completely ignored. It’s terrible.

Dr. Gabrielle Lyon [0:44:18]

I couldn’t agree with you more. In clinical practice, we use progesterone all the time, which you actually know this. We use micronized progesterone at night. How does an individual make progesterone, and is there a way that they could optimize natural progesterone production?

Victoria Felkar [0:44:40]

Progesterone in women is, typically speaking, going to be predominantly produced through the process of ovulation. There is other potential adrenal, but very little. We have to have an incredibly complicated array of systems in place to be able to promote ovulation and thus progesterone production. I put up this model in an event last fall, and people were like, jaws on the floor. I’m like, it is; there’s a lot involved. It’s not just as simple as our hypothalamus sends signals to our pituitary, and our brain sends signals to our ovaries, and we’re done. It’s so much more complicated because we actually have to have sufficient amounts of estradiol. We have to have sufficient amounts of DHEA and testosterone. We have to have sufficient gonadotropins, which are coming from our pituitary and our hypothalamus, so FSH and LH, and they have to be at the right frequency and ratio. All of that container of things has to also have the right amount of everything from mitochondria and how we utilize substrate. It has to be working properly to inflammatory markers, to thyroid function. There’s just such a crazy network of things that have to be in place. Now, the caveat is that not everybody has a sensitive reproductive function. A lot of women, if they have had derailments early on, are going to be more sensitive to subtle changes that can just derail this capacity for ovulation.

Dr. Gabrielle Lyon [0:46:28]

And ovulation, not to interrupt, would be releasing eggs?

Victoria Felkar [0:46:30]

Yes, releasing an egg, exactly.

Dr. Gabrielle Lyon [0:46:32]

For potentially the wing man who is listening, there you go. Now you know.

Victoria Felkar [0:46:39]

Come in and water that garden. There’s a big debate right now around the question of are you born with a set number of eggs, or do you continue to develop them? Do you degrade them, and can you get them back? There’s a big debate going on. But our ovaries contain little tiny follicles, and those follicles are how we create a ton of hormones and biochemicals, not just estrogen and progesterone. We have DHEA, as I mentioned, testosterone and androstenedione. There’s just a lot that goes on. In order for us to be able to ovulate, we have to have all of these  pre-hormones in place. We have to have an egg that’s healthy and responsive. When we do get that mid-cycle spike in luteinizing hormone and that egg is ready and in place, it has the ability to potentially be fertilized. If it doesn’t, then we will make progesterone. The corpus luteum has what the main part of that is that makes progesterone.

With progesterone production though, in order to optimize it, one of the things that I learned from one of my mentors was that progesterone production in women is not only a marker of health, but it also reflects it. Not only is it going to be a marker of somebody’s overall health state, but it’s also going to be able to reflect how their body is functioning. It’s reinforcing it, and it’s giving it. It’s this beautiful serendipity that occurs. With an individual that say they are not ovulating either at all, an anovulatory cycle, or if they are having insufficient levels of progesterone production, whether that be a shortened luteal phase or an egg that maybe just is not robust enough to be able to create as much progesterone as required, one of the things I recommend people doing is just taking that step back and asking, am I healthy? That’s the number one thing, very simple. It’s also being honest with yourself. Are you training more than what your body maybe is used to as an individual? If you maybe weren’t exposed to high levels of physical activity, particularly during that very important puberty place for individuals, if you’re training well over excess, then maybe we do have potential for your body to either need more substrate or recovery or to be able to support it through other ways.

Do you have optimal emotional and psychological coping mechanisms? Do you have any type of issues with sleep? Do you have a nutrient dense diet, including protein? We know that does play a big role in that we have to have the right amount of substrate. It’s like the Goldilocks, not too little, not too much. It’s that sweet spot. That will change over our life course, and what that’s composed of might change too. But we know carbohydrates are so important because they have looked at how low carbohydrate intake can directly impact inability to create an adequate amount of follicular genesis or the creation of steroid hormones from our ovaries. Start there and begin to explore what the potential factors are that may be negatively influencing ovulation to occur. What can we do about them? What makes sense?

A high-performance athlete that say, three weeks before a very big event, are we going to realistically say, yeah, you’re going to be ovulating? No, I’m very pragmatic there. More likely than not, we’re not going to ovulate. The more disruptive your bleed is, or that second half of your menstrual cycle, that premenstrual phases, the more destructive it is, the heavier the bleeding, the cramping, the mood swings, the changes in sleep patterns or digestion, or just overall irritability, that is a very important sign that something is probably off with that ratio of estradiol and progesterone. That gives us a point to go, well, what?

Cramping, we know, can be gravely affected from insufficient progesterone. We know that heavy bleeds can be impacted by insufficient progesterone. Mood disturbances, there’s a sweet spot. The PMS/PMDD literature, it’s evolving rapidly because they finally started to, I think, change the paradigm of progestins are not the same as progesterones, so we got to research it a little bit differently, but those all give us really important clues. For a high-performance athlete, typically what I see, and I know that we’re probably similar in this, is that they will experience disruptive menstrual cycles or none at all. If they’re producing none at all, there’s no bleed, we’re not then just looking at an issue of no progesterone. We’re then typically also looking at an issue of insufficient estradiol and insufficient androgens as well because we’ve got to go back up chain.

Dr. Gabrielle Lyon [0:52:02]

You bring up a really good point. Let’s say an individual is a high-performance athlete, and they’re not making any hormones. We also see that with individuals who are under a lot of stress, very entrepreneurial, people that are really pushing their minds and bodies to the next level. In sport, the question is, can you actually replace testosterone, and estrogen and progesterone? It is very difficult even when you show a clinical need. It has to go through multiple chains. Even at that point, the athlete is always worried about if they were to win a medal or if they were to win an event, are they going to be looked down upon? How do we begin to treat that? Do you have thoughts on initial treatments? I’m sure it’s going to include micronized progesterone. I’m sure it’s going to include estradiol, perhaps even testosterone. What are your thoughts on it? What does the literature indicate is reasonable for treatment?

Victoria Felkar [0:53:12]

Those are all great points, but I always look at who the individual is first, and then also what sport. Has this individual gone through puberty, had regular ovulatory cycles, and then they just go away three weeks before the CrossFit open or something like that, but they were able to maintain it all throughout the rest of the competition season? That individual’s pathway forward might look different for me than somebody who has had chronic menstrual cycle dysfunction, not sure if they’ve ovulated or not, maybe has been off and on hormonal contraceptives. That’s a different pathway that I would take that person. So I try to think of it almost as like I’m a very optimistic person. Typically speaking, if that’s an individual that just loses it three weeks before the open, and that in the past was able to spontaneously get it back, I try to buffer and support to the best of my ability, get them to continue to monitor and to track different variables that are characteristics of  hormonal fluctuations, and we just take it step by step.

I think if we come in too hard too fast with treatment, and we don’t know exactly where that person’s hormonal capacity is, we can actually cause more symptoms, or cause their system just to completely fracture and maybe end up in a more detrimental place than if we just had a more of a hands-off approach and said, hey, this makes sense. Based off of what you’re asking of your body, this makes sense that you may not ovulate for one to even three months around your major competition season. What we have to do though, is make sure that you have the tools in place to promote you to ovulate. We want to try to promote it to the best of our abilities, and then more of that hands off approach.

Now, as somebody who has had this more tumultuous relationship with ovulation, that’s where we do need to, in my opinion, investigate. Are you somebody that’s going to be competing off and on all year round? Or are you somebody that’s got more of a delineated on-season, off-season? That gives us a little bit more room to be able to actually not only figure out what’s going on, but then also be able to find the most optimal route to help elevate and bring back hormone levels, if you’re even able to do that, depending on why we’re not getting them in the first place. I can talk from personal experience, myself included, I had such a crazy first 10 years of my reproductive cycle that my ovaries now are like, hey, we’re not going to function the way that we should classically function. You add in epigenetics and genetics and everything else in there, and that’s okay. I am not broken. I know that is reflective of so many variables, so what I have to do is be able to monitor, control, and modulate to the best of my abilities. It is going to change over time as women’s reproductive functions do, and I am totally okay with that. But obviously, I’m a researcher in this world, so it’s a lot easier for somebody like me to do that.

I think for the average person, that number one thing is that giving somebody bioidentical oral, micronized, progesterone, awesome, beautiful thing to do, if they’re making sufficient amounts of estradiol. If their estradiol is also really low, they can be more symptomatic in terms of feeling more bloated, lethargic, or irritable because we’ve now created an imbalance. I have a lot of women I’ve worked with that feel better on no hormones than having this altered ratio of estrogen and progesterone that’s also non-physiological. So we definitely need to be able to pinpoint what’s going on and how can we really slowly, too add in and titrate up. Basic rule of thumb for me is that the research on transdermal or topical progesterone is very limited that they really don’t still quite understand that if you apply a progesterone cream, is that going to have the same benefits as an oral micronized bioidentical progesterone, drug name is Prometrium? Yes or no, we don’t know yet. Unfortunately, they haven’t done the same research to figure out if it’s just capillary blood or if it’s actually going systemic.

It’s the same thing with vaginal. Vaginal progesterone can be very effective in certain individuals, but we might not get that same beautiful effect for the brain. Progesterone will convert to allopregnanolone, and then down chain into GABA. GABA is a really important neurotransmitter that we need to have sufficient levels of, particularly as a high-performance athlete. With progesterone, we always have to go, and I think this is the same for all drugs, there are different forms. There are different routes of administration, and they don’t act all the same. With progesterone orally, we’re going to have a much different biochemical response in the body than transdermal or with vaginal. So we have to pick the right form for what we are trying to do. We also have to try to pick the right dose for what we are trying to do, and I always suggest to go slow. Go slow, even if you have to try to find it through compounding, go slow. Especially if you’ve never had progesterone production, and you start on 300 milligrams of progesterone, you’re not going to feel good. Your brain is not going to be happy with you. So you do definitely need to be able to be flexible and fluid with your dosing.

Estradiol is such a fascinating one because we know that with estradiol, transdermal routes, whether we’re talking about cream or the patch, are metabolized very differently than oral. We actually have seen in research a lot less risk when used transdermally. That is such a cool thing to actually be able to play with because some of the concerns about estrogen, specifically estradiol replacement around blood clots or liver abnormalities, that you don’t see that when it’s transdermal. The other cool thing about transdermal is that you can definitely titrate and tweak your dosing, which is a really important thing, in my opinion, to do it when we’re trying to get somebody’s body gradually exposed to something that maybe they’re not used to making on their own.

With estradiol, too there’s vaginal forms, and that can be really helpful for individuals. Even younger individuals that have seen never had proper estradiol exposure, to be able to try to create more integrity in not only vaginal tissue and vulvar tissue, but then also within our urinary tract, as that’s really important. There are different forms of vaginal. There are rings and creams. There’s a tiny little pellet that you  actually insert in. There are different types of suppositories. Each of these actually will act different in the body. Some of them are localized, and some of them are systemic. Some of them have a small ratio of systemic, but they’re still systemic. I know this sounds confusing, but it is. Even for somebody who’s been researching it, it is.

There are individuals, clinicians that will prescribe other forms of bioidentical estrogens, such as a estriol or even an estrogen like a tri-blend. The research is not quite there on those yet. They’ve  said, hey, there’s a lot of different forms. Let’s just focus on some. With female athletes, they’ve been looking at the combination of transdermal patch and cyclical micronized oral progesterone. They’ve seen amazing changes with bone and the actual micro architecture of bone. They’ve seen amazing changes for eating disorders and  attitudes towards bodies and food. They’ve seen changes also for just overall well-being in amenorrhea patients. But these have not been explored within your non-amenorrhea patient that just has hypohormonal levels.

When we go into the testosterone, androgens, DHA realm, not trying to get on my soapbox, but there’s a lot there within sport. As I mentioned at the beginning of the conversation, it’s because of how we’ve labeled drugs. We’ve labeled some steroids as being good and some steroids as being bad. This not only means for the body, aka, a synthetic estrogen and progesterone is, big air quotes here, good for the body, but as synthetic androgen is bad for the body. Even though when you look at their risk properties or their potential, what I call, unintended effects, because I think side effects is a little bit of an overrated term, and if you know you’re taking a certain compound, it’s going to have certain potential outcomes. But if you look at the unintended effects, what you see is that there are very similar things between an oral estrogen progesterone and an oral androgen. Lipid changes, you see similarities. Changes to liver function, similarities. Changes to certain type of brain and neuro chemicals, similarities. So when we actually look at what that compound is and we take away sex, and we take away the names and where they’ve come from and whose bodies they’re apparently supposed to belong to, we actually see these very similar profiles. But unfortunately, the powers that be within sport have labeled estrogens and progesterones as being okay, justified for use in sport, and androgens as not just.

As you mentioned, it is very hard to get a therapeutic use exemption. In all of my years doing this even working with doping control, I cannot tell you how many cases have been denied, and it’s insane. I’ve even seen individuals that have had hysterectomies getting an NNO-ectomy getting denied, which is just mind blowing, but it’s because we don’t associate androgens and testosterone with having a clinical need in the female reproductive body, which is such farce. There is so much science that says that’s not true. Yet, that’s the sporting powers. If you want to play in their game, you have to play by their rules, unfortunately, even if their rules are unethical and not based on solid science. That’s the super sad reality of the sporting world. I hope one day it’s going to change, but I can’t say that it is because I think we’ve actually headed in the opposite direction.

DHEA as an androgen, that’s produced both in the adrenals, ovaries, and fat cells, among other places, it has been under a tumultuous relationship. It’s been on the banned list. It’s been off. It’s been on for women, but only in certain circumstances. Now it’s off again. When you look at the science, I did a systematic review on the use of androgens in women and looked at a couple of the cases that were used by doping authorities for banning it, it was mind blowing. They use this one case of a young tennis player that had an adrenal virilizing tumor, to be able to say what the side effects of DHEA were, that’s not good science. That is terrible science. Unfortunately, that’s what was used and what gets used to either justify the use of a drug or ban and prohibit the use of a drug. It’s sad. It’s really sad because I wish there was a way that we could say for women that hey, if your testosterone deficient, here’s a pathway that you can take that will not create any noise with the powers that be. Unfortunately, there really isn’t. The testing is not a science in my opinion. You can take certain forms of hormonal contraceptives, and they will flag positive for certain androgens because that’s the crazy science of it all that the chemistry, the actual backbone of the molecules looks so similar to certain anabolic androgenic steroids that are banned, that they just get unambiguously put into that pile of hey, you’ve doped even though you’re not on a drug. Then you’ve got to fight it, and it’s ugly. It’s gross.

There are even natural metabolites that are very controversial, like nandrolone. I did a huge study on nandrolone that is all about the fact that here’s a compound that when drug testing got introduced, they did not realize that humans have nandrolone metabolites. So depending on when the person is tested, and their own individual environment, you may have higher or lower levels of it. But in 1976, they didn’t know that. In 1982, they didn’t know that. So there’s countless athletes that were getting banned for having natural nandrolone because the drug testing people said that it was, you must have doped. It was a prohibited substance. Over time now, they’ve increased the range that you’re allowed to have the upper limit. For women, it is a higher upper limit than men, and that you do see this almost linear increase as they start to learn more. But for example, if you’re an individual that has just normal natural, higher levels of nandrolone excretion, and that you also are getting tested right after you did an outdoor track session, and you’re dehydrated, and your pee is going to be really saturated, and you’re also in that post ovulatory phase, you will maybe potentially be on that higher end of what you’re allowed, if not sometimes over. Then it’s up to you. The burden of proof is on you to show, and that is just horrendous. It’s absolutely horrendous. It’s mind blowing.

To me, again, it’s like one of those things that this is stranger than what we should ever be allowed to accept. They’ve now also regulated the use of certain gonadotropins. Tamoxifen, for example, even fertility treatments, there’s a lot of restrictions around that. There are other types of compounds that clinically are used in medicine, but within the world of sport, they are not allowed.

Dr. Gabrielle Lyon [1:07:44]

What would be an example?

Victoria Felkar [1:07:45]

For example, different types of glucocorticoids and corticosteroids that would get used for treating injuries that you cannot use within sport even with therapeutic exemptions, or certain bronchodilators for asthma patients, certain types of ephedrine, pseudoephedrine, that’s a great one that a lot of people know about from just stimulants, and testosterone. If you have a clinical need, it is so hard to get it. But that is a drug that gets used in medicine. It is a drug that gets used a lot. Then, there are drugs that are allowed, that I shake my head and go, why? If I use that really easy, tangible example of my own research, why have pharmaceutical estrogens and progesterones received zero attention within the at least 21st century from anti-doping authorities? I’m not saying that they should be banned. But within sport, when a drug has attention brought to it, conversation exists. I know you had Rick Collins on back at the beginning.

Dr. Gabrielle Lyon [1:08:51]

I was just thinking of that when we’re having this conversation. For you guys who don’t know Rick Collins, he is a world leading expert in steroid use. He is the most knowledgeable lawyer that I know, really incredible. We had a whole conversation on exactly what you are talking about from more of a male perspective.

Victoria Felkar [1:09:14]

What he’s really talked about is that overstating of risk and that overstating of potential side effects, that the sporting literature has overstated it, and that has actually directly affected the medical perception of it. People always say to me, why are you studying sport? I’m like, if you only you knew that there is such a crazy relationship between what happens in the military, what happens in sport, and that those two vessels have a massive impact on our scientific production of knowledge and our medical and our pharmaceutical. There is this crazy relationship there. Even if you just look at some of the research that has been done on androgens and who’s doing it. There’s been some newer research by the British military on contraceptives and the use of certain forms for different levels of fatigue and things like that. They’re the people that have the money to do the research and fund the research because academia is not it. But that there is a huge relationship between what’s happening in sport, and it’s not just one way. It’s definitely bi-directional. There are individuals that are sitting on certain types of committees that will maybe allow or not allow a drug in place, and that they may not be the world’s leading expert on it. They might not be even doing research on that, yet they’re the ones that get to, unfortunately, make the decisions.

A great example is hyperandrogenism in female sport. If people aren’t aware of it, it started in about the 2010 to 2011, 2012, 2013, 2014  realm. There was a rule introduced that essentially was going to try to put an upper limit on a female’s natural levels of testosterone. That was an upper limit cap, and they essentially said, if you have more than this, you will need to do something to drop it down. It’s a human rights issue at this point. I have colleagues that have been pushing it as a human rights issue because that does not exist within medicine. This was a role that was introduced explicitly for sport. It’s not anything new. My research has shown that even the ideas around menstruation, sex testing in sport, these things are only being given to the female body. They’re only things that women are having to go through in order to enter in to do a sport, literally a game. It is so sad because what they were recommending was the use of a hormonal contraceptive, but specifically, a strong anti-androgen. My argument was always that not all androgens are fun and games. The female body, there are many different forms. there are some forms that might help depending on where they bind with muscle and performance and everything else. But then there’s also the ones that are going to just make you fat, hairy, and tired.

It was very terrible research. It was self-funded research, too. It was not done by an independent body. It was funded by the sporting powers that be. Luckily, there are a lot of really amazing academics and legal that have been pushing back against it and trying to suppress it. But there are some women that have still been forced to do it. That is so sad because there really is no scientific proof that this has to exist. There’s no scientific proof supporting that testosterone is doing what they claim in any body, male or female. And yet, this goes back to those ideas around what these hormones are, these so-called sex hormones, and whose bodies do they belong in, and what drugs we consider to be good or bad, right or wrong, ethical or not, and that within sport, it creates this microcosm that then reflects it into society. We see that in everyday life right now with all the attitudes around hormone therapies and testosterone and menstrual cycle and all this stuff. It all works together.

Dr. Gabrielle Lyon [1:13:19]

Yeah, and what is so fascinating is we typically turn our attention to sport and military personnel for being early adopters. Everything else that they are doing, whether it’s nutrition, whether it’s supplementation, whether it’s EMS stim suits, whatever it is, they are considered early adopters. With that, it becomes very interesting that when we think about optimal performance, and we are not even talking about super physiological treatment. We are simply talking about again, in this conversation, we talked about oral contraceptives. We talked about the replacement of low levels of estrogen or anovulatory cycles with extra estradiol patches, estrogen patches, depending, oral micronized, progesterone. Testosterone, we didn’t really talk about the delivery, but I’m going to assume it’s a subcutaneous shot typically. That’s what we use in the clinic, whether it’s subcutaneous or topical. The restrictions on sport do lend and have unintended consequences of what we think about optimal health, what providers consider to be okay. I see lab work come across my desk all the time and a testosterone level of 300 is perfectly acceptable for a guy or a pre-testosterone of a woman with a normal range of 0.9, and they’re okay with it. Changing the conversation and really thinking about what optimal health is, which is exactly what you’re doing, is critical. Understanding the history, you blending the humanitarian aspect with the science aspect is incredible. You and I, we could easily talk for another hour, if you’d like to.

Victoria Felkar [1:15:18]

I sure can, if you want me to. I’m more than happy to.

Dr. Gabrielle Lyon [1:15:22]

When we think about other ways, I do want to circle back in terms of other ways that we can leverage treatment or let’s say we have an individual who is not necessarily an aggressive athlete, but an individual who goes through an anovulatory cycles and/or heavy bleeding and is doing that. Let’s say she’s not even an athlete. She’s a life athlete, meaning she’s an entrepreneur or something like that. Where does other ways of contraception come into play, like the Mirena or a copper IUD? I’m just curious because I know that we’re going to get those questions.

 Victoria Felkar [1:16:07]

There are lots of forms of hormonal contraceptives that we didn’t talk about. The pill is just one of a whole giant array. If we’re talking hormonal, there are patches now. There are implants. There are the actual hormonal IUD-based as well as the vaginal ring. I think there’s a new sublingual one. There’s just lots of different routes of administration. With extra estradiol and progesterone, these do have different ways in which they interact within the systemic body, and then also locally as well on the actual reproductive complex. That depends on, for me personally, thinking about where was that individual before they started on or did some of these different forms, and I’ll use the idea of a Mirena IUD.

The copper IUD is a non-hormonal form. I have to say the research on the copper IUD is very much lacking. It’s an older method. It’s been around, but it definitely is quite lacking in terms of how does this impact the physiological makeup of an individual other than what we know is that it creates acute inflammation, and that in certain individuals, that acute inflammation can have more of a detrimental impact on their overall ability to maintain a healthy ovulatory menstrual cycle. One of the big things you see with the copper IUD is heavier bleeding, and that has a direct relationship to that acute inflammation that it’s creating. It’s literally the way that I explain that is that it’s like creating a defensive mechanism via inflammation. That is its defense. Well, that’s its little army that it’s creating to stop sperm from doing their job. So typically, the copper IUD is not used for non-reproductive purposes, unlike the other forms that will get used for non-reproductive purposes or non-contraceptive purposes.

The Mirena is quite interesting, because with the Mirena, it’s definitely increased in popularity in the last decade or so in particular. You see this change within the rates of use, not only in the UK and parts of Europe, Australia, Canada and the US, where you do see a shift in oral contraceptive transforming into the Mirena. One of the things that is great about the Mirena is that it is providing local hormones. It’s providing a localized progestins, not progesterone itself, and that can be quite stabilizing for the endometrium, which means that if you are somebody that experiences heavier bleed patterns, that can help to reduce your bleed patterns. However, what research has also shown, and this is actually done by the powers at Mirena itself, you just have to go crawling through their archives, you’d find it, is that it doesn’t do it in everybody equally. The way it actually influences somebody’s menstrual bleed varies dramatically whether it’s their first IUD, so is this the first time the Mirena has been implanted, or is this maybe a repeat, unless you’re on your second or third IUD? You’re going to have very different experiences if it’s at the beginning of implant or if it’s further to the end of implant. The thing about the Mirena IUD, like different types of other subcutaneous implants is that it’s a reservoir. What that means is that the hormones are getting provided to the body almost like a drip method, little by little by little. The longer you have it in, the less hormones that will eventually get taken from that reservoir. So you see with the Mirena, for example, within that first one to five years, that’s when they recommend to implant it for one to five years depending on the strength of it, but typically it’s one to five, and then they say that do not rely on it for contraceptive for year six and seven, because they cannot provide enough insight to say whether or not that the hormones being dripped from the reservoir are going to be sufficient to actually support not allowing contraceptive to occur.

The first few years of a Mirena, they have shown though, and this is again Mirena themselves, as I was saying this, that you are more likely to experience potentially, anovulatory menstrual cycles. That’s because there is a stronger effect of the hormones that are getting dripped out of that reservoir. Now in an individual that has a really healthy and robust each, hypothalamus-pituitary-ovarian axis, that might not cause the same amount of upset as somebody who doesn’t have a healthy ovulatory menstrual cycle. It really is going to be dependent on what was the state when we implanted it. Also some of the metabolic changes that you see, what was the state of their metabolism and their overall substrate utilization when that was implanted. It definitely is going to be based on that individual as to how you respond to it. With the Mirena IUD, one of the things that they do promote is that you can still ovulate. But even the company has now said like, well, maybe not in the first little bit, but then probably yes, you can maybe in some people.

Let’s say somebody has been diagnosed with polycystic ovarian syndrome, hyperandrogenism, and hyperinsulinemia. So that would be where we would see that at very high elevation of chronically high LH levels, with more of a moderate to low, in ratio respective though, FSH. You’re seeing chronic anovulatory menstrual cycles, possibly high levels of testosterone and DHA, impossibly high levels of total estrogen, estradiol, estrone as a result of that chronically high androgens as well. In an individual like that, if you put a Mirena in place, it’s going to definitely stop them from having a heavy, chaotic menstrual bleed because it’s providing a progesterone to stabilize the endometrium. But that’s what it’s doing. It’s not going to help you recover your hypothalamic-pituitary-ovarian axis. That’s not what it’s going to do. It’s just going to provide almost a symptom relief for one of the outcomes that you’re experiencing. That’s for me, where we do need to expand on that conversation of okay, it’s really important to provide symptom relief.

I am all about helping people get through day to day. But I also want us to think a bit more expanded and go, okay, is there other things that we could be doing that may be more optimal, not only for short term, but long term as well? If somebody’s experiencing these crazy chaotic bleed patterns because they’re having unopposed estradiol in their endometrium, why? Okay, let’s see, anovulation. Okay, cool. Could we get potential benefit then from doing something like a cyclical oral bioidentical progesterone level? We also know that can have positive implications, that progesterone for helping with that altered FSH and LH ratio, and that can actually help to get LH back in check after a while. Maybe that individual also needs something like an Aldactone or spironolactone to help as an anti-androgen, potentially.

But I also think we can’t look at that as being this end-all be-all cure either because there are implications of that as well. What else could we do? Metformin, for example, or a GLP-1 agonists, those are ways that we can actually help with more of that metabolic side of why are they experiencing this heavy chaotically to begin with. From a micronutrient, from a lifestyle intervention, there’s so many other interventions that I think we have to also look to that because of hormonal contraceptive, hormonal estrogen and progesterone, the synthetic revolution, we’ve failed to recognize. You go back in the medical history books from 1920s, 1930s, even before that, they were recommending that for menstrual dysfunction or irregularity, to eat a good diet. They were recommending for supporting your sleep and checking in on your mental health. Those were things that were listed as things you need to be doing. Then that advent of hormones led us in this total opposite direction that we’re getting lost in today. People will use these drugs, and they won’t actually have optimal health. They will mask symptoms that are reflecting this poor overall state. But because they’ve masked the symptoms, they go, I’m healthy, I’m good, I’m great. But then eventually, the towers can crumble because they can’t sustain that for a long period of time.

Dr. Gabrielle Lyon [1:25:01]

I think that is so important to highlight. Ultimately, what you’re saying is how do we leverage the body to be able to maintain lifelong vitality without a whole bunch of other additives? I don’t mean necessarily food. I mean oral contraceptives or even addressing, like you said, PCOS. What are the things that we can do, rather than masking symptoms, really getting to the underlying cause, even if at the underlying cause, if we do have to address insulin resistance or metabolic dysfunction for a short period of time, are we using a Metformin or a GLP-1 agonist?

Victoria Felkar, thank you so much. You’re brilliant, a wonderful interview. I know that we’re going to have a ton of questions. I’m going to include all the links on where to find you. I’m so hoping that you will come back to talk more about your research. We didn’t even get to be able to talk about a portion of what I wanted to talk about. You guys consider this an intro course to the mind of Victoria. We will do another episode. What I’d love is if you guys would submit questions. I know that this is going to be a very popular episode and we will have her back to walk through questions and perhaps we’ll even do a case study. Maybe we’ll even do one together, Victoria. Thank you so much.


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