Recap: Menstruation - what everyone needs to know | Jen Gunter & Sarah Berry

Summary

ZOE Science & Nutrition Podcast Summary

Episode Title: Recap: Menstruation - What Everyone Needs to Know | Jen Gunter & Sarah Berry
Release Date: March 4, 2025
Host: Jonathan Wolf

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Introduction

In this insightful episode of ZOE Science & Nutrition, host Jonathan Wolf delves into the often-taboo topic of menstruation, aiming to demystify common misconceptions and provide practical advice for managing menstrual health. Joined by esteemed guests, Professor Sarah Berry and Dr. Jen Gunter, the discussion sheds light on heavy periods, iron deficiency, menstrual pain, and the role of hormonal contraception.

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Understanding Heavy Menstruation

Dr. Jen Gunter opens the conversation by defining the signs of heavy menstrual bleeding. She emphasizes that soaking through menstrual products onto clothing or needing to change pads or tampons every one to two hours are indicators that one should consult a healthcare provider (00:46).

Notable Quote:

"If you have to soak through your menstrual products or change them every one to two hours, those are signs that you should probably see your doctor and be investigated."
— Dr. Jen Gunter [00:46]

Dr. Gunter highlights the critical link between heavy periods and iron deficiency, noting that approximately 40% of women under 22 in the United States are iron deficient (01:29). Professor Sarah Berry confirms that similar statistics are observed in the UK (01:31).

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Iron Deficiency Among Young Women

The prevalence of iron deficiency among young menstruators is alarming. Dr. Gunter clarifies that iron deficiency can exist without anemia, a condition often overlooked because normal blood counts may mask low iron stores (01:36).

Notable Quote:

"Iron deficiency itself is a medical condition with consequences, even if you don't have anemia."
— Dr. Jen Gunter [01:36]

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Menstrual Blood Loss: Debunking Misconceptions

Professor Berry seeks to quantify menstrual blood loss, to which Dr. Gunter responds that, on average, a menstrual period involves about 80 milliliters of blood loss (02:02). However, she points out that the actual perceived flow might be higher due to cervical and vaginal discharge, as well as the shedding of the uterine lining (decidua) (02:07).

Notable Quote:

"The actual blood lost is about 80 milliliters, but when you account for discharge and other factors, it might seem like more."
— Dr. Jen Gunter [02:07]

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Challenging the "Normalcy" of Painful Periods

A significant portion of the discussion centers on the misconception that menstrual pain and heavy bleeding are normal and should be endured. Dr. Gunter argues against this notion, stressing that severe pain and heavy bleeding warrant medical attention (03:11).

Notable Quote:

"Having heavy bleeding is not something people should just suck up or suffer through. It's critical to get it treated."
— Dr. Jen Gunter [03:11]

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Physiological Causes of Menstrual Pain

Dr. Gunter explains that menstrual pain arises from uterine contractions necessary to shed the uterine lining and control bleeding. These contractions can be intense, likened to the pressure experienced during the second stage of labor (04:31).

Notable Quote:

"The intensity of the pressure can be the same as in the second stage of labor, which is when you're pushing."
— Dr. Jen Gunter [04:31]

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Managing Menstrual Pain Effectively

The conversation shifts to managing menstrual pain, where Dr. Gunter outlines several effective strategies:

1. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Medications like ibuprofen and naproxen can significantly reduce menstrual cramps, especially if started a day before the period begins (06:12).

2. Hormonal Contraception: Options such as hormonal IUDs, birth control pills, Nexplanon implants, and Depo Provera injections not only prevent ovulation but also thin the uterine lining, resulting in less cramping and lighter periods (06:15).

Notable Quote:

"Starting NSAIDs a day before your period can be very effective at reducing menstrual cramps."
— Dr. Jen Gunter [06:12]

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Hormonal Contraception: Safety and Benefits for Young People

Addressing concerns about the safety of hormonal contraception for teenagers, Dr. Gunter asserts that these methods are generally safe and beneficial. She counters the negative perceptions fueled by social media, emphasizing the importance of treating severe menstrual pain to prevent long-term health consequences (07:57).

Notable Quote:

"Untreated painful periods can prime the nervous system to heighten the pain experience, making individuals more susceptible to other pain conditions."
— Dr. Jen Gunter [07:57]

Dr. Gunter acknowledges conflicting data regarding hormonal contraception and depression but maintains that the benefits of managing severe menstrual symptoms outweigh potential risks (07:57).

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Addressing Iron Deficiency: Practical Advice

As the discussion winds down, Dr. Gunter offers actionable advice for those experiencing symptoms of iron deficiency, such as fatigue and hair loss. She recommends:

• Blood Tests: Beyond a standard blood count, individuals should have their ferritin levels checked to assess iron stores accurately (11:21).

• Iron Supplementation: If oral iron supplements are ineffective, intravenous iron is a safe alternative (11:21).

• Investigating Underlying Causes: Persistent heavy periods may necessitate further medical evaluation to identify conditions like endometriosis (11:21).

Notable Quote:

"If your ferritin level is low, it needs treatment, and if oral iron isn't working, intravenous iron is a safe option."
— Dr. Jen Gunter [11:21]

Professor Berry adds that taking iron supplements every other day may enhance absorption due to the body's regulatory mechanisms, a recent finding that optimizes supplementation effectiveness (12:54).

Notable Quote:

"Taking iron supplements every other day can prevent the body from blocking absorption, making the supplements more effective."
— Professor Sarah Berry [12:54]

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Conclusion

This episode of ZOE Science & Nutrition successfully breaks the silence surrounding menstruation, providing listeners with a comprehensive understanding of menstrual health. By addressing heavy periods, iron deficiency, menstrual pain, and the role of hormonal contraception, Dr. Jen Gunter and Professor Sarah Berry offer valuable insights and practical solutions to improve menstrual health and overall well-being.

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For continued insights and to embark on your health journey with ZOE, consider exploring their membership offerings and following ZOE Science & Nutrition on your preferred podcast platform.

Transcript

[Zoe]

Hello and welcome to Zoe Recap, where each week we find the best bits from one of our podcast episodes to help you improve your health. Today, we're tackling menstruation. Despite affecting half the world's population for a significant part of their lives, menstruation remains clouded by taboo. This lack of open conversation can leave women without the knowledge they need to address pain, discomfort or irregularities associated with their period. So what sign should raise concerns when it comes to menstruation? And how can we manage symptoms effectively? I'm joined by Professor Sarah Berry and Dr. Jen Gunter to break the silence around menstruation. Jen starts by outlining the signs of a heavy period.

[Dr. Jen Gunter]

If you are soaking through your menstrual products onto your clothes, if you're having to change pads or tampons every one to two hours for, you know, more than just kind of once. So if you have to do that or if when you stand up, you have a feeling of gushing sometimes. So all of those things can be signs of heavy periods. Sometimes they're not, but you don't know. But those would be all the signs that would say, you know, you should probably see your doctor and be investigated. And the reason this is so critical is if you look at the incidence of iron deficiency, it is very high amongst young women. And in the United States, the study I'm referencing is from the us, so I don't know if the data is the same in other countries. 40% of women ages 22 and younger are iron deficient.

[Professor Sarah Berry]

A similar prevalence in the UK.

[Zoe]

40% under 22, do you say are iron deficient? That's extraordinary.

[Dr. Jen Gunter]

It is, and it's often dismissed because people can have iron deficiency and not have anemia. And often people are told if they don't have anemia, they don't need to worry about it. But that is incorrect. And iron deficiency itself is a medical condition with consequences.

[Professor Sarah Berry]

So how many mils on average? As a scientist, I always like data. How many mils on average would a person that's menstruating lose during a menstrual period?

[Dr. Jen Gunter]

So it's about 80 milliliters, which doesn't seem that much.

[Professor Sarah Berry]

Wow. It doesn't.

[Dr. Jen Gunter]

But there's also cervical discharge and vaginal discharge and so the amount that comes out may actually be larger. There's also the decidua, which is kind of the lining, which isn't counted in that. So the actual blood comes from tests where they do, you know, radio labeled stuff and to see, you know, how much blood has Been lost. So the actual blood itself is 80ml, but it may seem like more than that.

[Professor Sarah Berry]

Okay, so you might have double the amount actually coming out, but it's mixed with, you know, other fluids.

[Dr. Jen Gunter]

And so all the studies that look at the actual volume of blood, they're not, they're either weighing pads or they're actually doing these sort of radio labeled blood samples to try and figure out, like, how much has, you know, been lost. And so we say 80 milliliters, understanding that for some people that might look, it might may be more than that based on the amount of discharge and, you know, other things that are going on.

[Zoe]

So, Jen, having explained that really well and thank you, and I've already learned a lot and it sounds like Sarah's learned something as well already. What's the biggest misconception that you find people have about menstruation?

[Dr. Jen Gunter]

One is that having heavy bleeding is normal. You know, it's something that people should just suck up or suffer. And again, we have this sort of epidemic of iron deficiency amongst, you know, young people, which is, you know, really not acceptable. You know, I think that if you have a lot of pain, that that's normal and you should suck it up. And, you know, there's sort of this dichotomy of either people saying, oh, women are able to tolerate more pain, or they're complainers. Like, you know, it's sort of like I always say, being a woman is like walking on the edge of a knife. You're either too much in one or too much in the other. Right. You know exactly what I mean. So there's that. And so people who have terribly painful periods get untreated and they don't get investigated.

[Zoe]

So lots of pain is not just normal for everyone to have to experience?

[Dr. Jen Gunter]

Well, I always tell people that if the pain is interfering with your activities of daily living, then it should be evaluated. You know, I think that, you know, there are some people who have minimal cramping and don't have much, and there's other people who are at the other end of the spectrum and there's people everywhere in between. And unfortunately, pain is a byproduct of menstruation. That's how, you know, it takes uterine contractions to get the blood out. It takes uterine contractions to stop the bleeding. And so that is part of it. But for some people it can be very painful.

[Zoe]

And Jen, just to understand that, actually, I just want to make sure is that what is causing the pain around the time of your period?

[Dr. Jen Gunter]

So yeah. So the uterine contractions are a big part of it. They can be quite intense. As we sort of talked about in the rapid fire, the intensity of the pressure can be the same as in the second stage of labor, which is when you're pushing, you know, you're talking 120 millimeters of mercury. It's a lot of pressure. Like, you know, when you blow up a blood pressure cuff, you're blowing it up more than 120 millimeters of mercury sort of for that, you know, and that's quite uncomfortable. Right. When you're getting your blood pressure checked and then it goes down, you're like, okay, that's better.

[Zoe]

And this is. Why is your body doing this?

[Dr. Jen Gunter]

Well, one, to get the lining of the uterus out. So the contractions help move things along also to squeeze blood vessels. Right. So, you know, when you're bleeding, you put pressure on something, so it's actually applying pressure.

[Zoe]

So your body is both. It's a bit like you're saying there, this is a little bit like delivering a baby. Like it's squeezing this out. Yeah, it's pushing things out and then it's compressed. It's doing its own sort of tourniquet on the inside.

[Dr. Jen Gunter]

Exactly.

[Zoe]

To shut down the bleeding.

[Dr. Jen Gunter]

Yeah. And then that reduces blood flow to the uterus. So there also is probably pain related to ischemia or low blood flow. Prostaglandins, which are released, which are hormones that are sort of produced locally at the site of injury or inflammation, those cause pain. And so there's, you know, other inflammatory chemicals that are also probably contributing as well. And some people who have more pain, you know, they may have stronger contractions, they may have uncoordinated contractions. So that might be more painful and, you know, or they may have heavier bleeding and that can be part of it. Or they could have a medical condition that's, you know, contributing to pain, like endometriosis. There are people who have, you know, very minimal cramps and like, yeah, it's a nuisance, but, you know, but I can deal with it. And there's people who are, you know, really debilitated.

[Professor Sarah Berry]

So you said some people have them as strong as if you're actually having birth contractions.

[Dr. Jen Gunter]

Yeah.

[Professor Sarah Berry]

What can we do to counterbalance that?

[Dr. Jen Gunter]

So ibuprofen, non steroidal anti inflammatory drugs, naproxen, and even starting them a day before, like if you have an idea when your period is gonna start. So they can be very effective at reducing menstrual cramps. I think it's important to point out that if those don't work, it could be because you have something else going on, like endometriosis, which is a condition where tissue very similar to the lining of the uterus is growing outside in the pelvic cavity. But also I think it's about 10% of people that these drugs just don't work for them. So it's just kind of, they don't help. Then all of the hormonal methods of birth control can be very effective. And so a hormonal iud, the birth control pill, the nexplanon implants, the Depo Provera injection, those are all very effective ways and they work by one the implant, the injection and the pills work because they stop ovulation, but also there's a hormone in them called progestin, which is a synthetic form of progesterone. And progestin keeps the lining of the uterus very, very thin. So when there's less lining to come out, there tends to also be less cramping. And you can take these medications every single day, so you don't even get a period. So that's also an advantage.

[Professor Sarah Berry]

Yeah. And it's interesting cause the hot topics amongst many of my friends who are in their late 40s is either menopause or thinking about their children who are having quite extreme symptoms, some of them. And something I know they would be desperate for me to ask you while you're talking about this, is is it safe from a young age for someone who's 14, 15, 16 to go onto some of these contraceptive pills in order to alleviate these symptoms, these kind of cramps?

[Dr. Jen Gunter]

Yeah. So we do think it is safe. And I think that unfortunately hormonal contraception gets a very bad rap on social media because fear sells. And if you think about the risk to you medically of having untreated painful periods, so people just think about, oh well, you're missing school. But we know that people who have very severe period pain are more likely to develop other pain conditions in their life. And that we think that early exposure to severe pain can prime the nervous system in a way to actually heighten the pain experience, meaning it makes you more likely to develop other pain conditions. So could we be setting somebody up for more likely getting migraines later in life? Could we be setting them up for other medical conditions by under treating their pain? Nevermind, if they have to miss two days of school cycle, then that could affect their academic performance, which could affect getting into the university they want to go could affect their job performance, it could affect their career. So it's really important for people to think about this. Not just as well it hurts, but which is important itself to treat because people deserve to have their pain treated. But what are the ramifications of untreated pain? Right, so then you think about it from that standpoint, that the birth control pill, the iud, the nexplan, they would all be a net positive. And so. So, yeah, so we think that they're very safe to be on. There is some conflicting data on the risk of depression related to starting hormonal contraception, and the data is very conflicting. And there are some studies that show that there could be an association for some people and some studies that show that it isn't. If we say maybe it could be, if we err on that side of caution, then the incidence of depression associated with the pill for teenagers might be 1 in 200, but that's not certain. It absolutely could be less than that. And I think one of the problems with the data is so people start the birth control pill because of something they don't. Just like, I'm totally fine and I don't have a new partner and I'm just going to go on the pill because so teens can be in domestic violence situations, right? So starting the pill could. That could be part of that. They could be in a relationship that's having an impact. They could be starting the pill because they have pms, which is associated with mood disturbances, and maybe they actually have depression and not pms, and it's been misdiagnosed, so they're not getting their depression treated. Polycystic ovarian syndrome, which is a reason many people go on the pill, is associated with a higher risk of depression and suicide. So it's very difficult to study. It's an active area of research. But I think that people always have to look at the reason you're going on, and there is a massive impact of untreated pain. And, you know, the idea then. So then what are we supposed to do? Just let kids curl up in the corner and like, you know that that's not a solution.

[Zoe]

Jen, we're, we're running short of time, but I do want to pick up on this comment that you talked about earlier about the iron deficiency, because you described something like 40 of girls under 22, which sounds huge.

[Dr. Jen Gunter]

It is, yeah.

[Zoe]

And I've also, I've got Sarah as well. So both of you here, I really want to make sure we follow up. That sounds like very actionable advice like, what can you do about this?

[Dr. Jen Gunter]

Yeah. So if you are someone who menstruates and you have symptoms like fatigue, brain fog, hair loss, you just don't feel right, you need, you know, and you get a period. So if you're somebody who hasn't had a period for five years because you've gone on a hormonal iud, then, you know, you could have iron deficiency for another reason. But most of the younger ones are related to menstrual. You need to not just get a blood count to check for anemia, you need to also get a ferritin level because a ferritin is a reflection of the iron stores in their body because you don't want to be brushed off. You can have a, you can have a normal blood count and not have anemia and still have severe iron deficiency. I, I diagnose that maybe every single day in my practice because iron deficiency is associated with a lot of other symptoms. So I'm often testing people because of those other symptoms. And the number of women that I identify every week, you know, who have iron deficiency is pretty staggering, which fits with the, with the data that we see. And so, so I think people need to get their ferritin level checked. And if their ferritin level is low, they shouldn't accept that that's normal, that that's okay. It needs treatment. And if oral iron's not working, then there's intravenous iron, which is actually really very, very safe. Intravenous iron now. And also the reason for the iron deficiency needs to be investigated. So someone needs to ask you about your periods and if you're soaking pads of these things because there's treatment for heavy periods as well. And their investigations may need to happen too.

[Professor Sarah Berry]

You talked about oral supplements of iron, and there's some fascinating research coming out now to show the benefits of, if you are taking iron supplements, of having them every other day. There's a particular chemical increases when you have an iron supplement that actually prevents you absorbing too much of the iron. Because again, our body's really clever mechanisms to make sure we don't iron overload. And so actually, if you can miss out a day means that you'll then absorb it, you know, 48 hours later. Yet if you're having it every day, this particular chemical that stops the absorption is at its peak and then blocks the absorption.

[Zoe]

That's it for today's recap. If you want to continue your health journey with Zoe, why not try our membership? Zoe is your daily coach to better health for life. Click the link in the show notes to get started today. And don't forget to follow Zoe Science and Nutrition in your favorite podcast player so you never miss an episode. See you next time.