Dr Rupy: If you had a higher fruit intake, in particular, so fruit more than vegetable, you actually had a decreased risk of developing endometriosis. And this study to me is so important because I think that we've become quite scared of eating fruit. Welcome to the Doctor's Kitchen podcast with me, Dr Rupy. Today we're going to be talking with one of my favorite for the podcast, Anita Mitra, who's a gynaecologist, a lifestyle medicine advocate. She also has her own book out now. It's called The Gynie Geek, Your No-Nonsense Guide to Down There Healthcare. It's absolutely fantastic. It's actually a collection of patient anecdotes, questions that she often gets asked in clinic. Essentially, Anita is the gynaecologist, the women's health specialist that everyone wishes they had. She is just incredible and you'll know from the previous podcast where we've talked about polyphenols and yoga and all these different sorts of lifestyle features that are really important for well-being, she is an absolute wealth of information. In today's episode, we're going to be talking about what endometriosis actually is, why you should avoid things like colonic irrigation. I can't believe people are still having that. The importance of drinking water, eating fibre and why pooing properly actually has a very important place when it comes to women's health. The importance of estrogen and what estrogen does in your body and what can happen if we have estrogen dominance, exercise, fruit and why fruit actually has a bad reputation when actually it's one of the best things you can do to put into your diet and why we shouldn't be neglecting it. You're going to love this episode. Let's get into it. Anita, welcome back to the show.
Anita Mitra: Hi, thanks for having me for the hat trick.
Dr Rupy: The hat trick, I know. You're the first person to complete the hat trick.
Anita Mitra: I know. It's like the Doctor's Kitchen challenge. Kaching.
Dr Rupy: Yeah, and you're looking very bright and sprightly today.
Anita Mitra: Thank you.
Dr Rupy: Do you want to explain why?
Anita Mitra: Yeah, well, so, if you haven't listened to our last podcast, it was about PCOS and eating for PCOS. And I had a really, really nice message from a lovely girl at Bobby Brown called Zara who kindly offered to do my makeup. So I took her up on the offer and I think she's really nailed it. So…
Dr Rupy: Hey Zara. She has nailed it. You look very nice. Not to say you don't look nice all the time, but extra.
Anita Mitra: She had her work cut out this morning. Let's just say that. I was quite tired and I've had teaspoons on my eyelids this morning.
Dr Rupy: And what, why have you got the makeup done today? Because you've got some exciting stuff that you're doing.
Anita Mitra: Yeah, so I'm shooting some video content this afternoon for my book. So that's pretty exciting. So lots of things going on in the Gynie Geek world.
Dr Rupy: I'm so, so excited. Yeah. The way I describe you is the women's health doctor that every woman wished that she had. That's literally how I, and that's the feedback that I get. It's not me actually, it's not me saying that. It's a lot of people like, oh, I wish she was my doctor, etc. So your patients are very lucky, but everyone can get access to you because we're going to be talking about lots of things today.
Anita Mitra: Yeah, absolutely. And that's the kind of reason for doing this whole Gynie Geek thing is just to kind of make all that information more accessible and as a conversation starter. So that's what we're here for.
Dr Rupy: Absolutely. All right. So why don't we kick off by talking about the different topics that we we're going to be discussing today. So we're going to be talking about periods in general, and endometriosis and fibroids. Why don't we talk about what is defined as a heavy period? How do we know that they're abnormal?
Anita Mitra: Yeah, so I mean, the thing is there's lots of different ways that you can define a heavy period. And I think it's important to just mention at this point that your period is the lining of the womb falling away. So it happens usually every month and average bleeding would be about two to seven days. So we would say on average, an average period would be about 30 to 40 mils. But what does that actually mean? I mean, who actually sits there and measures it? Lots of people have moon cups these days, so I think people are kind of getting in tune with how much they're bleeding, but the textbooks…
Dr Rupy: Do the moon cups actually have measuring amounts on them though? Because how would you…
Anita Mitra: Well, I think you know the capacity of them. I haven't checked a moon cup lately, so I don't know. But yeah, you can kind of see how much is in and they they do say on the box the capacity. But anything over 80 mils is classified by the textbooks as being heavy bleeding. But I really like the definition by NICE, which is the National Institute for Health and Care Excellence. And they define heavy bleeding as excessive blood loss that interferes with a woman's physical, social, emotional, and or quality of life. And I think that's the best definition that I've ever heard because heavy bleeding isn't going to be the same for everyone and everyone has kind of different expectations and different things that they will accept. So I really think that if you think that your period is very heavy and it's affecting your life, then you should absolutely go and talk to someone. It doesn't matter whether you've worked out how many mils you're bleeding per month.
Dr Rupy: Yeah, yeah. That's a really key point because I think women will be different from person to person and what is defined as something that is disruptive to your daily life can be completely different. And that's why I really like that definition that you pulled up there and I think it's a lot more measurable or probably perhaps less measurable, but it's a lot more intuitive for the person, the patient in front of you.
Anita Mitra: Exactly. It's just much more holistic and it's just saying that you don't have to be a textbook definition. It's what's important to you.
Dr Rupy: Okay. So now we've sort of defined what is a heavier period. There are lots of different causes.
Anita Mitra: Yeah, absolutely. So I mean, I think one of the one of the really common causes is people who are having irregular periods or PCOS and that's something that we talked about a lot in our second podcast that we did in series two. So have a listen to that. And that happens because if you're not having regular periods, you've got longer for the lining to build up. So there's more to fall away when it happens. Other common causes, so things like endometrial polyps, which is like a little skin tag in the lining of the womb, that can be a cause. Also blood clotting disorders. So if your body's not able to cause the blood flow to stop, then that can be an issue. That tends to run in families often. Also thyroid problems, generally having a low thyroid problem. So that's something that your GP should be checking if you're if you're presenting to them with heavy periods. I think the copper coil is something a lot of people don't realize also can make your periods heavier. It's a very trendy form of contraception these days because lots of people want to avoid hormones. But I've taken out quite a lot because people are like, God, this thing is causing my periods to be so heavy. And I think that we're not always necessarily so good at explaining that it can make them heavier.
Dr Rupy: I've definitely referred a lot, I think. Yeah, certainly as a GP, I've noticed that and this is purely anecdotal. I'm not too sure about the actual evidence behind this, but certainly women who have introduced the copper coil because they want a more natural way of regulating their, sorry, a natural form of contraception, are having them removed because they just can't tolerate the side effects.
Anita Mitra: Well, it's actually the commonest reason to have it removed before its expiry date. So we do know it's a big problem. And so if you do find that your periods are on the heavier side, I wouldn't go for it personally. But yeah, something to think about. I think cancer is something we always are really scared about. And I have to say that actually, if we have a thousand women with heavy periods, cancer will be the cause of the heavy periods in one of them. So it's 0.11% of women will have cancer of the lining of the womb, so that's endometrial cancer. So it's very rare. I think the things that we will talk about today though, very common causes of heavy periods, will be fibroids. So that's where you've got a thickening of a part of the muscle of the lining of the womb. And then I think endometriosis we're definitely going to cover. And then also something called dysfunctional uterine bleeding, DUB. It's basically a diagnosis of exclusion. So when you've excluded that there's no anatomical cause or no kind of cause with your thyroid or clotting disorders, those kind of things, then we call it dysfunctional uterine bleeding. It generally means that the lining's just quite thick, and that's why you're having a heavier period. So I think, yeah, they're the things that we're really going to to focus on today.
Dr Rupy: Yeah, cool. All right, so let's kick off with fibroids. So it's a thickening of the muscle of the lining of the womb and there's lots of different categories of this. I'm not going to get into that, the anatomical changes, but I remember it from general practice training, all the different types and stuff and how we grade them on ultrasound. But yeah, why don't we just kick off with with fibroids?
Anita Mitra: Sure. So I mean, about 70% of women will actually have a fibroid at some point in their life, but only about 25% will be symptomatic.
Dr Rupy: 70%? I didn't realize that.
Anita Mitra: Yeah, it's really common. And so we have lots of patients who come and have ultrasound scans, which is the way that we find fibroids. And you know, you'll say, okay, there's a little fibroid there. And you ask them about their periods and whether they have any problems with kind of pressure symptoms and most a lot of people don't. So, yes, fibroids can cause what we call pressure symptoms. So if they're very large, they can press on the bladder or the bowel or make you feel very sort of full and bloated. They have to be quite big for that. When I'm saying quite big, the kind of people that I'm talking about are my patients who have fibroids about 10, 15 centimeters in size. Loads of people will have very tiny ones about, you know, one, two centimeters and they shouldn't be causing those kind of symptoms. But you can also get problems with bleeding. So fibroids that particularly the ones that press into the cavity or are really in the in the wall, they can increase the vascularity, so increase the blood flow to the womb, and also they can increase the surface area of the womb. So there's basically more lining to shed. So that's one of the reasons why they they tend to cause heavy bleeding. They tend to be more common in black Afro-Caribbean women. And we don't really know why. It's probably a genetic thing, but there's lots of, you know, lots of theories, but no one is really sure. If you have a family history, then that also is a strong predictor of of having fibroids.
Dr Rupy: I've had plenty of patients actually that come in in their 20s and they have big fibroids, the ones that you can just feel on examination and you know, we grade it according to weeks of pregnancy in in the clinic and stuff and and and yeah, and they unfortunately have to be surgically removed and there's there's lots of options for women out there.
Anita Mitra: Yeah, absolutely. Yeah. So we can we can operate on them, but there are also lots of medical treatments that can be used. Generally around managing the symptoms though. It's very difficult to really shrink a really, really huge fibroid. There are ways that you can block off the blood supply, but they're not really recommended if the fibroid is very, very large, or if you're planning on having children in the future, that can be a problem. But there are lots of ways that you can manage the symptoms without having surgery.
Dr Rupy: Yeah. Yeah. Symptomatic management comes down to trying to reduce the heaviness of the periods, the pain that can be associated with fibroids as well. And there's lots of options that you can actually go to for your general practitioner and gynecologist as well if you're referred, right?
Anita Mitra: Yeah, absolutely. And so all the kind of lifestyle things that we're going to be talking about today can absolutely be used in combination with all the kind of conventional medicines. And I'd really encourage that because I think that there are lots of things that you can do with diet and lifestyle, but ultimately, I think they you have to use conventional medicine as well. I don't think that you can really completely cure everything by just changing your lifestyle, but you can definitely optimize things a lot.
Dr Rupy: There's definitely, I think, a case for using it together as adjuncts really, because, I mean, I do a lot of work in A&E now and the last thing I'm going to be doing as a first intervention is trying to tell them to change their diet. I'm going to be trying to get their pain under control, trying to get the bleeding under control, trying to make sure that they've got clear referral pathways in place. So when they go home, there's definitely an action plan, but then also complementing that, it's let's look at your diet and lifestyle. Are there things that we can optimize that can reduce the frequency of symptoms and the progression of the condition as well?
Anita Mitra: Absolutely. And we're really open-minded to these kind of things as well because if you're changing your diet and lifestyle, it's going to have an effect on your general health, a positive effect that is, as well as hopefully helping your gynecological problems. So we're definitely keen for you to try lots of different things that we're going to talk about now.
Dr Rupy: And there's a crossover with the diet and lifestyle changes that we would recommend with endometriosis as well, right?
Anita Mitra: Yeah, absolutely. So I think endometriosis is something that is getting a lot of interest in the media these days and I'm really glad about that because it is a big problem. Lots of women suffer with endometriosis. It's between one in 10 to yeah, one in seven. So endometriosis is a condition where the lining of the womb, so the endometrium, that's the bit that you shed when you have your period, it grows outside of the womb. So it can grow on the pelvic organs, so it can grow on the bowel, the bladder, liver, and also on the skin of the of the pelvis, so that's the peritoneum. And it tends to cause pain. So endometriosis itself doesn't strictly speaking cause heavy periods, but we see a much higher rate of endometriosis in women who have heavy periods. And one of the reasons why we think that's the case is because we think it may be caused by what we call retrograde menstruation. So that means when you're having a very heavy period, the blood flows out backwards through the tubes. Now, it's important to say that that can actually happen even when you're not having a heavy period. It's completely normal. But some people think that that's how the lining gets outside and kind of like seeds into the pelvis. There's lots of other theories about lots of immune theories, lots of genetic theories and we still don't really know and that's kind of one of the frustrating things about a lot of conditions in women's health is that we don't really know how it works.
Dr Rupy: I remember having these conversations with women in clinic actually because like you said, it is so common these days and it's diagnosed usually with a constellation of symptoms and on laparoscopy, which is where you put the port in, you have a look inside the peritoneal cavity. But it it's very frustrating for women when I say, I can't tell you exactly why this happens. There are lots of theories, genetic, something to do with inflammation perhaps, maybe there is an immune component as well, which is related to inflammation, oxidative stress. But there are lots of ways in which we can manage this as well with lifestyle and conventional treatments.
Anita Mitra: Yeah. But I think another thing that's quite important to mention is that it's never your fault if you get any of these conditions because there are lots of lifestyle factors that have been associated with them, but I don't want anyone to feel that they've done this to themselves because it's it's lots of things that come together that cause these diseases. It's not just one. So if anyone's listening and is worried, that's absolutely not your fault.
Dr Rupy: Yeah, definitely. So let's talk about the lifestyle measures because I know you've done tons of research into, you know, other things that you can do. Out of sheer demand, I think a lot of patients are just like, you know, what else can I do? I've tried the drugs, I've tried the oral contraceptive pill, I've had the surgery even because there's there's, sorry, we didn't talk about the surgical interventions, right?
Anita Mitra: Yeah, so with endometriosis, you can remove the the tissue that's that's there in the pelvis. So it can be there and it reacts to the female hormones throughout the cycle in the same way that the lining would inside the womb. So it builds up, becomes thicker, and then sheds. But when it sheds, it doesn't have anywhere to go. And blood is really, really irritating to the peritoneum, to the the lining inside your tummy. And so it can cause really, really painful periods. But endometriosis doesn't just cause pain during your period. It can cause pain all throughout the month. And that's because eventually you can get quite a lot of inflammation building up from this irritation and it can cause scar tissue. So you can get scarring that can, for example, stick the bowel to the wall of the of the pelvis or it can stick your bowel to your womb or your bladder. Things just don't move as freely as they they might normally. And that's one of the reasons it causes a lot of pain during sex. And I think it's really important to get that message out there that it's not normal to have really severe pain during intercourse. And a lot of women feel really embarrassed to go and talk to their doctor. So that's one message I really want to get out there that it don't feel ashamed. It's actually a very classic feature. Not all pain during sex is endometriosis, but it definitely is suggestive in a lot of cases. So please don't feel shy. And also, sorry if you feel embarrassed when we ask you that in clinic, but it is actually one of the things that we really want to know about.
Dr Rupy: I was just going to say that actually because I have to ask the question, which is sometimes very embarrassing for the patient in front of me, you know, do you, when you have intercourse, is it painful? How long is it painful for? Is this been going on for a while? And these aren't, you know, questions that we're asking purely to embarrass you. There's actually there's a clinical reason behind it and it's really important. It's a really important symptom that a lot of people aren't confident enough to talk about.
Anita Mitra: Yeah, definitely. Yeah. So we can do surgery to remove that scar tissue and to remove that sort of endometrium that's not supposed to be there. But we do know that there are quite high rates of recurrence with this kind of surgery. So that's why it's quite good to try and implement some kind of lifestyle changes if you think that they might be relevant. And so certainly, I get asked a lot in clinic about diet and endometriosis, and also fibroids. So I think you put a question out on your Instagram stories yesterday to just get some idea of what people wanted to know and I think quite a few people were asking about dairy and gluten in particular. So I think that, well, there's not really any studies to show that for example, going gluten-free is a successful intervention to decrease pain when it comes to endometriosis. I know a lot of gynecologists that do actually encourage it. And I think that, you know, the theory definitely is there because if you've got a lot of inflammation in the bowel, and then it's kind of pressing on all the tissues in the pelvis, potentially there's a bit of scar tissue and it causes a bit of pulling and tethering, that could definitely be a problem and so therefore going gluten-free might help. Some people think there's a crossover between the population of women that have endometriosis and celiac disease. So then…
Dr Rupy: This is an interesting association there, isn't it?
Anita Mitra: Yeah, so that's also a potential of why there might be an association. But I also meet lots of people who say, I've gone gluten-free and it's done absolutely nothing for me. So I think really the thing is to just try it. And so when you're eliminating things from your diet, I often think it's best to just try one thing at a time because it might, you know, you're not going, if you cut everything out like dairy, sugar, gluten, you won't know which one it is and you might not need to cut them all out. And then you just end up on this really restrictive diet that's not doing anything for you. So I definitely think it's worth trying. And with anything where you're trying to have an impact on kind of hormonal issues, you need to give it a good three months really to see if it's having an effect. But if it doesn't have an effect, please don't feel that you're doing anything wrong by eating gluten again because it just didn't work for you. So don't don't feel guilty about that because I do feel a lot of patients do feel guilty because they're like, I'm really trying but it's just not working.
Dr Rupy: Absolutely, yeah. And I think it's important to, you know, speak to someone, get some guidance, whether it is from your general practitioner or a registered dietitian or nutritionist. And there are lots of gluten-free alternatives that are in the whole form. So one thing that I've decided to get back into is polenta. I absolutely love polenta. It's amazing. Such a good versatile ingredient, very easy. So we can watch out for some good polenta recipes from you. Yeah. There's also amaranth, there's quinoa, there's buckwheat, and there's other additions to your diet that can give you really good source of fiber, really good source of phytonutrients that we'll be talking about in a second, whilst removing gluten and it's not for everyone. I think that's important to say and you've made that point.
Anita Mitra: And I'm really glad you said the F word. Fiber. Because that is so important. So, when we're talking about endometriosis, fibroids and just generally heavy periods, they're all quite estrogen dependent conditions. Now, I hate demonizing estrogen because estrogen does so many good things for us in our body. Estrogen actually helps your brain function. It's useful for muscle strength, bone strength, so important. Heart health as well. But the thing is when you have lots of estrogen, particularly on its own, so unopposed estrogen, that will make the lining thicken and it's been shown to increase the growth of fibroids and endometriosis because we know after the menopause, when you have very low estrogen, fibroids tend to shrink and endometriosis tends to not cause such a problem. But fiber is one of the ways in which you can actually rid your body of all the junk estrogen that it's done with. So you get rid of estrogen by pooing it out. And I've said the P word, sorry.
Dr Rupy: Don't be apologizing for using the P word. It's a very natural activity that we all have to do, probably more often.
Anita Mitra: Exactly. So it's so important to get rid of it in your bowel. And also lots of foods that contain lots of fiber will also contain lots of good plant-based nutrients, so phytonutrients that we love talking about, that actually help your liver to detox the excess estrogen, the old estrogen that it needs to get rid of. And then it will break it down and then again, you'll poop it out. So that's so important. And also, again, talking about poo, so you're thinking, gynecologist talking about poo, this is totally the wrong hole. But it's not. Most of us don't drink enough water, okay? So Rupy and I are being very good boys and girls and we've got our water next to us, which we're sipping throughout this podcast. But yeah, being…
Dr Rupy: We did just caffeinate. We did. But yeah, no, we are drinking, yeah.
Anita Mitra: So it's so important to make sure that you're having lots of water to make sure that you don't get constipated. If you're constipated, your bowel is just full and then again, it can press in the pelvis, cause aggravation of any sort of endometriosis that's there. If you've got big fibroids as well that are already taking up lots of space, having a full bowel again, capacity overflowing. So really…
Dr Rupy: It's all about space in that cavity, you know, it's just yeah, simple physics.
Anita Mitra: But you know, I, I examine so many patients every day and I can feel that they need to have a really good poo. And I ask them, are you constipated? And they say, no. So I think that it is just this general concept that we're not having enough fluids, we're not having enough fiber and we've become kind of used to being, not constipated, but maybe just used to not emptying our bowel quite properly. So, if you're not getting your kind of two liters of water a day, I think that's something you need to think about. Also…
Dr Rupy: To digress, whilst it, because I know I get asked this a lot. Colonic irrigation. Have you come across any patients that have used this method to remove themselves of the poo in their bowels?
Anita Mitra: Well, I think that's kind of like if you're super, super constipated. But what I would say is that you can't cheat the system. So I'm telling you that you need to go for a good poo so you can get rid of all your old estrogen by having colonic irrigation is not going to go along the same physiology, so you're not getting the same pathways. So I don't think it would be as effective at clearing out all the old estrogen. There's no studies to do that and I hope no one's ever going to do that at least.
Dr Rupy: I I'm not a fan of colonic irrigation. I really don't think it's something. And I I it's something I see the worried well, and I I hate using that term, but the worried well use out of fear, I think a lot of cases and they generally have fairly good diets. They drink lots of water, they have lots of fiber. And like you said, I think that's a very good way you've put it, cheating the system. You can't cheat the system. There's no poo hacks here. There's no poo hacks. And you'd be washing away that huge microbiome as well and all the good stuff that they're doing. So, yeah. Not a fan. Okay, sorry. Digress.
Anita Mitra: And so you touched on the microbiome, which obviously is one of our favorite topics. I think we have to remember that we actually make lots of estrogen in the gut. And that's not a bad thing. But you need that healthy bacteria in your gut to be making sure that you've got good healthy estrogen turnover, so good healthy production as well as getting rid of it. And so that's why I think we need to make sure that we are getting all those healthy fibers into our diet, so fibers with lots of prebiotic properties that are going to really feed that healthy gut bacteria.
Dr Rupy: Chicory, artichokes, garlic, leeks. All that good stuff. Yeah. And then yeah, going down our favorite phytonutrient little line of talking. I will do actually on the show notes at the doctorskitchen.com is actually do a diagram of the liver's detoxification pathway. So you can see there's two main stages. And all the different nutrients that we're about to talk about and the ones that we have talked about, including fiber, it will show you really just why this is actually helping your main estrogen recycling or estrogen detoxification system, improving its function. So it actually gives you, because there's no such thing as like you introduce something and it detoxifies your body. Your body is your only detoxification mechanism other than when if you go to A&E and you have to have something like a charcoal for to to ingest some to pull out some pollutants that you've ingested on purpose. Exactly. Yeah, that's the only way you'd ingest something that would literally detoxify your body. Your liver's doing it, your kidney's doing it, your skin's doing it. So that's really important to know.
Anita Mitra: Yeah, definitely. So yeah, on the phytonutrient topic, there's a quite interesting study that was published this year actually in a really respected journal called Human Reproduction. And so what they were doing was looking at fruit and vegetable consumption and risk of endometriosis. So this was actually really, really interesting. What they found was that if you had a higher fruit intake, in particular, so fruit more than vegetable, you actually had a decreased risk of developing endometriosis. And I think it's not helped by lots of posts that I see on social media and on line with, you know, pictures of fruit next to cubes of sugar. Of course, fruit has sugar in, but it's not the same as, you know, having sugar in a cake or something really processed. There's so much goodness in fruit that we're missing out on if we're not eating it. And so in particular, the study mentioned that they thought that potentially citrus fruits were actually the most protective. And that's because they contain a compound called beta-cryptoxanthin. Didn't say that very well today. Beta-cryptoxanthin. And so this is just kind of like a real reminder that there's so many nutrients in fruits that actually really help our bodies. You know, our bodies are just massive chemical processes and all these chemical processes need help from all the vitamins and minerals and all the phytonutrients. So, I think that study was really important and I think that we do need to remember that fruit is a healthy component in our diet. I think that people are getting much better at getting lots of veggies in, but I think that most of us could probably add an extra piece of fruit every day or something.
Dr Rupy: Absolutely. Yeah, you've got the carotenoids in there and also the fiber constituents as well. So apple, I think it's one of my favorite fruits because it has pectin, it's got quercetin, it's got all the different other phytonutrients as well. But that fiber is super important, right? When you have it in its whole form, you're not really just having the sugar, you're actually having a whole wonderful set of ingredients that are going to be giving so many different benefits to your body, not only your liver, not only your your gut system, but the fiber and and actually it might help with estrogen too. Oh, sorry, yeah, we were talking about estrogen dominance and how it's being like vilified almost. Ask a menopausal woman about symptoms and you'll realize why estrogen is so important. Dryness, skin, cognitive abilities, mental fatigue, sleep, bone, sleep, thermoregulation. I mean, it just the list is endless. So estrogen is very important. It's the excess. That's a podcast for there, isn't it? Yeah, I know. I think there is. I'm getting lots of questions about that actually. So we'll have to we'll have to say that for another one. But yeah, no, it's super important and I think it's the balance of everything. I think that's kind of like a metaphor for most things we talk about on the pod, whether it be sugar, whether it be the amount of meat in your diet, for example, it's all about balance. And we have these incredible innate homeostatic mechanisms that when you introduce more whole unprocessed foods into, it just knows how to look after itself.
Anita Mitra: Yeah, absolutely. And I think as well that, you know, there's not one compound that's going to do all of these things. It's all about getting it as a whole food and again, you can't cheat the system. And so that brings me on to talking about resveratrol, which is another one of our favorite phytonutrients. And this is something, one of the compounds I used to research in the lab back in the day when I did my phytonutrient research.
Dr Rupy: With Professor Karen Brown?
Anita Mitra: She was one of the people who was in the group. I didn't work directly under her, but she is a girl boss of phytonutrients.
Dr Rupy: I'm a fan. I'm a massive fan. So I'm doing my masters in nutritional medicine at the University of Surrey right now and she gave an entire lecture on resveratrol. And she's fantastic. I love it. I mean, she's also known for the the work on curcumin and turmeric and stuff like that. So it's fascinating stuff. I really like it.
Anita Mitra: So if you're wondering what resveratrol is, it's a it's basically a red compound that you tend to find in very high concentration in grape skins. And so it's in wine. So this is one of the reasons why lots of people say, okay, well, I'm drinking my wine and that's really healthy. A lot of people who have endometriosis tell me that drinking wine really, really aggravates their endometriosis. So some people say it's because of the sugar, a lot of people say also because of the sulfites that are in in wine, which tends to be higher, I think in white wine than red wine. But so yeah, resveratrol, a lot of people have said can be really helpful because it's an aromatase inhibitor. So aromatase is the enzyme that converts testosterone into estrogen. So if you're not making as much estrogen, then potentially you might be helping with your estrogen dominant problems. But if you want to have enough resveratrol to actually act as an aromatase inhibitor, you'd have to drink 20 glasses of wine per day.
Dr Rupy: I remember this from her lecture and just just thinking…
Anita Mitra: So it's a lot. Okay, yeah, it's not great. But the concept's pretty interesting. So then could you potentially take a supplement? And they are available. But thankfully, somebody has kindly done a randomized control trial for us. And they looked at using resveratrol in a randomized control trial to reduce pain from endometriosis. But actually, so they had half their group of 44 women having a resveratrol supplement and half had a placebo. They didn't actually find any significant difference in the pain scores in the two groups. So it does suggest that maybe it doesn't actually work.
Dr Rupy: Yeah, was pain the only outcome that we're looking at?
Anita Mitra: Yeah, just looking at pain. But it doesn't mean that it's not something that you could try and get in your diet. And so it doesn't have to just be found in wine. Also, you could have the grapes just on their own. But it's also found in things like blueberries, pistachio nuts, which I'm obsessed with at the moment.
Dr Rupy: Oh, I didn't realize they were in pistachio nuts. Oh, fantastic.
Anita Mitra: Even the humble peanut.
Dr Rupy: Nice.
Anita Mitra: So, yeah. I mean, just, you know, just ideas. So this is, you know, really our whole concept, isn't it? That you can't just pick out one compound, but if you can try and get lots of these little bits in your diet, then, you know, potentially might be having having a good effect.
Dr Rupy: Absolutely. And if you listen back to our earliest podcast, we talked all about phytonutrients, where you get them from and actually it's about the incredible array, the matrix of different thousands of different compounds that you find in whole foods rather than supplementing individual ones. Although there might be some benefits in certain situations. The one that comes to mind is curcumin for osteoarthritis and different forms of arthritis actually, which is some really interesting stuff. On the subject of aromatase, I've come across loads of people suggesting that when you spike your insulin, maybe from high sugar diets, maybe from other constituents of the diet, you increase your aromatase activity, which is responsible for testosterone being converted to estrogen, therefore creating an imbalance in your estrogen.
Anita Mitra: Yeah, that happens and that is also one of the kind of problems with PCOS with the insulin dysregulation. So again, have a listen to our second podcast. But yeah, I think that's kind of one of the reasons why we also do need to think about making sure that we've got a good constant level of insulin, not having lots of big spikes. That's why, you know, I don't like saying don't have any sugar, but you know, I think if you're thinking about you want to have a snack, you know, go for something that's not going to really spike your insulin. If you're, of course, it's fine every now and then, but every day if you're doing that, then that's going to to really have an impact.
Dr Rupy: Yeah, and I see the most effect that I've had with lifestyle interventions for PCOS in particular, and I'm sure it would have the same with endometriosis, although I haven't had personal experience with it. Just by removing a lot of the refined sugary products that a lot of people have in their diet, unbeknownst to them actually, they won't realize that, you know, there's that biscuit and I always have that around 11, or, you know, a mid-afternoon snack, I'll just go out and get a croissant or something like that. When you actually, not remove those completely from your your diet in totality, but replace those with some healthier options that actually spike your sugar levels less, reduce your insulin levels, create a lot more balance, you actually improve a lot of your symptoms.
Anita Mitra: Yeah, absolutely. And that's why it's good to find those kind of snacks that are going to do all that kind of thing. Dairy and red meat. This is something I I get asked a lot about. You certainly get asked a lot about.
Dr Rupy: Definitely.
Anita Mitra: Yeah. So, okay, guys, don't shoot the messenger. Okay, but there have been some really good studies looking at dairy consumption and endometriosis. And in particular in the in the US, there's this cohort of nurses who've been studied for years, and they've looked at a lot of reproductive outcomes in those women. And what they found was that people who did actually have frequent dairy intake had a reduced risk of developing endometriosis. Now, it's thought that actually it's because they're getting lots of vitamin D in their diet from dairy. And I think that that's one of the really big benefits of having having dairy foods is that you're getting plenty of vitamin D. Now, at the moment, it's a gray, drizzly day. It's December. It's probably not December when you listen to this, but you know, over the winter months, when we're not getting a lot of sunlight in the UK, everybody should be having a vitamin D supplement. I've been using one of those spray ones these days and I just put it next to my toothbrush, so I use it in the morning. And that's actually helping me take it a lot more. Last year, I was trying to take the tablets and I just kept forgetting. But I think it's…
Dr Rupy: Compliance is a massive issue.
Anita Mitra: I know, yeah, clearly, as demonstrated by myself. But, I mean, it's so important because vitamin D is, a lot of people talk about it in terms of reducing the number of colds that you get over the winter. But actually, vitamin D plays a huge role in the immune system. And particularly with endometriosis, as I kind of suggested before that there probably is a big immune role. And we see low vitamin D levels in lots of women with endometriosis. Now, I just, to be honest with you, I just feel like most of my patients are vitamin D deficient. And obviously, you know, I work in in the hospital. I don't work in a GP surgery, so I'm seeing the real, real tip of the iceberg. I'm seeing the people with, you know, lots of really quite serious problems often. So I think that my impression is a little bit skewed, but it is important that we all get it in our diet and take a supplement in the winter. So I think, yeah, the the dairy thing, I think that that could be like a whole podcast series. But I think it's just important to remember that it does have some very good things in it and certainly vitamin D is one of them.
Dr Rupy: Absolutely. I think it's really important to to be mindful of how different ingredients affect different people. And I think it's that's a super interesting study. I think there's probably a whole cohort of people who would say, you know, dairy was flaring my endometriosis up or I felt worse on it. So it really depends on you as a person. I think vitamin D, I'm no longer surprised when I see low vitamin D's on on blood results these days. It's just so rife and and that's coming from a general practice point of view. And no wonder it's now become part of national guidance during the winter months to supplement with vitamin D3. And you can get more guidance on that on the NHS website as well. But super important. It's a, it's, it's not even a vitamin, it's a master hormone that regulates so many different genes and it's involved in immune resilience as well. So it's really important.
Anita Mitra: Yeah, super important. So make sure you're taking that. Um, yeah, red meat as well, you touched upon and um, very kindly, the US nurses study has published some more data for us this year. So this is a study that was in the American Journal of Obstetrics and Gynecology. So, you know, this is the big guns here. And it was a study looking at the amount of meat and fish that people were consuming and their risk of developing endometriosis. And they found actually that there was a slightly higher risk in people who had lots of red meat. So they found that chicken, fish and eggs were not associated with a higher risk. And what they suggested is that potentially, if you had lots of red meat, you had lower levels of sex hormone binding globulin, which is SHBG. And that is a carrier for estrogen. So what it does is it mops up all your free estrogen and when estrogen's free, it has a much higher activity level. So that was the suggestion from that study. And I think it's quite interesting because I think something that you've always said and what you've actually really taught me is that it's all about quality over quantity. So I think that most of us could do with reducing our red meat intake, particularly there's lots of environmental arguments for that. But also, it seems like it does have an effect on a molecular level of what's going on in your body. So potentially, if you've got problems with endometriosis or even estrogen dependent conditions, like heavy periods and fibroids, maybe reducing the amount of red meat you're having might actually have an impact.
Dr Rupy: Yeah, that's really interesting. I think there's so many different ways in which you can look at a particular subject and dissect it down into the molecular pathways that might be triggering it. Because I know like, at the same time, there'll be a lot of people that would be recommended to have red meat in their diet because they're having low iron, they're having heavy periods, they're feeling fatigued and stuff. And I think again, it's about taking a step back, and we'll talk about iron in a second, but it's about taking a step back and actually figuring out why is this person having low iron? Is it purely from the periods and is simple iron replacement therapy going to be the best option? Do we need to look at other aspects of the diet? And just going back into red meat, you know, there are lots of different reasons why red meat for certain people might not be the most beneficial thing. It can reduce, it can increase inflammation. Perhaps mediated through the effects on the microbiome. Certainly having lots of heme iron might have a pro-oxidative effect because iron, unfortunately, when it's unbound form is oxidant, it's an oxidant, which is why it's always protein bound in the large majority of cases. And the processing of certain red meats as well contain other additives to them which can irritate the gut lining, which can worsen inflammation, and there's a whole bunch of other effects on the liver as well that we don't probably have time to go into. But yeah, so those are things to just to bear in mind.
Anita Mitra: And I think it's an important point that you've made actually, because there are lots of potential mechanisms, but there aren't really any good studies to support any of these. So a lot of people might think, well, you know, they're just like extrapolating the data. But the thing is that there isn't, people have just haven't done the studies. It doesn't mean the evidence isn't there. I think there just hasn't been a lot of interest necessarily in looking into these mechanisms and I'm sure that they are there if and when we hopefully do the studies.
Dr Rupy: Yeah, hopefully, yeah. So if anyone's got a spare couple of million and they want to fund some studies, then just go to gyniegeek.com.
Anita Mitra: Yeah, doing research is not cheap, unfortunately. I've got loads of ideas, so if anyone wants to fund them.
Dr Rupy: Yeah. Nutritional deficiencies. So B vitamins, magnesium, zinc. Are these things that you've come across in the literature that might be fueling things like fibroids and endometriosis?
Anita Mitra: Yeah, absolutely. But the thing is there's not really kind of one nutrient or one vitamin that really stands out. And so it's a bit of a tricky one when it comes to again, supplementation, which is why I think that, you know, we really need to put the focus at the moment until we get that evidence on everything generally coming through the diet. But we did sort of touch on iron and this is something that's really, really common if you're having heavy periods. And actually iron deficiency is the commonest nutrient deficiency worldwide. So if you're bleeding a lot, you're essentially getting rid of lots of iron that your body might not be ready to get rid of. And so that's why heavy periods tend to be associated with anemia. So anemia is where you have low levels of hemoglobin. And that's one of the components of your red blood cells for which you need iron. A lot of people are really worried that they're anemic if they are tired when they have their periods. It's quite common to get feel quite tired during those few days. But it's often not specifically due to anemia. If you're just tired when you have your period, it's actually more likely to be the fact that you're low in estrogen, which is normal when you have your period. But yeah, that causes tiredness and again, that kind of ties into what we were saying about in the menopause, when you can feel very tired and that again is the lack of the estrogen. If you're kind of generally feeling very tired throughout the month, and some people get sort of shortness of breath or feel very fatigued when they're exercising, that can be a sign of anemia. But I don't think everyone should just be kind of blanket supplementing with iron because there are other nutrients that you can become deficient in that can also cause anemia. So your GP should be checking what we call hematinics. So that's the iron, but also the vitamin B12 and also folate. They are also vitamins and minerals that can contribute to anemia that your body needs to make the red blood cells.
Dr Rupy: Absolutely. Yeah. There's so many different things that you can present with with iron deficiency and unfortunately it does overlap with so many other things. So when anyone comes in with tiredness all the time or TATT, which is what every GP will see every single day of their clinic, you know, we're going to be thinking yes about iron, particularly in the case of a woman who has got heavy bleeding or any menstruating women actually. But also thyroid deficiencies, nutrient deficiencies, vitamin D deficiencies. If there's any other correlation with anything else that they've got going on as well. I always tend to look for more clues as to why they might be iron deficient. So is it just the lack of iron? In fact, a lot of cases, women are quite replete in iron and if you were to remove red meat from it, you'd still maintain quite high levels of iron. So what else is going on? And and I find the absorption of iron may be limited by a number of different things. Some interesting stuff. I I did a paper as part of my masters in nutritional medicine a couple of months ago now on post-bariatric outcomes. So bariatric surgery is where you use a restrictive or malabsorptive procedure. You essentially remove part of the early part of your small intestine. And that part, as well as part of the stomach, is responsible for where you actually absorb iron. So these post-bariatric surgery, these are the surgery you do for obese patients, can actually lead to some quite severe nutritional deficiencies including iron. So replacing just iron isn't the way to go. You actually sometimes need to inject it. And if you've got gut inflammation, inflammation that is affecting your absorption of iron, blindly just taking iron supplements is not going to do anything. You actually need to get to the root cause of why you're having poor iron absorption and a lot of cases inflammation can be can be fueling that.
Anita Mitra: Yeah, and also, so if you've got inflammation going on in the gut, then that can certainly impact on the gut microbiome as well. And so there's a pretty interesting study of women in India who were iron deficient and they actually found that they had a very different gut microbiome and particularly they had less lactobacillus species in their gut compared to women who weren't iron deficient. So I think, yeah, there's lots of things that we need to think about. It's not just simply supplementing with with iron.
Dr Rupy: With iron, yeah. I think anything that will fuel inflammation and it could be stress, both physical and emotional, high sugar diets, unfortunately, the excess of sugar rather than just sugar in the diet at all. Those are things that we need to look out for, I think more. And when people improve their diet and improve their lifestyle as a whole, you see some quite incredible stuff.
Anita Mitra: Yeah, definitely. Yeah.
Dr Rupy: Okay, our producers are are hurrying us along. So we have to talk about exercise really. We could just talk about here all day about all the different aspects of this.
Anita Mitra: Yeah, but you can't send me away with letting me not talk about exercise.
Dr Rupy: No, let's talk about exercise.
Anita Mitra: So, okay, exercise. I think this is something that's really important and a lot of people kind of don't appreciate how important exercise can be for good gynecological health. And there are some studies that have shown that frequent exercise can be really helpful for endometriosis pain. But also there was a really good study again in the American Journal of Obstetrics and Gynecology, which was a meta-analysis of looking at physical activity as a potential intervention for period pain. So this is something that pretty much applies to everyone. I mean, I don't know any woman that's never had period pain before. Some people can just get it for a couple of hours, some people it can be something that really affects them for several days. But this study basically included 11 randomized control trials where they used different exercise interventions and they found that it significantly decreased the intensity of the pain during their periods and also the duration of it. So then lots of people subsequently ask me, well, what's the best exercise?
Dr Rupy: Yeah, yeah, that was literally my next question.
Anita Mitra: No one really knows because all the studies use something different. Like some used walking, some used yoga, some used dance. I think the real, you know, my best advice would be do what you enjoy because if it's an arduous task to go and do exercise, then you're not going to do it. So, yeah, pick what you enjoy. I really don't think it's going to make a difference. No one's really sure what the mechanisms are. It might be that it increases the blood supply and therefore you get rid of the compounds that are there that cause the pain. But also another quite interesting concept is that when you exercise, you actually increase your sex hormone binding globulin. So then you've got less free floating estrogen. So that may be one of the reasons. But I think ultimately it doesn't really matter what the mechanism is. You're doing something that's actually having a positive impact on your periods but also your general health.
Dr Rupy: General health, exactly.
Anita Mitra: But it's really important to say you should be doing it all month. It's not, it's not something you can be like, okay, I've got period pain, I'm going to do exercise. That also might help, but really the studies were looking at this intervention throughout the month to to decrease the amount of pain. And it's also been shown to decrease PMS symptoms, which again are a massive problem for lots of women. So something that you might think is quite removed can actually really have an impact on your gynecological health.
Dr Rupy: Absolutely. I like the sound of dancing to be honest.
Anita Mitra: Yeah, definitely.
Dr Rupy: Yeah, yeah, I definitely. Shake it out. Yeah, just shake it out. No, there's some super interesting research actually looking at the impact on inflammation pathways with exercise in general. So there's probably like loads of other ways in which you could dissect it, but like you said, it's going to be good for your women's health and for overall health as well. So something.
Anita Mitra: Yeah, and I think we're going to cover that in another podcast, aren't you?
Dr Rupy: Yeah, yeah, I'm going to speak to Dr. John about that because he's got a special interest in exercise medicine and he will look at the mitochondrial pathways as well as IL-6, which is an inflammatory cytokine and how that has an impact with exercise and all different types as well. So it's really about moving as much as possible.
Anita Mitra: Yeah, definitely. And just do what you like to make it more enjoyable.
