Progesterone, Seed Cycling, and Cycle Charting (Episode 411)

Full Transcript: Episode 411

Lisa Hendrickson-Jack:

Welcome to the Fertility Friday Podcast, your source for information about the Fertility Awareness Method and all things fertility. I’m your host, Lisa Hendrickson-Jack. I’m the author of The Fifth Vital Sign and the Fertility Awareness Mastery Charting Journal. I’m a certified fertility awareness educator and holistic reproductive health practitioner with nearly 20 years of experience teaching women to connect to their fifth vital sign through menstrual cycle charting, balancing hormonal health, and optimizing the menstrual cycle without hormones. I’m outspoken about hormonal birth control and its impact on fertility and overall health because you have the right to know how your body works and how artificial hormones disrupt that natural process. I teach women’s health professionals how to utilize the menstrual cycle as a vital sign in their practices, and I host live coaching programs to help you achieve optimal fertility and health, because it’s important to have healthy menstrual cycles regardless of whether or not you want to have babies. I’m also a wife and mother of two beautiful boys. I know, I’m a busy girl, but I managed to fit it all in. This podcast is designed to empower you to take full control of your cycles, your fertility, and your overall health. And I’m so excited that you’re here with me today.

Today, I’m excited to share a brand new episode. I’m sharing my interview with Dr. Nora Pope and Dr. Jessica Liu. And in today’s episode, we’re talking about progesterone as always, but we’re also talking about seed cycling, and Dr. Jessica Liu has some really interesting information to share about it and even some research about why it works. So before we jump in, I’ll just tell you a little bit about Nora and Jessica. Nora Pope is a retired naturopathic doctor and Creighton Model FertilityCare Practitioner with a private practice in Toronto up until 2019. She is the creator of Cycle Charting: The Key to Fertility, and together with Dr. Jessica Liu, they have created the Fertility CE Continuing Education Program for medical health professionals, including naturopaths, doctors, and everything in between. Dr. Jessica Liu is a naturopathic doctor with over 16 years of expertise and clinical excellence in the field of fertility, women’s health, and pregnancy care. With an extensive background in natural reproductive medicine, Dr. Liu has helped hundreds of families conceive healthy babies, both naturally and with assisted reproductive technologies. Her program, Creating Vibrant Fertility, has a particular focus in supporting women to move through the emotional trauma of subfertility and pregnancy loss in order to awaken their optimal fertility potential. She is published in Seed Science Research and has lectured as a speaker at the Canadian Fertility Show. And without further ado, let’s go ahead and jump into today’s episode.

And I’m really excited to be here once again with Nora Pope and Dr. Jessica Liu. Welcome to the show.

Nora Pope: Thank you. So excited, Lisa.

Dr. Jessica Liu: Good to see you again. Lisa, it’s been far too long.

Lisa: Yes, I know. I think the last time we saw each other, you had been presenters for my FAMM practitioners, which was incredible.

Nora: That was fun, so much fun. Great group.

Lisa: Yeah, so informative and they loved it. So we’re excited to have you back. And I mean, today we’re going to be talking about pharmaceuticals, progesterone, their use in the cycle. So lots of really great topics to jump into today. And I’m just kind of actually looking at some of my notes that I have for a call, and I think a good place to start — which will get us into the pharmaceuticals — is one of the questions: could you talk a little bit about infections and how they’re related to miscarriage? I mean, let’s just jump right in.

Nora: Sure, yeah. We offer a six-hour course for healthcare professionals, and in one of the sections on the pharmaceutical section, we want to talk about sort of the hidden causes of miscarriage or preterm birth or obstetrical emergencies that are below the radar. And low-grade chronic infections of the lining of the endometrium can cause complications like preterm birth, like miscarriage. And they often go undiagnosed because people aren’t really taught about charting. So Lisa, as you know, when you teach a woman cycle charting, it’s not just about her hormones, it’s about her overall health. And it’s a fifth vital sign. And it’s a reflection of her systemic situation. And so what’s very common and what’s more popular in the sort of pop culture is, “Oh, that egg white discharge, that’s your fertile mucus.” So this is a good start. But there’s all kinds of discharges. And there’s a lot of non-fertile discharges. And one of them is called wet without lubrication, or 2W in the Creighton model world. And this is like a drip, drip, drip, drip, drip. And if a client comes to you and says I’m always needing pads, I’m always wet, I’m always dripping — that drippy, white, clear discharge can be an occult infection. And that can hinder a healthy pregnancy. And so antibiotics given in the ER — if a woman’s coming into the ER and she has premature contractions and the ultrasound reveals that the baby’s still quite young — they don’t do anything else. And it’d be nice if they maybe considered progesterone, but the progesterone is not going to work as well if she has an infection. So maybe do a swab, ask about her discharge, and give her a broad-based antibiotic, and that will halt the contractions, whereas anti-contraction drugs or tocolytic drugs won’t work. It can really help save a life. It’s just knowing about the signs and presentations of what is a low-grade infection jeopardizing a full-term pregnancy.

Lisa: And you mentioned the infection potentially of the endometrial lining. Is that something that would show up in a similar way with the wet discharge or does that show up in a different way?

Nora: That’s a good question. Types of infections that you’ll notice on charting — 2W can be one of them. Another one is the red spotting — red spotting before period, red spotting after period. And that could be a cause of just chronically low hormones, and not necessarily an infection initially — the initial insult was low hormones. And what’s happening is that you’re not building up a healthy lining of the endometrium, and then you’re not having a proper shedding of the endometrium during your period, because you’ve had low hormones and it’s not giving you those clear demarcation lines of, “Okay, my cycle is starting today and my cycle is ending this day.” So what happens is you had low levels of hormones, and then the lining of the uterus is not healthy and it starts breaking down, and you have that premenstrual brown bleeding or premenstrual spotting. And what happens is, because it’s friable and not well formed, it becomes a vulnerable tissue, and it becomes vulnerable to opportunistic infections. And then it can lead into endometritis. And so spotting needs to be monitored as well. That’s another powerful tool of cycle charting. And so there are many signs, but cycle charting is of course our roadmap. And Jessica Liu and I are just very, very passionate about getting this information out to clients and to practitioners. So we do cover antibiotics in our course, because it can save a life, but also it can really restore fertility.

And Jessica, remember we were talking about the several classes of antibiotics — there’s one for infection, but then there’s actually an estrogen enhancer in a class of antibiotics.

Dr. Liu: Yeah, so one of the things you have to think about now — and I’m happy to see that the literature is catching up — is that there’s this crazy association between the gut microbiome and our hormones. So this whole idea of the estrobolome now, so how our microbes inherent in our system can actually impact estrogen metabolism. So there are pathogenic bacteria that live all the time in our gut that can decrease or increase the metabolism of estrogen out of our body. And so one of the things that we’ve seen in some of the cases we looked at — so interesting — is that a course of antibiotics, when LSD fails, they threw in an antibiotic for an infertile woman. And what that ended up doing was actually improving her estrogen retention in her body, because the antibiotic kind of slowed down the liver metabolism of estrogen, and that ended up helping to grow a stronger egg and improve fertility. And increased cervical fluid too, so it extended her fertility window. So it’s so interesting — you do this lateral move to help a woman augment her hormones and it can also restore fertility. And so antibiotics have multiple applications in the restoration of fertility. Very, very interesting.

So we of course, you know, we’re trained as naturopathic doctors and of course we want to restore health with acupuncture and botanicals and nutrition and diet and lifestyle, and we’re big proponents of progesterone. But when drugs are used in a low-dose fashion and a very strategic fashion, very targeted action, they’re very restorative, and I would say very naturopathic.

Lisa: Well, I have a couple of follow-up questions, because I feel like at this point I’m in the mind of at least most of my listeners. So I just want to touch on two things. The first thing is the spotting. Because someone’s listening and thinking, “I have spotting.” As an educator who’s working with clients all the time, a lot of women have spotting — a lot of women have spotting before their periods, a lot of them have spotting after their periods. So again, for the listener who’s like, “I have spotting. Does that mean I have an endometrial infection?” Are there some things to look for so that every woman who has spotting isn’t automatically thinking she has an infection?

Dr. Liu: Yeah, that’s a good point. I think it has to be a diagnosis of exclusion to an extent, right? Like you want to follow up — obviously optimizing hormone levels and then seeing if there is a change. Does optimizing progesterone specifically on let’s say peak day plus three to twelve — is physiologically where we want to hit that range — and you’re doing that for a few cycles? Does that clean up the spotting? Does it clean up the menstrual cramping? Does it clean up the PMS symptoms, perhaps, or modulate those? And if you’ve been doing that for a while and it changes things, great, we’re on the right track. And if it doesn’t and you’re still scratching your head, there may be a history of multiple use of antibiotics possibly disrupting things. Has she had a history of E. coli UTIs? Is she prone to vaginal yeast infections, vaginosis? Has there ever been a history of vaginal discharge that’s looked a bit off? Those are questions that I have that maybe lead you down that path. It’s not necessarily an automatic thing because occult means hidden, right? It means it’s not obvious. So obviously you want to rule out the obvious things. If you have a rampant candida happening, then obviously treat that, right? Clean up the terrain. Occult is where we want to start putting on our hats and going, “Could there be something here?” Because there are actually many microbes that can cause dysfunctional uterine bleeding — not just one. You could have Group B strep, you could have enterococcus which is a fecal bacteria, you could have E. coli, all kinds. And they’re not necessarily going to zero in on that right off the bat. They’re going to rule out the obvious — chlamydia, Gardnerella, yeast — they’re going to deal with those first. And in some of my fertility patients, Ureaplasma and Mycoplasma are sometimes completely asymptomatic. Sometimes there’s no discharge to pin it to. So this is where you sort of rule out the stuff that’s obvious first, and then start thinking if it still persists and there’s no other answer that’s reasonable — you’ve ruled out endometriosis, you’ve ruled out PCOS — maybe look at occult infection then.

Lisa: That’s really helpful. Because it gives a little bit of context because it’s such a common issue. So the other question, question two, is — in order to identify something like that, if you go in and ask for a swab and a culture, is that something that would be identified just by one of those typical vaginal swabs, or would identifying a uterine infection require additional testing?

Dr. Liu: It would. I think a vaginal swab can give you a clue, but it’s not the full picture. I have a patient right now who’s going through a fertility treatment cycle, and they’ve caught endometritis that was never found before, and that was only found recently on a biopsy. There are, interestingly, new labs that are coming out — I’m not going to say which one — but there are labs, if you look into it, that are actually doing menstrual blood cultures, which is a much more direct view of what’s in that sloughing, in those cells, what’s growing in that milieu, that terrain.

Lisa: Is that something that like you could ask your doctor to do?

Dr. Liu: You can. There is one lab in Canada, I think, that outsources it to a lab in Europe, that is doing that. And any doctor can requisition it. It’s a simple menstrual blood sample. You ship it off and they come back to you with a whole microbe view of what’s growing in there. It’s quite brilliant, actually.

Lisa: Fascinating. So then the other question, last question, and then we can move on. So about the antibiotics, because of course a lot of my listeners would be familiar with potentially the link between overuse of antibiotics and the disruption of the gut microbiome. So maybe share with us a little bit about how it can be used in a positive way, because it’s really interesting what you’re saying — that it could potentially stop the contractions, lengthen the duration —

Nora: We’re trying to help couples either postpone or achieve pregnancy. When they’ve achieved pregnancy, have a full-term pregnancy. So if women are coming to the ER in Canada, it’s woefully inadequate what’s helping them. They’re just given tocolytic therapy — so anti-contraction therapy — and they’re given an ultrasound, and that’s it. So we advocate that they should be tested for progesterone, but you should rule out infection as well, because even if you give progesterone, it will be less effective if you have an infection, because it’s the infection that’s causing the disruption in the lining of the uterus, which is bringing on the contractions. So it’s a two-pronged effect. But definitely progesterone is getting better press in terms of preventing miscarriage in the ER, and we’re talking about antibiotics as well. It would be nice to get more ER doctors and nurses on board.

And chances are that woman had 2W. She had that wet without lubrication discharge, or she had spotting. So you have to ask your clients — have they ever had a miscarriage before? That’s one question part of the workup. And was the spotting before or after their period? Have they had their hormones tested properly on peak plus seven? Were the hormones high or low? Have they had the estrogen tested on peak minus three or five or two? Have they had a follicular ultrasound done during their white flow days? What’s the size of the follicle? Ideally you want to grow to about two centimeters. Is it smaller than that? And that’s going to indicate low hormones also. So there’s a whole kaleidoscope of questions and features to help you point the person in the right direction.

I had a patient who had suffered a — now it would be considered stillborn — because she lost the baby at 21 weeks and they couldn’t find anything. They had no explanation for her. Progesterone was not tested. Nothing was wrong with her cervix. Just spontaneous delivery. She remembers asking the doctor about her discharge, that it seemed irritated, it was a bit smelly, and nothing was even looked at — no culture done, nothing. It was just brushed off. It happened again in her second pregnancy. She’s in it right now. And we treated it right away. We had her go for a culture — nothing came of the culture — but she did notice that discharge resolved after treatment. She’s okay. Everything’s good. We’re monitoring progesterone.

Lisa: So I think what there’s a couple of things that are kind of like one thing is that this kind of stuff is in many ways for the average woman specific to having some degree of understanding of their cycle and what’s normal and what’s not. And so with the cycle charting, if you are — many women do chart, but cervical fluid is not something that’s necessarily taught in detail in every method of charting. So there are plenty of women who chart their cycles, but if you go online to a Facebook group or to websites where they just showcase pictures and pictures of mucus — I had a conversation actually with one of my colleagues about this, because she was showing pictures on this website — but you have to have context. Plenty of people have mucus that is not healthy, and you’re looking at it and thinking, “Oh, it’s totally normal to have this gunky yellow stuff.” And no, it’s not.

And then the other aspect of it that can be challenging — for anyone who doesn’t know, when Nora and Jessica are talking about peak plus seven or peak plus four, peak minus three — peak day would be the last day of your clear, stretchy cervical fluid, which is in line with ovulation in a healthy cycle, so within a couple of days usually. And so this is a very good marker of when we should do these types of tests based on the cycle. And many women who are going to their regular physicians who are not necessarily trained in the same way that the two of you are trained wouldn’t necessarily automatically be doing it that way. Maybe you could just talk a little bit about that, especially for the women who are listening who are kind of like rapidly taking notes and kind of like, “Why didn’t my doctor do that?”

Nora: Well, this is so easy. Dear listeners, please work with Lisa and do some cycle charting. And here I’ll give you some good news. It seems daunting to learn about your cycle. But dear listener, I promise you, if you invest 90 days, or about three cycles, this is what you’re going to see. You’re going to see patterns that emerge. You’re going to see X number of bleed days — we call them red flow days at our company Fertility Continuing Education. Ideally you want five, because we believe in the rule of five — five means you have healthy hormones from the previous cycle. Then you have a variable number of dry days, and then you’re going to have five days of white flow. And that shows that your follicle is growing — and ideally it’s growing from that little follicle up to two centimeters — and that growing follicle is pumping out estrogen in the blood, and it travels to the cervical crypts to the cervix and turns on that wonderful cervical fluid production. We call that white flow because it’s media-friendly. And then when the white flow ends, that’s your peak day. And that correlates to peak estrogen day — that’s the last day of estrogen activity. And then after that, you want anywhere from 10 to 15 days before your next cycle. So we call that rule of five again — five days times two or five days times three.

And that rule of five, you want to see emerge. You’re going to want to look at the patterns for three months of cycle charting with Lisa. And then you’re going to say, okay, well, I have three days of red flow, and I have four days of red flow, then I have five days of red flow. And in this cycle I have three days, four days, and four days. And then my post-peak phase is okay, it’s about 11 days, 12 days, 13 days. So you’re going to get a sense of the patterns in your cycle. And then when you’ve identified your peak day, you’re going to know that you want to test your hormones — estrogen and progesterone — at peak plus seven. And then when you’re told to get an ultrasound series, a lot of doctors say go on cycle day nine. And we say at FCE, no — go on your white flow days. So when your white flow starts, it could be cycle day 12, it could be cycle day eight. So go and use your cycle chart as your roadmap to time your blood tests and time your ultrasounds. So you go in on your white flow days, you look at how your follicles are growing, and then you want to see it rupture, and then you want to go in one more time to see it shrink into that yellow body, or corpus luteum. And that’s the power of cycle charting.

So if you have more than five days of red flow, if you have that drip, drip, drip, spot, spot, spot — you want to consider getting your hormones monitored. If you have one day of white flow, you want to look at the stress in your life, or do you have some kind of hypothalamic dysfunction which is not syncing up your hormones to produce that nice sequence of FSH, then estrogen, then LH, then progesterone? And the cycle charting is your roadmap. And in 90 days, you’re going to gain this body literacy. And after four cycles, you’ll be able to do the ultrasound series as well. And you’re going to be really accurate. And you’ll be teaching your doctor on how it’s done. And you’re going to be your own advocate because you know what your body’s doing. And that’s the power of cycle charting and working with Lisa.

Lisa: Well said. Yeah. No, that’s great. I think it’s hard though, because many — I would never want to say it’s going to be easy, because you’re right. Once you chart your cycle for several months and you have your data and you know when you’re ovulating, and you go to your doctor and they say, “Come back on cycle day 21,” and you’re like, well, I’m not ovulating until — da da da. So it’s never easy. But I do feel just like what you said, Nora, it’s really important to get that base of understanding. And then you start demanding the care that you need. And if your practitioner unfortunately is not playing ball, then you can kind of move on to the next one.

Maybe we can talk a little bit then about the pharmaceuticals, because I find this whole conversation to be very interesting. As you can imagine from my side of things, there are a lot of people, a lot of women, a lot of practitioners of different kinds, who are kind of really anti-medication. They don’t really want to stay away from it completely. And then we have the medical system where it’s like all medication all the time. And what I think is so interesting is the very specific way that the two of you use different pharmaceuticals in your practice in a way that’s a lot different from the medical system — a lot less harsh maybe, and a lot more in tune with the cycle. So why don’t I just let you take it from there?

Dr. Liu: I think that the easiest thing that I’m very blessed to have access to is bioidentical progesterone, because it can save a life. We’ve been able to save — was it Nora — was it due to the antibiotics or progesterone? We had a student who took our course, a registered naturopath, who was telling Nora in real time, “I am saving a pregnancy as we speak because we’re properly timing the prescription.”

Nora: Yeah, she was in Winnipeg. And we say on our website, we offer one-on-one phone support after the course to clarify course content. So we’ve had several hundred students take our course, and I think we’ve had maybe 14 call us. And I love it because I find on the phone you can clarify a gazillion questions quickly. And then I always hear the good news — “By the way, I’m advocating for my patient right now and she’s getting cultures done, and the antibiotics have stopped the contractions.” And for me, I’m just jumping out of my seat — we’re saving a little life in Pegasus as we speak. And so it’s very, very exciting.

And so again, the concept is minimum dose, targeted to the cycle, targeted to the individual woman. And so as Jessica was saying, naturopathic doctors have access to compounded progesterone in Ontario, and I think oral progesterone as well is available for BC naturopathic doctors. Is that right, Jessica?

Dr. Liu: Correct. Yeah. So but it’s really not every province in Canada. And so the job of a naturopathic doctor in the other provinces and in several states is to collaborate with medical doctors. And unfortunately there are some very strange, negative conclusions being made about progesterone in the States, because so many studies have been poorly designed — not based on the woman’s individual chart, it’s based on the biomarker of last menstrual period. And so they’re going to test for progesterone on day 21, and they’re going to start prescribing progesterone, let’s say, on cycle day 17 or 18, which is not necessarily in sync with 80% of women. And so you’re going to have a destructive effect on women’s health if you time the progesterone at the wrong time.

Lisa: Yeah, I’ve seen all kinds of prescriptions.

Dr. Liu: Yeah, day 12 to 24, day 14 to 28 — so arbitrary.

Nora: It’s very arbitrary. And so in the Creighton world, it’s very precise. You want to give progesterone from peak plus three to peak plus twelve. And that’s in sync with the woman’s cycle. And you want to sort of overlap the natural crescendo-decrescendo of progesterone production during that luteal phase, which is P plus three to P plus twelve. And if you bring it in too early or too late, you’re going to either hinder the corpus luteum or hinder the follicle. Because if you bring it in too soon, the follicle’s not going to rupture. If you bring it in too late, you’re going to artificially prolong corpus luteum action. And then it’s going to be action-reaction — you’re going to sort of deregulate the next cycle. So it’s very harmful. And that’s why it’s not being concluded in the studies. What’s being concluded is that progesterone doesn’t work. Well, it does work, if you time it based on ovulation or on peak day.

So it’s getting quite a bit of bad press with respect to PMS, because the thought is it’s going to elevate even more that metabolite of progesterone, allopregnanolone, which can make the mood symptoms of PMS or PMDD even worse. But I have to say clinically, when we get the right dosing and the right prescribing — peak plus three to peak plus twelve — as far as some of the more physical symptoms like the bloating and the spotting, it works. So I think more studies, better-designed studies for sure. But the chart again becomes such a beautiful, informative way to manage your prescriptions — again, minimal effective dosing.

Lisa: Well, I mean, ironically, today I had a class with my FAMM practitioners, and one of the case studies is a client who was administered progesterone. There are many situations where progesterone is administered, obviously. One of them is the challenge for women who are not cycling at all. So in her case, she was post-pill and she wasn’t really having a cycle. And it was quite soon after coming off — maybe within three or four months — and the doctor gave her progesterone and told her to take it on whatever day 14 or whatever it was. And so she had these charts where there were three or four charts back to back where there was no ovulation. Because she was taking this progesterone on whatever day they told her. There was no ovulation. And so until she actually stopped taking it, we weren’t even able to see if she was ovulating and when it was happening in the cycle.

And certainly I’ve seen women who are trying to conceive and their doctor tells them to take it on a certain day. A doctor’s word is very powerful. And so if the doctor tells them to take it on this day, that’s the day they’re taking it. And so I’ve certainly seen cycles where they’re trying and they think they’ve ovulated because the progesterone raises their temperature, but they didn’t. And so they kind of lose that cycle. So certainly for me, this is a big topic in my work. And I certainly have seen the resistance of clients to wait two days, wait three days to start taking it, just so that we can confirm that you’ve ovulated, because they’re so scared something bad is going to happen if they don’t take it right away.

Dr. Liu: It’s a huge pet peeve of mine, to be honest with you. Yeah. I have a patient who’s a PCOS patient. I think we’ve ruled out hypothalamic amenorrhea, but again, she’s never known a cycle without it being a forced withdrawal bleed, because her doctor has just kept her on cyclical progesterone this whole time. So we’re not fixing anything here at all. The whole goal is to actually — let’s actually help you ovulate on your own. And we’re never going to know if we’re doing that right unless we see what your body wants to do without that help.

Lisa: So I think there’s definitely a place in time for progesterone. And I have a question about progesterone because obviously when you time it correctly, when you dose it correctly, there’s no question that it does work, I think for most people. Sometimes the question that I have about progesterone though is that if a person is not making enough, then from my perspective, there’s a reason why. So how do you find that in your practice?

Nora: Oh, this is your favorite million dollar question.

Lisa: I’ll just finish my thought, because my question then from a practitioner perspective — you’re giving this client progesterone to help their PMS and their symptoms go away. So are they just going to take it forever, or what happens there?

Nora: Yeah. I don’t believe in taking anything forever. The goal of any prescription is to restore health. But absolutely, why is progesterone low is such an important question to address. So just as naturopathic doctors, if you step back — I mean, if the patient has eczema or psoriasis or arthritis or rheumatoid arthritis or high blood pressure or diabetes or osteoporosis — all these conditions in their own way will hinder the production of progesterone. So it’s one thing to give progesterone — it’s sort of the band-aid, and it’s a good band-aid — but you really want to step back and restore bone metabolism and cardiovascular health and blood sugar balance. And so it’s a question of looking at the whole person.

So absolutely — my geeky little hobby is cyclic AMP, and cyclic AMP is low in all those conditions I just listed. And it’s cyclic AMP, if it’s not optimum, that will hinder progesterone production as well. So think of histamine — like allergies — allergies will also hinder progesterone production. So you really want to build up the person inside out and restore their health, and then the progesterone can thrive. And ideally, you can get off the progesterone. So absolutely you want a whole person approach.

Dr. Liu: Yeah. And I, you know, as a naturopath, I used to actually be really against progesterone — any kind of bioidentical hormones — previously to me starting to use them, because I thought this is not naturopathic at all. We’re not treating the cause, we’re just plopping in some exogenous hormone. I have to say though, now that I’ve been using it to see it restore a woman’s health and fertility, help her maintain a pregnancy — it’s safe. Why not? So I think the important thing is we’re using it in context of other things to support the why. So if you have inflammation, if you have eczema or psoriasis, you’re not just forgetting about that and throwing in progesterone for the fun of it. You have to treat the cause. Look at the terrain. Treat the microbiome dysfunction. Treat the inflammation. Work on the adrenals. Make sure the thyroid is working well, because you need T3 to make progesterone. You need progesterone to make T3 — it works both ways. And then think: is there a place for a little bit of minimum effective dosing just to get them to where they need to be health-wise? Because for me in my fertility work, mental health is right up there on my list of priorities to support. And so the longer the journey, the more complex the journey, the more intervention, the worse off they are from a mental health standpoint. So if we can restore that ahead of time and help them to avoid more invasive procedures like IUI or IVF, then it’s a win for me. And progesterone is safe. So that’s where I’m at now. I’ve evolved.

Lisa: Yeah, I think from many different perspectives — I mean, when your option is miscarriage or when your option is IVF — a lot of these subtle, timed, very nuanced approaches to that kind of perfect combination of medicine and the menstrual cycle, it really does achieve, in many cases, the result you’re looking for, with minimal potential side effects compared to the full dosing of certain types of medications in the medical system. So I think it is really important. And of course, that’s why — I’m not personally a NaPro practitioner — but certainly I speak about NaPro and I’ve interviewed NaPro practitioners, because that approach is kind of like the best version of medicine as far as I’m concerned, where it’s allopathic, yes, but it also works alongside the menstrual cycle. And of course you take a bit of a different approach because you are naturopathic doctors, so you’re taking more of a holistic approach. So I think it’s just really nice actually for clients to have so many different options to really achieve what they’re looking for.

Nora: I did the NaPro training in about 2010. I loved it because for me it introduced drugs in a whole new light. And we’re speaking at a conference in April to naturopathic doctors, and we’re going to cover low-dose naltrexone, and we’re also going to cover progesterone and thyroid HRT. I think how they all tie in is that on the ovary itself, there are receptors for progesterone — obviously, because it makes the corpus luteum — but also there are receptors for opioids and thyroid. So in that little ovary, you need your opioid or endorphin system to work, you need your thyroid system to work, you need your progesterone system to work. And that for me is amazing. And I’m sure there are more receptors on the ovary we just don’t know about. But it’s really amazing how health and fertility have so many interrelationships. And that sort of introduced that concept to me — that there are many avenues in the body to restore hormone balance.

Lisa: So I mean, one of the questions that I get a lot, obviously, in the work when you’re kind of mucus-focused, is around mucus production. So I thought I would just throw that out there, because the conversation about progesterone really addresses a lot of the questions around the cycle length and the length of the luteal phase and things like that. I think it’s really good to know that you do have those types of options depending on your practitioner and what they’re willing to do. But when it comes to mucus production — this is kind of again one of the most common questions; you look at my DMs, it’s like, “Where’s my mucus?” — so maybe share a little bit about some of the approaches that you have with clients who are concerned that their mucus production is less than that five days that you mentioned.

Nora: Nora, you want to go? Or do you want me to start? Yeah, we’ll do it together. But I’ll start. Just think of no mucus as no follicle.

Dr. Liu: Yeah. So your follicle isn’t growing. Because if you don’t have a growing follicle, you don’t have growing levels of estrogen in the blood, and that can’t turn on the cervical crypts in the cervix to produce the white flow. So why isn’t the follicle growing? And then Jessica has a lot of interest in PTSD and stress, so I’ll take it away, Jessica.

Yeah, I mean, I’ve seen that in many, many patients where, you know, we don’t even talk about mucus. We’re just addressing their anxiety, we’re addressing their sleep deprivation, we’re addressing their high cortisol levels. And the minute we do — boom. The minute they start to feel joy, or actually activate their pleasure centers — boom. Cervical mucus comes, starts to come back. And not just arousal fluid — like actual slippery, stretchy from the crypts, mucus is starting to appear. So it’s lovely in that sense.

And nutritionally, we obviously would think about things like B6 and flax seeds and things like that. Also, what’s interesting is looking at more of the thyroid piece — that oftentimes, hypothyroidism is going to interfere with follicle growth and also estrogen production. And so you could have a patient with, let’s call it subclinical hypothyroidism. So on paper they look fine, but they have all the markers: their eyebrows are thinning, their hair is thinning, they’re always freezing, their skin feels dry, they might be constipated, difficulty losing weight, they’re exhausted all the time. This person — either there’s a receptor problem or there’s a conversion to activated T3 hormone problem. Something’s not right in there. But you might see it in their basal body temperatures are too low, both pre and post-ovulation. And so that can also contribute to dysfunctional white flow, and also dysfunctional bleeding as well — too much bleeding sometimes.

And I think yeah, a lot of patients are already aware, right? So we do get a lot of patients who come in and that’s all they want to work on. But we have to take a step back. If their diet is really inflamed, if their psoriasis is out of control and it’s using up all their reserves just to manage that — and the body isn’t going to give it to things that it doesn’t need to for survival — that’s kind of big picture thinking. But that’s how I kind of look at it. You’ve got to clean all that up first. And then you start to see a real change in their cycle.

Lisa: Yeah. Because there’s this huge connection — obviously you need the estrogen to make the mucus. What I see a lot as well are potentially the damage to crypt situations, to kind of add to that problem — where you have potentially history of surgeries because of HPV. I work with a lot of people who come off of contraceptives, and then the contraceptives themselves can have a suppressive effect. So I think it’s helpful to have this kind of big picture. So when you ask that question of like, “Why don’t I have any mucus?” — I mean, the answer just took about five minutes to go through potential reasons why. So it might seem like a really simple issue, but sometimes you really need to dig to figure out why. Is it structural? Is it hormonal? Is it stress-related? Is there an underlying condition?

I do feel like I need to do more research there, but certainly patients who’ve come off LEEP procedures — they’re noticing, at least in the cycles immediately following that procedure, they’re wondering, “Is that going to permanently damage my cervical mucus?” Luckily, the cervical crypts go all the way up the cervix. As long as some of them upstream are preserved, I think over time there is cell turnover. And the hope is that with good nutrition — things that support cellular health, like folic acid, dark leafy greens — that can help to recover that mechanical injury down the road.

Well, another question I get all the time — very popular topic — is seed cycling. And so I’d love to have you share your perspective and experience with that. I mean, from my perspective, I think it’s so interesting because there are some practitioners that are like anti-seed cycling. You’re like, “It’s pumpkin seeds!” Like, is there an RCT double-blind study? What could go wrong here? So definitely in the ether, in the kind of socials, there are certainly different perspectives on this. Some practitioners are very much against it. And then I fall somewhere in the middle because I do think that there are a lot of benefits, but at the same time I think a lot of the clients that I see are facing some bigger problems. And so they might need more than just the seed cycling protocol. But I’d be interested to hear what you found, because you shared that you’ve seen some really interesting research about it, which is fascinating.

Dr. Liu: The research primarily is on flax seeds, probably for their lignins and their mildly phytoestrogenic capacity. But there was an interesting study that I came across that showed — they didn’t test other seeds, but looking at flax seeds — and I would maybe extrapolate that maybe hemp hearts would work too, maybe chia seeds, because they’re all kind of in the same family — is that it could regulate cycle length. And I have seen that to be true clinically. A patient with 25-day cycles gets on regular flax seeds and now they’re having more like 28-day cycles. Not that that’s the goal, but it’s more to optimize the event, which is ovulation. We just want them ovulating. Well, we want that follicle growing. So whatever it is that can support them.

I just like it for the fact that everybody can probably use more fiber. Everybody can probably have better bowel movements. And it’s one less pill they have to take that they’re willing to do. They feel like they’re in control of their bodies. They’re using it in conjunction with their cycle tracking. It’s motivating for them. And if they enjoy it, I say, why not? There’s no harm, absolutely.

Nora: Yeah. And I’ve seen some patients — even amenorrheic patients — have their cycles return with seed cycling. So don’t knock it. It might be gentle, but even gentle things can be very powerful in my opinion.

And in terms of pre-peak and post-peak seeds, the rule of thumb is that pre-peak you want to be eating the omega-3 seeds, so like flax and pumpkin. And then post-peak, you want to start at peak plus three or peak plus two, the omega-6 seeds like sesame and sunflower. And if you sync it up that way, then you’re augmenting estrogen balance in the first half of the cycle and progesterone balance in the second half of the cycle. But you really don’t want to do day one to fourteen omega-3 seeds and day fifteen to twenty-eight omega-6, because that’s what’s being taught. And we don’t agree. And I have to say, pre-cycle awareness training with Nora, I was guilty of that too — sort of a standard protocol that we’re given right out of school. And now it’s changed.

Lisa: Yeah, well that’s really helpful. So for all of the seed cyclers who are tuning in — basically Nora and Jessica are suggesting that instead of doing it based on days of your cycle, so calendar method, we’re suggesting to actually pay attention to your cycle. So before you ovulate, as Nora shared, it was the flaxseed and the pumpkin, the omega-3s. And then after you have confirmed ovulation — so peak plus three — and then of course I teach cervical-thermal, so a third high temp or the evening of the high temp, or both — and so then you would take the omega-6 seeds, so that was the sunflower seeds and the sesame seeds. Is that right?

Nora: That’s right, that’s right.

Lisa: Okay, so we’ve got it now. And then hemp contains all the fats so you can enjoy those any day. And also chia I believe is omega-3 and that’s good for pre-peak. So there’s a lot of options out there.

Dr. Liu: Well, and chia seeds are excellent for that — again, for that gentle fiber that helps you go. So lots of positive things there.

Lisa: Well, so you and Jessica have some exciting things coming up. So before we go today, why don’t you share a little bit about your conference that’s coming up, and how the listeners can find out more about that. Also Fertility CE and where they can get ahold of you too.

Nora: Thanks. So we’re going to be guest speakers at this Canadian conference, and it’s called Collaborative Education. It’s a company that has done an amazing job of delivering continuing education to healthcare providers all over North America, but they really feature a lot of naturopathic doctors, which is nice. We’re one of the keynote speakers, and that’s the weekend of April 23rd and 24th. And the website is collaborativeeducation.com. And we’re very excited. We’ll be talking about progesterone, thyroid, and low-dose naltrexone, which is an opioid receptor antagonist, which in turn will help the body make more endorphins. And that’s one way of restoring ovulation. And that’s our talk at the end of April.

Dr. Liu: And then Jessica, you want to talk about our six-hour course? Yeah, our six-hour course is sort of evergreen now. And we’ve taught to almost 300 practitioners across the world — mainly North America — and not just naturopathic doctors. Nurse practitioners, pharmacists, we’ve had a couple midwives, and some MDs. So we have accreditation for all naturopathic doctors across North America, and also accreditation with the American Academy of Family Physicians. So if you are a nurse practitioner, you can get credits for our course too. It’s a full restorative course with the highlight being cycle charting, and then from that, being able to time properly your blood tests, your ultrasounds, and then timing your treatments — whether it’s botanicals, whether it’s nutrients. We talk about things like endometriosis, PMS, PCOS. So it’s a full gamut. And we have a lot of fun with it. And so you can check us out at fertilityce.com, or on Instagram, we’re at fertility.ce.

Lisa: Awesome. Well, I will have all those links for the listeners in the show notes. And so of course, thank you as always for being here. It’s always fun to chat with the two of you. You have a wealth of information. And again, I think it’s wonderful for women to just learn about all these different options. I think so many women go to their doctors and they think that’s it — like they think that’s all that there is available. The good news is that there is more. So the doctor should be part of your team, but there’s more room, more chairs at the boardroom table, and we should fill them with Nora and Jessica.

And I want to say last thing — like I’m living proof. I was the post-pill amenorrhea PCOS case. And this is why I’m here, because I went through literally every pharmaceutical option there was to offer, and nothing helped me until I worked with my naturopathic student at the time — she was a clinician — to recover my cycle and help me have my two beautiful children. So I’ve lived it and it works.

Nora: All the work that you’re doing, Lisa, is paving the way for all these women. So thank you.

Lisa: Thank you so much. Well, I will talk to you both very soon. Thank you so much for this wonderful chance to chat.

Dr. Liu: Always great to talk to you, Lisa.

Lisa: Thank you for listening. If you enjoyed today’s show, please share it with a friend. You’ll find the show notes page for today’s episode over at fertilityfriday.com/411.

I hope that you enjoyed today’s episode with Nora Pope and Dr. Jessica Liu. It was a treat to have them on the show, and of course they are a wealth of information. And the topics that they’re touching on — it’s interesting because I first had Nora Pope on the show many years ago. And ironically, one of the big topics that we discussed, which is the use of progesterone in terms of when it’s appropriate to use in the cycle, seems to have become a bigger kind of challenge since our first episode, if you will.

So it’s certainly one of my biggest pet peeves when working with clients because, in my experience, most practitioners to this day who prescribe progesterone do not provide sufficient instructions as to when is the appropriate time to take it. And I think one of the reasons is because generally speaking, progesterone doesn’t necessarily have a lot of side effects, it has a lot of benefits. And I feel like compared to other medications it’s certainly considered to be low risk. And from a health perspective I suppose it is kind of low risk. But when you’re trying to conceive or trying to sort out your menstrual cycle health, when progesterone is given at the wrong time, it can do a lot of things that you’re not wanting to happen — particularly for my conception clients who follow their doctor’s instructions and take the progesterone on a specific day of the cycle instead of waiting until they’ve confirmed ovulation. Actually confirmed it — not just with an ovulation predictor strip — but to actually confirm after the fact with temperature, or a progesterone test, or an ultrasound or something. Basal body temperature tends to be the easiest way to confirm ovulation at home. But when they’re taking it before they’ve confirmed, I’ve seen it many times on the chart where it will prevent ovulation, and then that cycle is unusable.

So again, that’s one of my biggest pet peeves about progesterone. And then a smaller pet peeve about progesterone is that now that it’s become a lot more common and a lot more mainstream — although many doctors still wouldn’t necessarily prescribe it unless you ask for it — it does seem to be the go-to fix-it strategy, which can then replace the important step from a functional perspective of actually looking at why she’s not making enough.

So I think because low progesterone is one of the most common issues women face when they start charting their cycles — they see short luteal phases, spotting, PMS symptoms, all these kinds of things — the progesterone is a super easy fix to get all of that under control artificially right off the bat. It’s very effective. It obviously helps to prevent miscarriage and it’s a very important tool to have in the tool belt. But ultimately, most women are able to produce sufficient progesterone when they take away some of the factors that are preventing them from making enough. So it’s an interesting conversation. And I think if I had my way, there would just be more nuance. We would just have more of a nuanced conversation about it — including looking at the whole woman, some of the reasons why she’s not producing it, not jumping to the conclusion that she’s not capable of producing it, and having a strategy for whether we’re going to be on it forever or just for a period of time. But most importantly, when in the cycle is the most appropriate time to take it.

For those of you who are struggling with progesterone-related issues and wondering if supplemental progesterone is right for you, I would encourage you to head over to episode 383. In that episode I shared a number of effective strategies that do actually work to improve progesterone in most women, outside of some of the other challenges that can cause endocrine issues and things like that. But the most common reasons for low progesterone, I discussed in that episode, and strategies that I effectively use with my clients to help them lengthen their luteal phase and reduce some of those progesterone-related issues — like the spotting and the moderate to severe PMS and things like that. So again, episode 383, and I would suggest trying some of those things first before jumping to the progesterone, unless it’s a more dire situation related to fertility challenges and things like that. So with that said, I hope you have a wonderful weekend whenever you’re tuning into the show. And of course, as always, until next time, be well and happy charting.