Hey everyone, it's Mikki here. You're listening to Mikkipedia. This week on the podcast, I speak to Dr. Claire Badenhorst. Claire is a researcher, associate professor, and an athlete. And we discuss in depth the often overlooked intersection of iron status, performance, and menstrual health in women. Claire's research dives deep into why iron deficiency is so prevalent among active women, and how factors like menstrual cycle phase,

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hormone fluctuations and even menstrual fluid loss can all influence iron markers. In this conversation, Claire breaks down these complex concepts like luteal phase, defect and hepcidin regulation in a way that's incredibly accessible and relevant for anyone who trains hard or supports female athletes. She also shares

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insights from her recent studies including neural approaches to defining heavy menstrual bleeding and exploring whether menstrual fluid could be used as a tool to assess broader health markers. those of you who are regular listeners of the show will remember that Dr. Stacey Sims and I chatted about this study when I had the pleasure of chatting to Stacey. So Claire gives us an update on where they're at with that research. So if you've ever felt fatigued,

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foggy or flattened training and wondered if iron could be the missing piece. This one is a must listen. Equally for anyone who engages in sport or knows a woman, which is pretty much anyone listening to this podcast, recommend it to your mates as well. So those of you who don't know Claire, she does fly under the radar a little bit, but she's so amazing. She is an associate professor in exercise physiology at Massey University and a leading researcher in female athlete health.

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with particular focus on iron metabolism, menstrual health, and performance. With a background as both an endurance athlete and academic, brings a unique perspective to her work, combining scientific rigor with real-world athletic insight. Her recent research explores the impact of menstrual cycle status on iron markers, the role of Hepatin in active women, and novel approaches to assessing menstrual fluid loss and defining heavy menstrual bleeding. Claire is passionate about improving the health

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performance and clinical care of active women by advancing the conversation around hormones, iron and recovery. And I've popped a link to where you can catch up with Claire on social media, Instagram, Claire Bates underscore Bates, and for you to get more on both Claire as an athlete and also the research that they do over there at Massey.

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Alright team, before we crack on into the interview though, I would like to remind you that the best way to support Micopedia is to hit the subscribe button on your favourite podcast listening platform and share it with a mate. Honestly, that is the way that I get more eyes across the information that I share on this podcast and the amazing guests that share their insights. And it's just a win-win all around. It costs you nothing, more people get to learn and we can advance our own knowledge and insights.

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in the podcast listening space. click like and subscribe. That would be amazing. All right, team, please enjoy this interview that I had with Dr. Claire BadenHorst. Dr. Claire BadenHorst, thank you so much for taking time this morning. Really great to, one, see your face because I've known you, I feel like I've sort of, I don't know you very well, but I've known of you. Obviously we've had comms for, I want to say at least 10 years. And I was so...

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tries to learn just now that you're just 35. I feel like you're a bit of an expert in this space, yet you're so young. Anyway, welcome to the show. Thank you so much, Vicky. I'm really excited to be here today. So, Claire, can you first, before we dive into this area, which I feel has gotten a little bit more traction of late, possibly in part because Dr. Libby has released her book and a supplement, which

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may or may not get into in today's conversation, but around iron and the importance of iron deficiency. So I just want you to share with me and our listeners just what your background is as an athlete and a researcher, and also did these things sort of come together to lead your interest looking at iron status and menstrual health, et cetera? Oh, absolutely. So I

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guess going all the way back to when I first went into university. studied sport and exercise science, so bachelor in that area. And then of course I finished my undergrad degree and didn't really know what I wanted to do with it. So I ended up doing my postgraduate research. So I ended up moving my way up through there, did a PhD.

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And my PhD focused on iron deficiency in endurance athletes and really nicely looked at the hormonal regulation of iron, which I'm sure we can get into a little bit, because most people often discuss it in terms of supplements and deficiency in terms of like the actual biomarkers. But we also got to recognize that there's this beautiful physiology.

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that allows us to almost regulate our iron stores, which prevents all of us from just becoming automatically deficient or at risk of iron overload if we eat a meal that has a lot of iron in it. So that's where a lot of my PhD research was in. And for me, I really was connected to that project and chose to do it in my PhD.

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because at the time I had started stepping into triathlons. So around the time when I went to university was when I first started dabbling in the area. And of course, like most endurance athletes, unfortunately, I got the bug straight away. And then it was a full-time hobby that pretty much encompassed the other half of my life, pretty much. So triathlon just started to become

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how I identified myself outside of this student studying sports science. And I had suffered from iron deficiency so regularly throughout my childhood, my adolescent years, and then even then as a early twenties woman at university. And I was just fascinated around like, I always do the right things. I always eat well.

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I go get my levels checked, I go on supplements when I'm told to, and I always end up back here. Like, how does that happen? And that curiosity just motivated me throughout that PhD. It pretty much pulled me all the way through it, really. And then when I finished my PhD, I got my current job, which was as an academic at Massey University in the School of Sport, Exercise and Nutrition.

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So then I relocated from Perth, Australia to New Zealand. And it's here that I've probably over the last eight years developed a research program looking at iron status and more transitioned from, I guess, the athletic setting where I was focusing on endurance athletes during my PhD to trying to really understand what is occurring in that physiology. And it's almost like that intersect

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with female physiology because again, I carried on being an endurance athlete as I moved. I then moved from doing maybe more of the sprint and Olympic distance triathlons to dabbling more in the Ironman, half Ironman as I'm also trying to be an early career academic at the same time. So that real good high achievement list where I balance everything at the same time.

08:12
And so again, it was like really trying to understand a big question that I often had for myself. And so I often joke to people like some of my most intrinsic motivations for my research have been incredibly selfish because I just couldn't answer some of these things for myself. And yeah, when I was looking at a lot of this research, especially post-PhD,

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And I was starting to develop this, I guess, program of research looking at women's health, well-being, their physiology, how it interacts maybe with like iron status. I suddenly started looking at the research and I recognized almost automatically that in most of the academic publications, we were writing that women were prone to iron deficiency because they menstruate. And then you'd get to the methods section of the article.

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And the sample population would be like N of whatever number, male participants. And I was looking back through it and I even looked at my own PhD and I'm like, we keep citing these stats that women are the group that are more prone to eye deficiency and then we get to the methods and we're doing it all in men. What is that, Claire? Honestly, like I was just like,

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Part of me was like, oh my God, I've actually contributed to the problem here. But also I think it's pretty much just, it's in a way being so much the norm because naturally if you look throughout a lot of health research, it was really only in like 1994 that women were required to be in clinical trials. Before then, the almost kind of

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perspective was there is this natural variability that occurs in a woman's physiology as a result of these dynamic sex hormone fluctuations that occur pretty much every roughly month for these individuals for about four decades of their life. That variability is something that we don't want to account for in research design. So if we look at a traditional research

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project, you want to standardize and control as many variables so that you can look at a specific relationship. So to do that, you're often defining very clear inclusion and exclusion criteria. So we want them in this age, we want them healthy, we don't want them with out this disorder, no inflammation, none of this, da, da, da, which means we've pretty much got a

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cohort of very nicely controlled individuals and our ability to assess a relationship in a more realistic setting is going to be a lot better than if we start adding in a whole lot of additional factors that could change our results. And so naturally, dynamic changes in hormones were considered something that was quite variable. And if we added them into a project, that was just going to mess up our study design.

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So it was easier to exclude versus include and maybe change how we were setting up those study designs, how we were asking those questions. And so as a result, you ended up with a huge amount, especially in like iron research, a huge amount of maybe population and epidemiological research where you're looking at just a single time point blood test and going, oh my God, like iron deficiency.

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huge issue in this age group of women, why that occurs. Okay, that adds a bit too much variability to the study design, so we'll look at men. Okay, interesting. So yeah, that's kind of where you ended up with that. that was one of my observations. And so as I was building this, as I was here in New Zealand doing this research, was like, I have to start answering this question because this is ridiculous.

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And so that's pretty much my background there. Yeah, and I hear it, and I hear you talking about the requirement to control every single little factor. And this is, I guess this is a thing with randomized controlled trials, which I often talk to people about that they're great for. And you can, you're in academia now, so you can actually correct my sort of line of thinking if you need, which is totally fine. But I sort of think, well, they're super helpful for understanding mechanisms. But actually, if...

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But then they're not always translatable to real life actually, because you've got this really homogeneous or homogenous group of people that aren't reflective of, they're only reflective of that particular population, which might account for 0.5 % of who's sort of out there as well. So I always like to put that caveat to people, but I don't know that, but the way that the RCTs are sort of held up as gold standard, yes, for mechanistic, but.

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maybe not necessarily real life? I don't know. What are your thoughts on that? Am I just spinning or what? No, I would probably say the same thing. And I'd often say to people, we need to look and value each different type of research study design for the information that it gives us. But as you say, a randomized control trial, in terms of understanding in people, those mechanistic responses, yes, they're brilliant, but

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They're very brilliant in that homogenous group of people that you've recruited. And if you read the methods, the inclusion exclusion criteria, you're literally like, okay, so this is a very, very specific population group we are dealing with. It's not everyone. Then you've got your what we call the cross-sectional study designs, which is where we at one point will ask a whole lot of people, maybe a couple of questions and

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Those are brilliant because no, they don't give us like exact mechanistic and correlation stuff, but they give us some really good understanding that we can then base some of our other projects off. So they're really good at generating our understanding of what is happening in the population. So incredibly valuable in terms of removing any bias that a researcher will have when interpreting.

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results because it's been informed by the wider population. And then the studies that I probably lean more into a bit more are our what we call prospective observational studies where we follow a group of individuals. We maybe have slightly less strict criteria compared to say the RCTs, but we're really following a group over time. And maybe we're using some of those cross-sectional methods

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to really start understanding what occurs in real world circumstances over time. And again, here we can start seeing potentially changes over time, things that differ between individuals. And again, once you get a better understanding, then maybe you can do a more mechanistic RCT in a specific area. But it's about really valuing each of the projects. I don't think you can really say

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one is better than the other without recognizing the other tools we've got in the toolbox. You can't say a hammer's better than a nail. No, yeah, yeah, yeah, I love that analogy. to build something effective. So I think actually understanding that we have all these tools in the toolbox as researchers and we can use them effectively to actually provide meaningful outcomes for people versus like saying,

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one is better than the other. I think that's my perspective on it, of it, because I've done all the various ones and I've used each of them to create an understanding of some topics. Yeah, nice. I love that. And it's you're using them for the purpose with which they were intended rather than drawing other conclusions or whatever from them. Exactly. Nice one. So Claire, on iron, which is your area of expertise,

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amongst other things, I'm sure. So clearly, it's a major issue in women and particularly active women, although I'll say, of course, as a clinician, I see it in like so many women, women who are vegetarian, who eat meat, who are active or inactive, whatever. So it's not just exclusive to that. can you just, mean, the 101, like why it's such a common problem?

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Is it, mean, clearly the menstrual cycle will play a role because we lose blood every month, but what are these other things like foot strike, hemolysis, obviously not eating enough? Like, is there anything else that comes to mind as to what might explain why it's such a common deficiency, such a common problem in women?

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I think there's quite a few factors. And so this is that beautiful thing of like when you're dealing with human beings, you can't really say it's like maybe just like one specific thing that's causing it. Cause okay, we've got to think about it as someone that exercises. We know that exercise will actually accelerate iron loss and it's not just one specific area. So you name it things like foot strike can cause hemolysis, which is where red blood cells, they're not

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as we say, the most highly, I guess, cells with the highest integrity to them. They kind of like break in that sense. And that's a natural process. That's how we recycle and we regenerate a lot of those red blood cells. But exercise through sweating, through that hemolysis and stuff can turn over our red blood cells quite quickly, which means naturally we are getting some of those accelerated iron losses.

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We don't just exercise maybe once a week. We do so maybe quite consistently. Depending on your level of exercise training, you might be doing that two, sometimes three times a day. So if you've got more iron losses or more processes that are encouraging iron loss, that's gonna maybe tip what we call your iron balance more towards that negative state. Because even if you're eating a diet that has

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adequate amounts of iron in it, if you are regularly doing something that's gonna accelerate those iron losses and you don't compensate for that in your dietary intake, that's gonna shift you into that negative iron balance in that most simple, almost explanation there as well. What we also know is that the main way in which our body gets iron is through that dietary intake. So of course that's gonna have a huge impact.

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And I think what's really important to highlight here is that there's always been these discussions around like, do you eat a vegetarian or vegan-based diet versus a non-vegan or vegetarian-based diet? And actually, what some of our research, especially some of the research done by my human nutrition colleagues and dietetics colleagues, they did a huge project in vegans.

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sometimes with those vegetarian and vegan based diets, individuals are very acutely aware of the how they structure their diet. And so they're paying attention sometimes more so than people that aren't on those diets to this specific amount of protein and how they structure it and getting it all nicely in. But I think it becomes a bit of a discussion then around like how you're maximizing the

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bioavailability of that diet to support iron absorption. So if you are having huge amounts of coffee and tea, so having a huge amount of tannins that are going to really affect that iron absorption, then you've kind of got the issue that even if your diet has enough iron, maybe you're not absorbing it as effectively and then you're exercising a huge amount, so you lose iron. So I guess at

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that initial level, you've got almost like these two things we need to balance in order to help us with that optimal iron balance intake versus accelerated iron loss with exercise. But then we've also got to think about, as I said, I looked at the physiology and hormonal regulation of which this was really only discovered in the year 2000. So in science terms, we're 25 years into understanding this hormone, so very new.

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I love how slow science moves sometimes, but at the same time, you're like, wow. So was only in the year 2000 that they discovered that there is a hormone that responds and helps us regulate iron levels because we don't necessarily make iron and we don't also effectively lose it or export it. So there are ways in which your body does lose it, but there isn't a specific, okay, this is our loss mechanism.

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If you've got normal healthy iron stores and you say, eat a meal that has high iron in it, you don't want to be absorbing all of it because iron as a, I guess, a chemical mineral is so important to our body, but it's also highly reactive. So you don't want too much of it because that's going to put you into that highly reactive oxidative state. you don't want that accelerate cell damage?

22:19
Yes. So you don't want to absorb too much from it if you've got healthy iron stores. And this is where this hormone is really important because this hormone, hepsodin, effectively, if you've got healthy iron stores and you eat a meal that has a huge amount of iron, this hormone is going to peak and it's going to effectively blunt a lot of the absorption. But

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If you are say, I'm deficient and you eat that meal high in iron, you're not going to get that hips and response and your body's going to absorb lots of it. Interesting. And what like, um, I guess my initial research group when I was doing my PhD found is that hips and has this almost evolutionary response, which is when there is inflammation in the human body, hips and levels increase. And that's because when we're sick,

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we get an inflammatory response. And that inflammatory response and that increase in hips and that occurs with it is to make sure that our body's iron stores are pretty much locked up in the iron stores and they're not being moved out into our bloodstream and everything and moved towards our bone marrow for red blood cell production or for any of the other processes. try to it locked in because if there's an invading bacterial or pathogen in our body,

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They also need iron. And if we keep the iron out, they don't have access to it. So it's almost like one of our body's immune responses to be like, this is how we're going to fight this invading pathogens so that I'm going to store the iron. It's not going to access it. I'm basically not allowing it to spread throughout my body. So that is incredibly beneficial.

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evolutionary response from this hormone. Problem is when we exercise, we get an inflammatory response, natural, and what our body needs to adapt to exercise load. But that then means that about three hours after exercise, you're getting a spike in this hormone, which means any meal you eat after exercise, you might not be absorbing iron as effectively.

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So now we've added in another system that's affecting iron absorption and maybe reducing it, but then we're still accelerating iron losses with exercise. So if you're looking at it, that combination for any exercise, the individual, male or females, naturally going to increase your risk of iron loss and increase your risk of iron deficiency. For women,

25:05
What we know is that regular blood loss also contributes to the onset of iron deficiency, probably more so than actually menstrual fluid loss is blood donations. Unfortunately, while very much required for our health system, very good at inducing iron deficiency. regular menstrual blood loss has been reported as a key cause. actually, when you look at

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more of what we call the empirical research, so the ones that have actually looked at variations in menstrual fluid loss. It's actually only heavy menstrual bleeding that is a key risk factor for iron deficiency because naturally in heavy menstrual bleeding you're losing a larger volume and that larger volume from some of the research, which we can maybe discuss a bit later that I've done now, seems to actually be a larger volume of blood within the sample.

26:02
And so with that regular loss, combined with all the daily stuff that I described before, that's just going to constantly put these highly active women in a negative iron balance. And if you're not aware of that, you're just going to constantly keep spiraling back down into iron deficiency. it's a bit of a, all the different pieces of the puzzle going into it there. Great, Claire. I've got a few questions. My first one is,

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With Hepsodin, is it a diurnal rhythm as well? is it higher at night than it is in the morning? that correct? Absolutely. So yes, they have found that. And naturally, again, it kind of reflects almost exposure to iron levels. So if we think overnight, you're not eating anything with iron in it. And so those levels are going to drop. And then throughout the day, of course, we've got all the...

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breakfast, lunch, dinner, and you might have like iron as a micronutrient in all the various types of meals. You might eat an iron fortified food. So the more exposure you get also to those iron based meals throughout the day, the higher that hormone is going to get. So yes, we do see the styonal variation in that hormone and it often reflects exposure to iron that the individual is getting through their diet.

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It's interesting with diet. I really loved how you said that vegetarian women are aware that they aren't getting the heme iron in their diet. So they may actually be in a position where they look after their intake and think about it a bit more. Whereas I do feel like some women who are on the floor, they're like, oh, but I eat meat. But they don't really stop and consider that chicken isn't a particularly high source of iron. And I'm just thinking from a clinical perspective, what I see.

27:52
And they may eat red meat like maybe once or twice a week because they've heard that red meat causes, you know, heart attacks and all the other things. particularly health conscious women might actually be more at risk, which I see. And my third thing is I'm interested with your understanding of this as well with the populations you've worked with, is that that Farragard, I never say it correctly, Farragrad, whatever it is, like so many women,

28:20
just do not take their iron supplements because it's really, that is particularly hard on the gut. And they, in their mind, they're like, well, this is the only option, it's this or nothing. So do you see that with the people that you interact with? Absolutely. And it's also one of the key things that I'll say to people. I'm always very clear that I am a physiologist. And if you want really good diet,

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dietitian or nutrition advice, please go to like a registered individual like yourself or a dietitian because like, I can tell you probably what you're doing wrong with your diet. Am I going to prescribe you? No. Like that's my, like I have a very clear line there, but it's like, as you say, I often very similar see in the health conscious individuals, there is a lot of potentially like the restrictive behaviors and that sometimes can be a

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bit more detrimental to your overall energy, macronutrient and micronutrient intake. Probably the diet that I often describe as most associated with iron deficiency is what I call the leftover vegetable diet, where maybe like an individual in the family decides to become vegetarian or vegan, but no one else really gets on board with them. So they eat the leftover vegetables and salad. And so the leftover vegetables,

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a salad diet, that one, because you're not getting in the good proteins or anything, that sometimes can be a bit of a red flag as well. So yeah, very much what you described there clinically, we sometimes see a lot of that in some of our research results as well. But on the supplements, yes, that is that most commonly prescribed one. And I think there is also now a beautiful discussion around potentially what

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becomes normalized maybe in, I guess, general practice. If that's what's there, that's available, that's maybe subsidized. Naturally, maybe that's what our general practitioners are going to prescribe to women because it's, okay, that's easy. It's there. We know it's going to work and it's subsidized. So, okay, that ticks all the boxes.

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If an individual struggles with those supplements and we know that iron supplements are notorious for causing gastrointestinal, I guess, upset and side effects, one of the key things I say to women is advocate for yourself, ask for something else, tell them that you have these side effects, because there are alternatives. There are alternative supplements. There's newer ones that are coming out.

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meltofa, I often say to women, one where it's like, actually, that formulation has been shown to reduce side effects in women. So you know what? Ask for that one. That can actually be really beneficial. There was research that showed that if you still struggle, if you have it in the morning, but every second day, that can reduce those symptoms again. And it's

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finding the strategy that works for you. And then there's some women where no matter what strategy you use, they always end up with those symptoms. And at that point I'm like, ask for an infusion, ask for an injection, because is it worth you staying iron deficient and your quality of life getting lower or taking these supplements, not improving your quality of life because of symptoms or having an alternative.

31:55
Like sometimes you have to push for it. Like I've had to push for it. And it's like, you actually have to, you might have to do that, unfortunately. So. That's great. And I, you know, there are a number of which I recommend women take and they feel or anyone take and they, and they do tolerate them so much better. I was interested to see, this is a bit of a tangent, the research on Floridics actually, which doesn't work as well.

32:24
as other iron supplements because of the plant polyphenols, I think, sort of doesn't make it as bioavailable, which is a real shame because, you know, that's the one that a lot of women will probably veer towards, you know, it's because they give it to their children as well and then I'll just take some fluoridex, but haphazardly, surely that's enough. But the symptoms that they still experience sort of tells them otherwise. Yeah, yeah. As soon, unfortunately, we do know that those plant-based iron sources, they're

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their ability to absorb is always gonna be slightly less. so, yeah, it's unfortunate, but it's like- That's the reality. It is the reality and yeah. Hey, Claire, question. This isn't something I actually asked you about in my little question I sent you, but you mentioned fortified food. Do we have an idea of how well absorbed the fortified food is with iron?

33:20
I don't specifically, I guess I haven't really delved deeply into that. Naturally with the fortified foods, I think it's always going to be based more on that non-heme. Even our supplements and everything are always that non-heme iron. So again, I think there's always going to be strategies of which you can maximize that. And we know that with the enhancers and inhibitors that can really help maximize that non-heme iron absorption.

33:46
But yeah, I haven't specifically delved into that area. I probably stayed more in the realm of the physiology, actually looking at some of those other areas there. Yeah, no, that's great. That's just really good context, I think. can we talk... So, one of your recent studies that you told me about in our email was looking at the menstrual cycle status in iron levels, which of course, you mentioned that one of the biggest sources of...

34:14
iron loss is in women with heavy menstrual cycles. So with the menstrual cycle status, you mentioned a number of terms like luteal phase defect, inovulatory, and of course, youmenorec, which is your healthy menstruating woman. But can you for us sort of just explain a little bit about your research and also explain those different menstrual cycle types and their impact?

34:43
just to give some clarity around the entire study actually. Oh, absolutely. I'm going to take a step back because one of the first things I'm going to describe to people is what I refer to. I'm probably a few more physiologists now are referring to as the menstrual cycle physiology. So I think when most people think of the menstrual cycle, they think of hormones, estrogen, progesterone, their fluctuations throughout a month.

35:11
The fact that women experience menstrual bleeding and then somewhere around day 14 we ovulate and then we have like, that's almost a description of the menstrual cycle. And I think most people's understanding of the menstrual cycle has become intrinsically linked to the changes of estrogen and progesterone. What I am often telling people is that the menstrual cycle is actually the umbrella term for

35:41
two very distinct cycles. The first cycle is the ovarian cycle. So this is the changes of what occur in a woman's ovary. And that is from getting signals from our brain to pick up a whole bunch of follicles, developing one of those follicles into a mature follicle, and then the rupturing of that follicle.

36:10
in response to a hormonal message and releasing an egg into our reproductive tract. So that is pretty much the ovarian cycle. What changes occur in the ovaries in response to signals from the brain and our chemical messengers, which are our hormones. The second key cycle is the endometrial cycle, which is what occurs in the endometrium.

36:40
in response to changes that are occurring within the ovarian cycle. So here, we're talking about that inner lining of the uterus and what's actually happening to develop that inner lining converted into a lining that's receptive to implantation if fertilization occurs, and then the shedding of that lining so that we can begin the whole process again. So actually, those are the two key cycles

37:10
that fall underneath the menstrual cycle. I'd probably say they're the main events. Hormones necessarily aren't the main event of the menstrual cycle. Hormones are chemical messengers. So I describe hormones as like a text message. You can't have a hormone if you don't have something initiating it or if it's going to have an action. So the initiation happens in the brain? Initiation happens in the brain.

37:40
So then you get a release of a chemical messenger, i.e. a formant. message. Yeah, text message down to the ovary. This signals the ovary to start its new process of picking up follicles. And as that one follicle develops into a maturing follicle, it's going to send a text message, in this case, estrogen, to the endometrium to start developing its lining. So estrogen is really just the message relayer.

38:09
between what's happening in the ovary to what's happening in my endometrium here. Then my brain's going to get a signal because estrogen is also going to send messages up there, text message up there. right, follicles develop now, signal ovulate to occur. We rupture, ovulation occurs, and then we develop another gland in the ovaries, corpus luteum.

38:34
And that's going to send both estrogen and progesterone, so text messages to the uterus. This is what you need to do with that inner lining. And if no pregnancy occurs, a corpus luteum breaks down, no more text messages to maintain the endometrial lining. So our body sheds it. So that's that almost like interlink. But if you're not...

39:01
saying that hormones are these fixed things, but rather the key messages that are being relayed from our brain to our ovaries, from our ovaries to the endometrium, you understand that the concentration of those hormones are going to change based on how those three areas are responding to either internal stress or external stress.

39:30
So what we actually see is this menstrual cycle and the presentation of the menstrual cycle sits on a continuum from where we've got amenorrhea, which is no menstrual cycle. So basically, brain's not sending signals down to the ovary. Nothing's happening in the ovary and we're literally not sending any information to the endometrium. So we're not having a menstrual bleed. So that's when

39:59
women don't experience any menstrual bleed and that happens before adolescent postmenopause and unfortunately with high amounts of stress or low energy intake in our reproductive years. Then if we start sending signals down from our brain to our ovary and we're maybe picking up some of those follicles, but we're not really developing them to that very senior mature follicle that will rupture and ovulate, we're getting

40:28
bouts of estrogen because what our brain is doing is trying to get our ovaries to kickstart. But with that, the amount of estrogen is going to be proportional to the development of that maturing follicle. So you're going to get spurts of estrogen, but you might not have, I guess, full proliferation or development of your endometrial lining. You're not going to have progesterone. And because of these spurts, you might have quite long cycles. So that's our oligomino-reaquiment.

40:59
And then we enter, so those two menstrual cycle status is very noticeable. You either don't have a menstrual bleed or you have a menstrual bleed huge, like maybe like every month and a half or every two months, so quite far apart. And then we've actually got it where women will actually experience quite regular menstrual bleeds, but we have almost these subtle menstrual cycle disturbances where our brains may be signaled, our ovaries,

41:29
to develop a mature follicle, but it doesn't actually develop almost to a point where we're getting a massive surge in that level of estrogen that will kickstart our brain to actually send the signal down for ovulation to occur, which means we'll get these massive spikes in estrogen, but we don't ovulate. And that is what we call an anovulatory cycle. But within that,

41:55
because you're getting this bout of estrogen and then estrogen breaks down, you're still having a menstrual bleed in quite a regular timeframe. So you might still have like menstrual bleeds roughly every month. Then you, after that, you might have a cycle where you do ovulate. So estrogen does get your brain to send that message down. But then when you form your corpus luteum, it either doesn't produce enough progesterone or

42:24
It breaks down within less than 10 days. So we actually need a corpus luteum to last a bit longer than 10 days to allow for successful pregnancy, but it can break down. And so if that breaks down, we don't get enough progesterone. And so that's what we call a luteal phase defect where we have a luteal phase because we have ovulated, but our progesterone levels are just not enough and not quite right. But.

42:54
we're still going to have a menstrual bleed every month. And then the final one is that what we all probably know as the healthy human ovarian ovulatory cycle where everything happens according to plan. So basically we have high estrogen levels. There is good coordination between our brain, our ovaries, our endometrium. We have that high estrogen. It tells us to ovulate our corpus luteum.

43:22
actually secretes enough progesterone and estrogen and that we menstruate. So a lot of research, what we find is that most research has focused on the extremes of menstrual cycle physiology. we know about potentially eumynorrhea and then amenorrhea and oligomynorrhea. But because

43:46
Most women don't actually know that this physiology exists or have it had it described. They think having a regular menstrual bleed means like, oh, that's great. I'm ovulating all the time. Actually in a lot of the population research, we find the presence of not ovulating and ovulation is at least like four times sporadically throughout the year.

44:12
And then in exercising women, and this is just not in athletes, but general exercising women, the occurrence of an ovulation or luteal phase defects sits anywhere around that 30 to 40%. So yeah, it's quite a prominent one, but because you still have a regular menstrual bleed, most women are not aware that they might actually be an ovulatory or having a luteal phase defect.

44:41
Is it clear, is it stress that is causing both of those conditions? from wherever, you know, the body will respond to it. Is that the major cause of an inovulatory cycle or a luteal phase defect? What else impacts there? Well, that's something that we're trying to tease out right now with some of our research, because I don't think really anyone has delved into why they occur. Again, this was one of the joys of women's health research.

45:11
There's so many things where you're like, why does this happen? And people are like, I don't don't know. Well, I guess we'll figure that out now. but yeah, some of the research that has looked at, say, monitoring either a psychological stress, there was one research project that looked at dietary restraint levels, so stress associated with dietary intake. There's another research project that's shown like getting exercising women.

45:40
and then monitoring that. So looking at the various types of stress and their results have kind of shown that the occurrence of these luteal phase defect and anulbilatory cycles tend to be associated with this increased stress response, whether it's psychological, emotional, dietary restraint, or with like the increase in exercise.

46:05
what specific one causes it. I don't think it could be a specific one because again, our bodies like we might cognitively differentiate between different types of stress. I often joke that like, I guess how physiology is quite dumb compared to our cognitive ability because we differentiate types of stress, but physiology is like

46:28
Stress. Stress. I describe it to people as when you describe someone as like mentally burnt out, the symptoms they present with are someone very similar to someone that's like overtrained and physically burnt out. So it's like, there is a symmetry here. And so we're really starting to look at, right, we've done it, I guess that

46:57
prospective trial. So we've monitored women over a period of time. And one of our, one of my post-grad students, she's actually going to be looking at associations between women's perceived stress, some of that dietary restraint, some of that exercise load, and then the occurrence of these menstrual cycle changes in a lot of women. Because what I actually think is happening

47:26
is what I'm probably now referring to as more of like a allostatic response. So I guess most people are aware of like homeostasis where we've like got a healthy baseline, we deviate away from it we come to baseline. Allostasis is known in more medical models, which is the human body has this incredible capacity to adapt to a stress.

47:53
And so the example I use is when you exercise, you expect your heart rate to increase. And when you're monitoring your heart rate during exercise, you're not seeing your heart rate trying to like come back down to baseline to come back to homeostasis. It stays elevated so that it can tolerate the stress that you're putting it under. And then once you remove that stress, then it comes back down to baseline. And so what

48:21
we're kind of seeing popping up in quite a bit of our projects, a few different ones, is that there's this allostatic response to a woman's physiology, which is you will put stress on it and it adapts and it will maybe stay down there. Once I remove that stress, I expect to see it adapt in the other way. And we constantly, we're actually seeing these flux and patterns with a lot of women. it's

48:47
To me now, I've probably shifted my terminology of a healthy menstrual cycle to being one that is adequately responsive to stress and responds appropriately when I remove it away. And so that's like probably, yeah, that's probably a key trend that we're kind of seeing coming out in a lot of our projects. So I guess that describes the whole menstrual cycle side of it. So when we add in the layer of iron status,

49:16
What we were also wanting to have a look at is key questions that again, I went through the literature with this project and I just couldn't answer. Probably one of the things was actually how does iron status change in women over time? What are the key things? What are the variations that occur with women? Is it duration of menstrual bleed? Is it self-reported heaviness? Is it dietary intake?

49:46
is an iron regulation. And so we've monitored iron status at different time points of the menstrual cycle, just to try piece a more holistic understanding of what's going on there for women and their physiology. Some of the things that we have noticed is that, and this is shown in some of the previous research is of course,

50:10
there are changes specifically in our more rapidly responding iron biomarkers. So you're looking at serum iron, total iron binding capacity, transfer and saturation, where we see shifts in response to iron demand, which means that naturally when a woman's having her menstrual bleed or her period, that's a huge stress on iron demand because you're losing blood.

50:37
And so as a result of that, we often see drops in those hormones. And then as that menstrual bleed ceases, those levels rebound and come up. Some of our more stable iron markers, so hemoglobin and ferritin, they don't show as much dramatic movements, but those other ones that respond quite acutely to iron demand and need, we do see that shift. And it appears to be very strongly due to

51:07
that loss, like that increased iron demand because we're losing blood at that time point of our menstrual cycle there. As you're talking there and wondering, does it, so acutely there is a change, are we, do we know how much of an impact it has long term for these women? Is that something that you're interested in understanding more? Absolutely, like that's one thing that we're trying to find out because again,

51:33
We're really only now starting, I think the first project that actually published variations in iron status in women throughout the menstrual cycle was done in 2015. So again, we're only 10 years past that. And if we think about the slow moving giant that science and research is, that was basically yesterday. We are really needing to play catch up in this area.

52:03
what impact does that have consistently over time for these women? And so yeah, actually monitoring and seeing these changes with their menstrual cycle is going to become so important to actually maybe providing women with better information around like, can we actually work with your physiology to make sure that we're prescribing, giving you information that's going to be really effective long term? Because

52:33
if we were giving information that was effective long term, why would so many women still be ending up iron deficient? That's such a great point, Claire. And I do have a couple of questions related to, as you were describing, the menstrual cycle and the ovarian cycle and endometrial cycle and the messages and stuff. my first question is, we probably don't know this, but

52:59
Are there any nutrients, micronutrients, involved in these cycles that may change how they operate in terms of a luteal phase defect or a novelatory cycle? is it just stress per se? you know, does a nutrient inadequacy... Like I said, do we know anything there about a particular nutrient? Probably the most well-reported

53:27
nutrient in this area that's come through some of the other areas. And we're not maybe looking at the micronutrient level, we're looking more at that macro level is of course that carbohydrate intake for women. So we know that carbohydrate intake or low levels of it is going to influence that signaling of our chispectum neurons in our brain. And that's very much linked with that.

53:54
I guess that key reproductive center in the brain that sends signals down to our ovaries. And so there is a bit of research showing that low carbohydrate intake, particularly when an individual maybe needs it, quite prominently can potentially down-regulate the signals from the brain to the ovaries, which means you're gonna start sliding down that continuum from.

54:21
a healthy ovulatory cycle down towards amenorrhea. But again, this is going to be quite individual dependent and we know this. So it's like, it's not a one size fits all approach. Like in some cohorts, I think potentially individuals that maybe are at risk of maybe some more of the metabolic conditions, that's going to be a bit more of a stress on the body than

54:47
the single macronutrient at this point. And at that point, are we prioritizing the individual's health and actually saying like, okay, maybe in this kind of case, like actually adjusting that diet to help alleviate the stress of this metabolic condition is going to be far more beneficial. And in that sense, by alleviating that stress, that can be quite helpful. But I think when you get to maybe that high-end, elite, highly active person,

55:16
I probably want to meet making sure that they are getting those carbohydrates because that's actually going to ensure that optimal functioning of that human body. So I do recognize that some of that research has probably more come out of the athletic environment. Does it apply to everyone? No, I think we still need to look at that appropriately there. See, Cliff would say that a lot of the low carbohydrate

55:40
availability is conflated with low energy availability, which is what I've seen as well. the teasing of it out, but I mean, is it a challenge or is it not? actually Cliff's dismissed it and I have too. you know, we just. Honestly, this is an issue that I think is prevalent throughout. So there's actually been like some really great discussions in the academic literature right now about

56:09
low energy availability. Is it low energy or is it low carbohydrate availability? Because when you actually look at the methods, you're like, oh, by manipulating the carbohydrates, you've really affected the energy intake there. you've kind of got like almost like two pools of research, some that are showing the effect of energy, some that are showing the effect of carbohydrate, which is so definitively, can we actually say it's one or the other right now? I think that two

56:38
I conflated, like they're too interlinked right now. so I genuinely, the methods of a paper will tell you so much. And so will the results. But honestly, it's like actually recognizing where that occurs can like really help because yeah, I don't think there's one thing or the other. mean, years ago, I was looking at some of the impacts of

57:06
low energy on Hepsilon responses and actually finding that in a low energy state, you were getting this exaggerated Hepsilon response. And then there was other researchers that were like, no, it's not energy, it's carbohydrate. was like, technically, I think we're both correct in some sense, it's there. to disentangle. It's so hard to disentangle. And if I, I always come back to like, what is

57:34
the most real world example of this. And I often think when someone goes on a diet, which is probably the key way in which they're going to reduce the energy intake, what's the first thing they're going to remove from that diet? It's going to be a carbohydrate. So how do you tease it out? Because most people's behavior is going to be that. And so that's been our norm is low energy, low carbohydrate. They go hand in hand together.

58:03
So it's like, I totally agree with both of you there. I think it's, yeah, the ones that have looked at it more in that reproductive side have focused more on that carbohydrate aspect, but how do we not know it is the energy? yeah, sorry, I'm probably adding to your question and answering No, no, no, it's good. It's really great to have the discussion, because I know if Cliff was listening to this, he'd be like, Mickey, why didn't you say this? Because I know he values your insights and opinions, and I'm sure that you guys have had that conversation anyway.

58:32
And I also think, Claire, whenever there is low energy, there's just low opportunity for nutrients. And so the micronutrient question I think about a bit too, the diet quality is always going to be compromised when you've got low calories across the board because there's just less opportunity to get those nutrients in. I guess to your point, there's just so much we don't know about this, which actually comes to my next question on the...

59:01
for you, which again, we'll get back to your study, but this is more of a big picture thinking. There is just a lot of debate right now on menstrual cycles and their importance of affecting outcomes, particularly related to sport, I think, is where a lot of this sort of opinion is. As I look at the, not the camps, but the reviews and stuff like that, I look at it and think, well, gosh, it's

59:31
if one of the criticisms is that the research that has been conducted to date, you know, isn't actually as well, as rigorous as what we understand it should be, can we really say that there is no, that there is no effect? And of course, there are always going to be individual differences and we need to order regulate and all the rest of it. I don't know that the science is settled here.

59:59
actually. I think that, and I know that there's been most recent research from Dr. Lauren Colenso-Semple and she's looked at a study of women and I think she just said, you know, no real difference. I mean, this is actually completely different from your level, your area of interest. So, but I'm just interested to hear your perspective in the female health physiology as to the debate, if you're happy to share with me your thoughts on this. Oh, absolutely. I guess for me it is

01:00:28
Yeah, if we go back to the most basic science principles, if the evidence is low quality and there's not enough of it, you cannot make a definitive conclusion. And that's the thing. Right now, when we actually do these reviews, the most prominent finding that comes out is the studies were low quality. So it's like, okay, so you've rated everything as bad, so you cannot make definitive conclusions.

01:00:58
And one of the key things that I think we really need to be mindful of in sports science is when we look at the study sample size, so we come back to those methods, we actually look at some of the total populations that projects have been done in. And N of 12 is not equivalent to every single woman in the world. I'm sorry, but it's not. And if you then look at the demographics table in the results section,

01:01:27
An N of 12 Caucasian woman is probably not going to be representative of every woman in the world globally either. So we've got an incredible bias towards very small sample sizes, which are statistically underpowered, which means our ability to draw definitive conclusions in a sample that I mentioned has incredible natural variability to it. And then you put it only in one ethnicity, really.

01:01:58
You are just doing an at like to me, I just like that. You've got to recognize the limitations of your work and be completely transparent about that. It's not saying that like, listen, I've done a bad job. This I wasted my time. It's like, I'm going to look at the data and recognize its strengths and weaknesses for what it is, but I'm not going to do a blanket rule on every single individual and

01:02:26
What I often say to most people is we've shifted from what we actually need to recognize is that when we're working with an athlete, one specific thing is not going to make or break their performance because we know as human beings, there's going to be nutrition, hydration, sleep, whether or not they've been sick, how recently they've been sick, how well have they tolerated their training, what is their perceptions, their motivations, their readiness to train.

01:02:57
For women, we have these natural variations that occur. And for some individuals, we know that because we've got receptors to the sex steroid hormones throughout our bodies, pretty much like most people, there's hormone receptors throughout the body. And we know that there's individual neuroendocrine sensitivity, which means they're gonna experience different symptoms at different time points of the cycle.

01:03:27
And depending on that individual's experience of those symptoms with the different concentrations that can naturally occur day to day, cycle to cycle, plus their social context of how they grew up with the menstrual cycle, whether or not I see this as bad, this is good, any endocrine disorder or not disorder, I guess.

01:03:54
a gynecological kind of condition that could exist there as well. That kind of social context is also really going to influence that individual's experience. So if I've, say, grown up with a mother, that's like all empowering. I've had my period. I feel great. Like I may be going to not register it as much as someone that maybe has experience of extreme pelvic pain that flares up when they move, who's watched her mother maybe

01:04:24
um, be on the couch for a couple of days, every single menstrual bleed. And so those kinds of variations, that's where I'm like, actually sometimes monitoring that for yourself. It's not to give those group level comparisons because we cannot do that in sports science because our samples are too small and the research to date is too low quality. So group level comparisons statistically like.

01:04:52
You take our maths to any engineer or data scientist and they laugh. That's the same with nutrition. Totally. Yeah. Yeah. It's too small. They're like, you can't make any group level comparisons. There's not enough data points. And so that's what we've got to recognize. And so at that point, individual monitoring, and it's not so much for the performance outcome. It's more as like a health marker. Like you would monitor someone's RPE or

01:05:22
readiness to train or motivation that can give you a bit of a trend and you can be like, oh, you can start educating that person that like this might come up in a couple of days. Like when you feel this way, it's not that something's gone wrong. It is this kind of happens with your change, your hormone levels every single time. And so I probably, when I look at it go, I recognize that there is still more work to be done.

01:05:51
A, we need to improve the quality. B, we need to improve the total sample size and numbers. And C, right now telling women that therefore it has no impact when we can see that women have these variations and experience, particularly when it comes to symptomology that can then, like that symptomology that's tied in with those hormone messages that can influence how they feel on any given day.

01:06:22
is literally taking us a step backwards in terms of empowering women. Cause you're basically telling a whole lot of women, I'm sorry, I'm just counting your experience and there's nothing wrong with you. Carry on. Which is how is that different from any other form of medical treatment that we've given women? So at that point, I'm like, absolutely not. Educate women. And at this point in the absence of group level comparisons,

01:06:51
empower yourself by understanding your unique trends. Because honestly, in our research projects, that was the thing that most women valued. like one key memory that stands out to me all the time is we had a participant at the end of our big project come to me and go, thank you so much. I now know I don't suffer from anxiety and depression. And you know, and you just like,

01:07:19
I'm not really sure how I achieved this, like, all right, like expand. And she was like, oh, throughout my life, I've thought I've had bouts of anxiety and depression, but because you asked me specific questions or would send me a text message going, your period's due in a few days time, because we were scheduling time points of data collection during their cycle. She was like, I now know I'm just, my period's going to start in like two, three days time.

01:07:49
Yeah, amazing. She an explanation. Explanation. And it's like, it's not devaluing you. It's not saying that you cannot do things. You cannot perform. We know women are exceptional performers in any given environment, but I'm really not for disempowering them in their experiences with their body. just because there's not numbers or quality of research. I'm sorry. I just...

01:08:18
I look at the limitations and I'm like, have to, as scientists, hold ourselves to better standards. So I guess that's my opinion there and I will totally stand my ground on that. Nice one. I love it, Claire. I really love it. So back to your study then, because I'm looking at the time going, God, I hope Claire doesn't have a 1230 appointment. And I will be quick, I promise. we're talking about the flow and the heavy menstrual cycle flow. And this is where

01:08:46
it can be a particular challenge. And of course, we're talking about active women, but let's not forget perimenopausal women often have quite heavy menstrual cycles to it. That's something that's developed. What is a heavy menstrual cycle even? at what point do women need to really be mindful of that becoming an issue in terms of their iron status? Oh my God, Miki. Like literally as you're asking this question, was like, oh my God.

01:09:13
She's opening another can of worms. I honestly, I love it. I could talk about this stuff all the time. so yeah, it's been actually really interesting. And so one of the actual things that like it's literally only something I probably have real knowledge about now having done some research where we've actually collected menstrual fluid samples, but also

01:09:40
looking at some of the things where it's like, okay, what is this definition of heavy menstrual bleeding? And so if we look more back in the research setting, what we actually find is that heavy menstrual bleeding or blood loss occurs when a woman loses or like, like this is research based definition, they lose about 18 mils of blood within their total period. So every single day that you have your bleed, you lose

01:10:09
80 mils of blood. What we actually need to be really mindful of is that your period is not, and the fluid that you lose during your period is not solely made of blood. Blood is actually a sub component within the total fluid sample. So actually there is no corresponding

01:10:36
volumetric measure of total menstrual fluid loss that correlates to the subcomponent of blood that would classify someone in a research setting as a heavy menstrual bleeder. Because of that, most people have classified an individual as a heavy menstrual bleeder if their menstrual bleeding

01:11:00
impacts their social, emotional, and physical quality of life. So if you are experiencing a menstrual bleed that causes a huge amount of emotional distress, anxiety, it impacts your ability to engage with social activities, or you find that you are really struggling to control that menstrual bleed. You are finding that like

01:11:27
pretty much no resources helping you control that. You have leakage and everything that occurs. They've used that now as a definition of heavy menstrual bleeding. So yeah, it's quite tricky because we're probably now needing to actually look at like, cause we've got more of these reusable products where women can actually see their menstrual fluid, actually looking at what is the total volumetric measure that equates to

01:11:57
heavy blood loss because total volume of fluid, the volumes that we have, the ones that get put out there in any health communication of 80 mils is not for the total fluid sample. It's for a subcomponent. So what else is in there, Claire? People are going to want to know. Vaginal secretions, you've got endometrial tissue, you've got cervical mucus. And so you've actually got like other cells and probably the

01:12:26
bigger one that kind of comes out that's more visibly able to see, you're able to see is that cervical mucus. Most people, women won't recognize it initially, but if you've got like a cup and you actually can see the sample, you might find that the total fluid sample is potentially a bit more stickier. Blood is quite runny. It's quite liquid. Menstrual fluid can have this really fascinating, almost like sticky consistency to it that comes from

01:12:55
cervical mucus. So it's not just liquid. But what we've actually found in some of our projects where we did collect it is of course, the heavy menstrual bleeders on the day where they have the heaviest flow because what we've also looked at is that every day of your period, there is different volumetric losses. So actually, the first day of your period, you don't actually lose a huge amount.

01:13:24
But generally you get this wave where it goes from low and then you peak and you have your most fluid loss around 24 to 48 hours and then it drops off. And that drop off can either be quite exponential. So women experience a rapid drop off and others will experience quite a more reduced kind of drop off and it like peters out over a period of time. But on those that 24, 48 hours of heaviest flow, a woman that has a

01:13:53
heavy flow will have a sample that is a bit more liquid because there's more blood in the component of their menstrual fluid sample versus a non-heavy menstrual bleeder where you'll get the sample. Literally, I mean, you can do it if you want, but if you tipped it into a container and swirled it around, you would actually see that it's quite sticky. It's almost like moving around like very runny honey kind of thing. Yeah. Yeah. It's a lot less blood.

01:14:22
a lot less blood in the sample. that's pretty much. So yeah, if you want to have a look at it, we actually had some women collecting samples at home. So like a few of them have done it for us. For some women, I know that this is like an absolute no-go zone. They're like, Claire, you have lost the plot. I'm like, that's fine. Yeah. In that case, if it is impacting social, emotional, physical quality of life, that is almost the key, I guess, more

01:14:52
I guess subjective description of that heavy menstrual flow loss for women. Which actually makes a lot of sense given that we're talking about lived experience through the menstrual cycle and just how much of an impact that has and why we can't discount the idea that there is an effect because you could potentially be discounting all of these experiences. makes sense to Absolutely. And it's just like, you look at that and it's like you've really got to take

01:15:21
the person that you're working with at face value because no one else knows their body better than themselves. And so you've got to really acknowledge that experience that the individual has, and especially if they feel comfortable sharing it with you. of course, each woman's experience is going to be so unique to to her basically. But it doesn't mean that there's something wrong.

01:15:47
Like I genuinely think like we actually need to understand that there is this natural variation. We keep seeing it so much in our data, but it's like that doesn't mean that you're broken. In some cases, it can be an incredible warning sign for you to get the help that you need. always an example that stands out to me is that pelvic pain experience that occurs with menstruation that so many women experience.

01:16:15
but our current healthcare system maybe doesn't recognize it. And so we have these five to eight year delays for a common condition like endometriosis. It blows my mind. And it's like, at some point, we're actually going to have to be a bit more people centric and actually recognize these things because that is an, like that condition, like how it can impact fertility for so many women.

01:16:45
is yeah, it just, and because women aren't, I'm probably having done this research, the more you I guess you're accustomed to it, the more you just realize how little filter you have about any of this. And so I often have a lot of women coming to me and talking because they know they can come talk to me about this. And I've just had to point them to various areas because it's like, we've got to actually be able to have these discussions with our feeling like something's wrong.

01:17:15
It's like, do I get good quality information about what's happening with my body? And then how can I use that to actually improve my health? Like at the end of the day, health and quality of life is so important. Yeah, nice one, Claire. I love it. Now, as I understand it, and you mentioned yourself, these women in some part of your study were collecting their menstrual blood, bringing it back in because you hope to look at

01:17:42
blood biomarkers within the menstrual fluid. Is that correct? We actually did that. So yes, we actually did the assessment. So we almost had two arms, one where they went home and they were collecting and weighing their menstrual fluid so I could see what was happening every day. So bless them, honestly. These women that were doing it, my colleagues thought I'd lost the plot. They were like, no one's going to do this. And then when I was like, we're going to collect menstrual fluid samples and we're going to

01:18:10
tested for diabetes and cardiovascular disease markers. And again, everyone was like, you have genuinely lost it. And honestly, recruitment for that project was the easiest one we've ever done. Oh, amazing. Yeah, women were just like, yep, when do you want me? Like, brilliant. Like, honestly, like, people were just like, we did not know this was a thing. was like, I think because

01:18:38
no one's done research on women for so long. They're just like, I'll help. Give me questions. Give me answers. Not give me questions. Give me answers to these questions. We actually had women come into our lab. We got a normal venous blood sample, so the normal blood test with the needle. Then women very nicely went into a bathroom, collected a sample of menstrual fluid for us. Then pretty much we did a Q point of care testing.

01:19:06
using a machine which is used for immediate testing of biomarkers for diabetes. So we used HbA1c. We did lipoprofile and we did CRP just because those are the ones that were available to us in lab. And we tested that in both menstrual fluid and venous blood. So we don't only have it in one, we've got a comparison to gold standard venous blood. And actually we're

01:19:35
like that data is done, collected. I think we have over, yeah, close to about 102 women that came into our lab for that one. So huge, brilliant. And yeah, we're actually, probably the key one that's standing out is maybe right now the HbA1c. It's quite a stable molecule.

01:20:00
And so I often now joke, I'm like, actually our results would suggest that we can tell if you're diabetic or not from your period. Yeah, that's amazing. It's amazing, so cool. And it's not yet published? Not yet. So we're literally in that point where data collection's finished and we're in that data analysis, but right now, data analysis and write up. we're in it right now, looking at it.

01:20:27
The inflammation, can also tell a bit about that. Lipids is quite interesting because naturally when we're shedding our endometrium lining, we're getting the breaking of cells. It's that whole process of breakdown. So with the cell breaking, you're getting the release of some of that contents. And so that has influenced lipids a little bit, but we're seeing it almost mirror venous blood.

01:20:57
So it's like, oh, maybe there's like a correction curve or standard that you need to apply there. Um, but yeah, like when you actually looked at it, I was like, this is non-invasive. It's coming out and it is a goldmine in terms of information about the woman's reproductive system, their whole bodies and the amount of woman that came out and they were like,

01:21:23
going in there, giving you the sample of menstrual fluid was easier than you sticking that needle in my arm. I was like, amazing. So you know what? It's like, I think it's time that we actually start looking at different options for monitoring health and why not use a resource that's coming every month? Hey, Claire, like question, can you tell an your, a novelatory cycle from an like

01:21:50
from a human erect woman based on her menstrual fluid? No, but this is something I really, really want to have a look at because what we know about, as I described, the signals, what happens with that endometrial cycle is estrogen builds the lining, progesterone stops estrogen from building the lining and goes, okay, we've got enough, let's convert it into secretory phase. So now we're at the point where it's

01:22:20
Not building, but we're converting it into a plush environment for the implantation. And so one of the things that I want to ask about are women, heavy menstrual bleeders, if they are an ovulatory or luteal phase defect, because they've got unopposed estrogen in their bodies. So they have huge amounts of estrogen, but they're not getting exposure to progesterone or they're not getting enough.

01:22:48
Which logically to me would make sense because as you said, heavy menstrual blood flow occurs more frequently in perimenopausal woman. And what we know about perimenopausal woman is the first presentations of menstrual cycle disruption that occur, particularly in the early stages of perimenopause, are anovulation and luteal phase defects. So there has to be something in there. Yeah, you'd think so.

01:23:16
Wouldn't you like- no research that's kind of looked at it. And I'm just like, holy cow. Cause one of the other things that we're trying to look at, and I literally had a conversation with our physiologist about this is like, one of the really important roles of iron in the body is it works in coagulation. So blood clotting. So what comes first? Is a woman iron deficient because she-

01:23:46
is a heavy menstrual bleeder or if she becomes iron deficient, is she more likely to have a heavy menstrual bleeder? Oh, interesting. Because one of the other things that we found and sorry, I'm going on a tangent now, Mickey. Oh good, I it. I remember it was last year as well, I had a colleague, a really good master's triathlete and she got a blood clot.

01:24:13
going over to Europe, traveling from New Zealand to Europe. And of course, with that treatment, you get blood thinners, which is a very common treatment, particularly if maybe you've had surgery or anything like that. And she sent me a message just being like, oh my gosh, I am like, I don't know what's going on here. Anyway, it turns out she had her period and she was just like,

01:24:42
I think I'm hemorrhaging. Like I cannot stop this. And then when you read the side effects of the blood thinner, was basically one in 10 people might experience bleeding from nose, ears, gum, stomach, everything. And the very last bullet point was the vagina. And I was like, okay, only one in 10 women, individuals might bleed from there. But

01:25:11
So many individuals, if you give someone blood thinners, if you don't ask if they're a naturally menstruating woman, you're going to medically induce the menstrual fluid loss. So we know that if you alter someone's, their blood's coagulation ability, you're going to induce heavy menstrual bleeding. And so this is something that we've been trying to like, how do you do a project?

01:25:38
where you're trying to look at this because we know heavy menstrual bleeding is linked with iron deficiency, but is it the chicken or the egg? It's a question I currently I'm having to sit on because I have no idea how to answer this right now. Yeah. And luckily you're only 35. You've still got 30 years in academia at least to get through this. I laugh so much because people are always like, my joke is often...

01:26:07
apologies if people find this very poor, poor form. But I will often say, everyone always gets really upset that there's not a lot of women's health research. But as an academic, I sit back and I'm like, oh my God, I'm so excited. My career is sorted. Yes, totally. Oh, 100%. That's how I felt when I was in the obesity research area. was like, okay, this is absolutely job security for me. Yeah.

01:26:34
So Claire, a couple of final questions because I'm really mindful we're well over time, although I've really, really enjoyed this conversation to get your insights as an academic in women's health. For the women out there, let's practically bring it back to the topic of iron. So what is your recommendation for a woman out there who may either suspect they are deficient or

01:27:03
are unsure, like what tests should they be getting? And then what are some sort of signs of deficiency which you have seen, which might sort of get them to think about it? And then how often should a woman test? Awesome. Okay, so I'll start off with the signs. Generally, the main ones that come out are fatigue, exhaustion.

01:27:27
And that exhaustion is like physical exhaustion and brain exhaustion. And I often describe it to women as iron deficiency exhaustion is not the one where you're like, I'm tired post exercise. It is that exhaustion that you almost feel in your bones where you're like, I don't know. I'm motivated to do this exercise, but I don't know how I'm going to do it. That level of exhaustion.

01:27:55
That is probably the one where it stands out and it's the exhaustion that doesn't go away no matter how good sleep you have or how much sleep you have. It just feels like this is my norm. I'm tired all of the time. That level of exhaustion, the brain exhaustion where it's impairing, you feel like you're impairing your cognitive ability. You've got that bit of a brain fog that occurs. That again, key sign.

01:28:23
muscle weakness, shortness of breath or early onset of shortness of breath, particularly with exercise. Those are probably some of the key, key things. And I think for regular exercises that almost immediate like I'm constantly writing every single exercise session hard and my motivation, my readiness to train is just not there. Those are probably some of the more prominent ones that we actually see and which I'd say to women, please.

01:28:52
go to your doctor and get a blood test. When you get a blood test, make sure that you get full iron status, your, I guess, red blood cell or your blood count there, plus make sure you get a marker of inflammation as well, because some doctors will get a, I guess, results back and go, your iron levels are fine. But if you've got underlying inflammation in that body,

01:29:20
that's going to influence those markers of iron status and artificially elevate them. So you want to make sure that you've got the whole picture. What's happening in the blood cells? What are your iron stores and status? Not just the stores, everything. So I want to see serum iron, transfer and saturation, total iron binding capacity and ferritin, the stores plus marker of inflammation. Like that's probably a big one there.

01:29:48
Um, and so those are probably the ones I, I suggest generally, if you're going to go get a test, um, the requirements on make sure you're well hydrated, probably not a good idea to go get the test immediately after exercise. Cause again, exercise causes inflammation. So if you go then get a blood test, you are artificially going to elevate. know that.

01:30:13
Your body's iron stores is an acute phase reactant, so it responds to inflammation quite quickly. So that could like almost mask any iron deficiency. So go rested, go in the morning. You don't need to be fasted, but just make sure you're well hydrated. You haven't done any high intensity exercise the night before, maybe just an easier session than night before kind of thing. And for, guess, women, I'd probably say you want to be going at least

01:30:42
two to three times a year. If you're an exercising woman, please go get tested at least three times a year. It shifts you more from that like clinical treatment model of healthcare to more of that preventative healthcare where you can take a bit more ownership of your health. But to do that, it's giving yourself the correct information and knowledge about what's going on. And I think once you have that and you start just having that testing, maybe every

01:31:11
like three to four months around there, then you actually know and you can trial and you can see what maybe works for you. If you're iron deficient, does the supplement work? Have I responded to it? Has this change in my dietary pattern that I've implemented actually had a positive or negative effect? Like what's going on here? And you can then subtly adjust. And I think having that more as a habit prevents you from getting to that point where the ambulance is already driven off the cliff.

01:31:41
kind of thing, it stops you just before you get there. those are probably, if you recognize those symptoms, please go get tested and then make sure that you actually do it as like a regular, if you can make sure it's a regular thing for you. Amazing, Claire. You have been a wealth of information and perspective and really insightful as well. And I've just so enjoyed our conversation and I'm really excited for

01:32:09
next couple of years with your lab and you're building your female health physiology portfolio and you seem to have done so much already. Where can people find out more about what your lab is doing and of course you particularly? Is there any sort of place to go? I'm probably posting a bit more on LinkedIn and I guess Instagram a bit more. LinkedIn's probably where we're putting a bit more of the research specific stuff that

01:32:37
our lab and our programs doing, but also all my incredible students. I have a huge amount of them all doing incredible research projects that I just have the pleasure of nerding out on, if I'm going to be honest. So I love sharing some of their work on there. yeah, linked to Instagram, I sometimes post information updates. I love interpreting research articles and sometimes I pop a few things there.

01:33:04
So yeah, those are probably the two key places to kind of keep updated and if you want send me a message through there. I'm always absolutely more than happy to talk about this kind of stuff with everyone. Amazing, Claire. Thank you so much. Enjoy the rest of your day and again, really appreciate your time. Not a problem at all. I thoroughly enjoyed chatting with you today, Miki.

01:33:39
Alrighty, hopefully you enjoyed that and looking forward to getting more updates from Claire as her research progresses. I think this was just such a great conversation and she has a really, really good perspective on why it isn't appropriate just to draw a line in the sand to say that hormones mean nothing and we just continue on as we are. And I think Claire really laid out such a good assessment of where we're at with the research and what we still need to do. I mean, research is just constantly evolving, right?

01:34:08
Next week on the podcast, I am delighted to bring to you a conversation that I have with Aram Gregorian, Four Weeks to the Beach, fantastic nutrition coach who shares all his insights on social media, Instagram. That is next week. I would also like to tell you that I have a new fat loss webinar coming up on July 17. It is Unlocking Fat Loss Success, where I'm sharing evidence-based information to help you get the body you want.

01:34:37
We will put a link to that in the show notes. It is free. You just need to sign up to register and it is being recorded if you can't make it live. All right, team, you have the best week and I will see you next week.