Dr. Anne Hussain, ND
Episode Summary
What is a normal menstrual cycle, how do you know if you are ovulating, and when do irregular, heavy or painful periods deserve further investigation?
In this episode of Girls Gone Wellness, Jeanette and Victoria speak with Dr. Anne Hussain, ND, naturopathic doctor and author of The Period Literacy Handbook, about menstrual-cycle health, normal period length, ovulation, follicular and luteal phases, cervical mucus, basal body temperature (BBT), luteinizing hormone (LH) testing, premenstrual syndrome (PMS), polycystic ovary syndrome (PCOS), hypothalamic amenorrhea, endometriosis, heavy periods, spotting, painful periods, birth control pills and withdrawal bleeding. Dr. Hussain explains why understanding the menstrual cycle can help people recognize what is normal for their body—and when a change may warrant medical assessment.
The episode begins with the basics of the menstrual cycle. Dr. Hussain explains that the cycle starts on the first day of menstruation and continues until the day before the next period begins. She breaks down the follicular phase, ovulation and luteal phase, including the roles of follicle-stimulating hormone (FSH), luteinizing hormone (LH), estrogen and progesterone. Estrogen helps build the endometrial lining, while progesterone helps stabilize and mature it after ovulation.
What counts as a normal menstrual cycle? Dr. Hussain explains that 28 days is an average, not a requirement. Cycles between roughly 21 and 35 days can fall within a normal range, and variation is expected during puberty, breastfeeding and perimenopause. Ovulation largely determines cycle length, which means delayed ovulation can also delay the next period.
The conversation then examines how to tell whether ovulation actually occurred. Possible clues include regular cycles and changes in cervical mucus, while basal body temperature can retrospectively suggest that ovulation occurred. Ovulation predictor kits (OPKs) measure the LH surge but are not perfect—particularly in PCOS, where baseline LH may already be elevated. When confirmation is clinically important, post-ovulatory progesterone blood testing may provide more useful information.
Irregular or absent periods are also discussed in detail. Dr. Hussain identifies PCOS and hypothalamic amenorrhea as two common causes of anovulatory cycles. Hypothalamic amenorrhea can occur when the body does not have enough available energy for reproductive function because of under-eating, excessive exercise, psychological stress or a combination of factors. Importantly, it can occur at any body size and does not require a low body mass index (BMI).
The episode also answers common questions about spotting, heavy periods and painful periods. Occasional spotting may not be concerning, but recurrent bleeding between periods can warrant assessment for conditions such as fibroids, polyps or endometriosis. Heavy menstrual bleeding is discussed in terms of blood loss, duration and changes from a person's usual pattern. Period discomfort may be common, but pain that causes someone to miss work, cancel plans or rely on large amounts of pain medication should be investigated.
Dr. Hussain also explains the difference between primary dysmenorrhea and secondary period pain caused by conditions such as endometriosis. The episode explores possible supportive approaches including heat, exercise, transcutaneous electrical nerve stimulation (TENS), ginger, nutritional adequacy and conventional options such as anti-inflammatory pain medication, hormonal contraception and intrauterine devices (IUDs).
Finally, the conversation clarifies what birth control pills actually do. The pill suppresses ovulation and creates a withdrawal bleed, rather than restoring a natural ovulatory menstrual cycle. The episode also tackles PMS, “estrogen dominance,” menstrual cravings, water retention, brown period blood, ovulation pain, period-tracking apps and concerns about heavy metals detected in tampons.
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What is considered a normal menstrual-cycle length?A menstrual cycle of approximately 21 to 35 days can fall within a normal range, according to Dr. Anne Hussain. A healthy cycle does not need to be exactly 28 days every month, and a few days of variation can be normal. Larger or persistent changes in cycle length may warrant further assessment.
Does everyone ovulate on day 14?
No. Ovulation does not occur on day 14 for everyone. Dr. Hussain explains that ovulation timing varies and is one of the main factors determining total cycle length; for example, someone with a 35-day cycle may ovulate substantially later than day 14.
Can you have a period without ovulating?
You can have vaginal bleeding without ovulating. In an anovulatory cycle, progesterone is not produced in the usual post-ovulation pattern, but changes in estrogen can still destabilize the endometrial lining and cause bleeding.
How can you tell if you are ovulating?
Possible signs of ovulation include regular menstrual cycles and cervical mucus becoming more slippery, stretchy and similar to raw egg white before ovulation. Basal body temperature (BBT) can show a small temperature rise after ovulation, while LH ovulation predictor kits can detect the hormone surge that usually occurs beforehand. Dr. Hussain notes that no single home method is perfect.
Are ovulation predictor kits accurate if you have PCOS?
They can be less reliable in people with polycystic ovary syndrome (PCOS). Some people with PCOS have higher baseline luteinizing hormone (LH), which can make ovulation predictor kits more difficult to interpret or create apparent surges that do not result in ovulation.
What causes irregular or missing periods?
Common causes discussed in the episode include PCOS, hypothalamic amenorrhea, thyroid disorders, inadequate energy intake, excessive exercise, psychological stress and certain medications. Irregular cycles can also be expected during puberty, breastfeeding and the menopause transition.
Can hypothalamic amenorrhea happen if you are not underweight?
Yes. Hypothalamic amenorrhea can occur at any body size and does not require a low BMI. Dr. Hussain explains that inadequate energy availability, under-eating, high exercise expenditure and psychological or physiological stress can suppress reproductive function even when someone's body weight does not appear low.
Is spotting between periods normal?
Occasional spotting may happen, but recurrent spotting should be investigated. Dr. Hussain discusses possible causes including fibroids, endometriosis, polyps and bleeding triggered by penetrative intercourse, while noting that spotting may also occur with an IUD.
How much menstrual bleeding is considered heavy?
Heavy menstrual bleeding is traditionally defined as losing more than approximately 80 millilitres of blood per period, although measuring this precisely is difficult. Bleeding lasting longer than seven days or a major increase from your personal baseline may also be clinically important and worth discussing with a healthcare professional.
Are painful periods normal?
Mild discomfort can occur during menstruation, but period pain that interferes with everyday life should not simply be accepted as normal. Dr. Hussain recommends further assessment when cramps regularly cause missed work or school, cancelled plans or the need for unusually large amounts of pain medication.
What is the difference between primary and secondary dysmenorrhea?
Dysmenorrhea means painful menstruation. Primary dysmenorrhea refers to menstrual pain without another identified condition, while secondary dysmenorrhea occurs because of another health issue, such as endometriosis. Dr. Hussain notes that endometriosis may initially be mistaken for primary dysmenorrhea because it is frequently underdiagnosed.
What symptoms can suggest endometriosis?
Possible endometriosis symptoms discussed in the episode include severe period pain, heavy bleeding, painful sex (dyspareunia), painful urination (dysuria), painful bowel movements, bowel symptoms and bladder symptoms. Not every person with endometriosis experiences the same symptoms, and absence of painful intercourse does not rule it out.
Does the birth control pill regulate your natural menstrual cycle?
Not exactly. The birth control pill typically suppresses ovulation and provides synthetic hormones in a controlled pattern, producing a withdrawal bleed when hormone exposure is reduced or paused. It can create predictable bleeding and help manage conditions such as PCOS, but it does not restore a natural ovulatory menstrual cycle while it is being used.
Can the birth control pill cause PCOS?
The episode does not support the idea that birth control pills cause PCOS. Dr. Hussain explains that someone may have had PCOS or irregular menstrual function before starting the pill, but the symptoms may only become obvious once hormonal contraception is stopped.
Is PMS normal?
Minor changes in mood, energy or physical symptoms before a period can be common, but premenstrual syndrome (PMS) refers to symptoms significant enough to affect daily life. Dr. Hussain also cautions against assuming that symptoms such as breast tenderness automatically mean someone has “estrogen dominance,” because people with similar symptoms can have very different hormone levels.
Should you be worried about heavy metals found in tampons?
Based on the study discussed in the episode, Dr. Hussain does not recommend changing tampon use solely because heavy metals were detected. She explains that detection does not tell us how much is absorbed by the body or whether the levels create a clinically meaningful risk, and more research is needed before drawing conclusions about tampon safety.
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This transcript has been edited for clarity and readability while preserving the substance of the conversation.
Victoria
Welcome to Girls Gone Wellness, Dr. Hussain.
Dr. Anne Hussain
Thanks so much for having me.
Victoria
Of course. We are pumped about this episode today.
I'm a big believer in your menstrual cycle being like the fifth vital sign. I know everybody says that, but I think it's so true.
It's so important, and I think it gets undermined a lot. We haven't really touched on it yet on our podcast, believe it or not, so I'm very excited to talk this through with you today.
Dr. Anne Hussain
I love talking about periods, so here we are.
Victoria
Perfect.
Let's start with you telling us a little bit about yourself, how you got into naturopathic medicine and where your focus on hormones and the menstrual cycle came from.
Dr. Anne Hussain
I grew up in Karachi, Pakistan. That's where I did elementary school, so I got my period while I was there.
Sexual and reproductive-health education wasn't part of the curriculum at all.
My first period was a big shock to me.
I was one of the later people in my friend group to get it, but I'd never put two and two together when they would be checking the backs of their clothes or when the television channel would get changed during commercials showing blue dye on a pad.
I never really knew that had anything to do with me until I got my period.
I thought I was dying because bleeding from the inside is not a normal thing if you don't understand what's happening.
But it was brushed aside because my mom grew up in the same culture and hadn't really learned much about it either.
Then when I came to Canada, I didn't learn anything because menstrual-health education had been taught in elementary school and I started here in high school.
My periods were fairly irregular, but I didn't know what I was comparing them to, so I never realized there might be a problem until I started having more issues in university.
I went to McMaster and studied biochemistry.
My periods became more regular, but it turned out I had polycystic ovary syndrome, or PCOS.
I was put on the birth control pill and personally felt really awful on it.
Because I had access to scientific literature and the university library, I started researching menstrual cycles.
There was also a naturopathic doctor at the student health centre.
I started seeing her, and that was my introduction to naturopathic medicine.
I saw the principles of naturopathic medicine on her wall, and they really spoke to me.
I originally went to school wanting to become a cardiovascular surgeon, but I ultimately didn't want to go down that road because of the reactive nature of the work.
I wanted to have more in my toolkit.
That's what led me toward naturopathic medicine.
Then my own experience with PCOS and not having menstrual education played a role too.
As a fourth-year clinical intern, I saw lots of pregnant patients and lots of hormone-related concerns.
Eventually I thought, “Okay, this is what I'm going to focus on.”
A little bit self-servingly, but also because hormone-related issues are so prevalent and periods historically haven't been discussed enough.
There's still such low literacy around menstrual health.
So here we are.
Victoria
Absolutely.
It's funny that you mentioned the literacy piece because I grew up here and I would still say that our menstrual-cycle education was very limited.
I went to a Catholic elementary school, so I don't know how much that played into the sex-education piece, but anything to do with women's health felt like, “Boys, shut your ears. This is gross. Nobody wants to hear this.”
We never really got a good sense of what was normal or expected.
It's also hard to rely on parents to teach their kids when the parents didn't necessarily receive that education either.
Dr. Anne Hussain
Exactly.
Our parents' generation often didn't talk about these topics in school or even with each other.
Now our norms are changing.
With social media and the information age, we have so much data at our fingertips and we're talking more openly about these topics, which is great.
But there's still a lag.
Hopefully things keep improving.
Victoria
We were saying in an episode with Dr. Alpert that I had a patient literally whisper the word “vagina.”
They didn't want to say it, like it was a bad word.
That's a problem.
We have to move away from that.
I do think we're getting better, but it takes people like you to move the needle.
Speaking of moving the needle, you also have a book, The Period Literacy Handbook.
What inspired you to write it?
Dr. Anne Hussain
My own journey definitely inspired it.
But there were also things I kept seeing with patients.
As clinicians, it's part of our job to be specific about what we're talking about.
Even the word “vagina”—sometimes somebody is actually referring to the vulva or another structure nearby.
I often pull out diagrams because they're really helpful.
I'm like, “Okay, let's be more specific in our language so we're on the same page.”
A lot of the things I address in the book came from questions I hear frequently in clinic.
I also wanted to incorporate sociopolitical aspects of health and the social determinants of health, because we don't always talk about those enough in one-on-one healthcare settings.
They're big-picture issues, but they have very real effects on health.
The book has a textbook-like section, but it's written casually for a general audience.
Then there's a tracking section: how to track and what to track.
There's a section on menstrual conditions, a section on contraception and then the broader-picture issues.
That includes how medical research, the medical system and the wellness industry interact and influence how we think about health and make decisions.
I talk about period products and the historical stigma and taboos around periods and menstrual-health conditions.
Then the final section is about things we can do for menstrual wellness.
I'm a big believer that there's a difference between treating a medical condition and working toward wellness.
There can absolutely be overlap in foundational strategies such as sleep and stress management.
But these days I think we need to be clearer about the difference between a wellness practice and treatment of a condition.
Those things are conflated very often online.
Jeanette
That book sounds incredible. I'm definitely going to purchase it after this interview.
Vic, I don't know if you had this book growing up too, but my mom gave me The Care and Keeping of You, the American Girl book.
That was basically my introduction to my period.
My mom said, “Here's a book. Go read it.”
I opened it and was terrified.
I was like, “What is going on?”
Nobody really talked about it.
I think these conversations are improving now, but a book like yours would be incredible for people who have so many questions.
Victoria
Girl, I had that book.
A bunch of my friends and I did competitive dance together, and all of our moms bought it for us.
To this day, we talk about the trauma.
We'd flip to a page talking about growing breasts and giggle.
I see it on shelves now and I'm like, “Oh my gosh. PTSD.”
That book taught me everything.
Jeanette
Even in that book, I remember there only being a couple of pages explaining what a period actually was.
There are so many questions.
Dr. Anne Hussain
There are lots of questions and so many variable answers.
That's the hard part of sifting through information online.
Does this apply to me?
And if you Google almost any symptom, apparently everything is cancer.
So we'll talk through some of that.
Jeanette
We've been talking about the lack of menstrual education.
Can you walk us through what the menstrual cycle actually is, the different phases and why it matters for health?
Vic mentioned the menstrual cycle as another vital sign.
Dr. Anne Hussain
The menstrual cycle starts with a period and ends the day before the next period starts.
Technically, I usually explain it as two phases and two major events.
The period is an event that begins the follicular phase, which is the first half of the menstrual cycle.
Then ovulation is the event that marks the beginning of the luteal phase, or second half of the cycle.
We often break the cycle into four phases simply because it makes it easier to discuss what is happening.
The menstrual phase is the period itself, although technically it's part of the follicular phase.
During menstruation, you're shedding the endometrial lining, which is the innermost lining of the uterus that grew during the previous cycle.
The menstrual phase is typically around three to seven days.
On average, most menstruators lose around 30 to 50 millilitres of blood over the period.
While that's happening, follicles in the ovaries are developing during the follicular phase.
We have a hormone called follicle-stimulating hormone, or FSH.
It's a very literally named hormone—it stimulates the follicles.
A small group of follicles is recruited.
Follicles contain eggs.
Eventually one becomes the dominant follicle.
Meanwhile, after the uterine lining has been shed, it starts growing again under the influence of estrogen.
Estrogen stimulates the endometrial lining to grow.
As we approach ovulation, estrogen levels rise.
That high estrogen level helps trigger another hormone called luteinizing hormone, or LH.
LH signals the dominant follicle to rupture and release its egg.
That is ovulation.
Ovulation itself is a relatively short event.
Then we enter the luteal phase.
The follicle that released the egg becomes something called the corpus luteum.
The corpus luteum starts making progesterone.
Progesterone has several roles, but one of its main jobs is to stabilize and mature the endometrial lining that estrogen helped build.
Estrogen also rises again somewhat during this phase.
If pregnancy does not occur, estrogen and progesterone levels eventually drop.
That hormonal drop leads into the next period.
And there you have a menstrual cycle from beginning to end.
Victoria
I have a dumb question.
Dr. Anne Hussain
There are no dumb questions.
Victoria
Does progesterone also contribute to growing the uterine lining?
Dr. Anne Hussain
Progesterone contributes to a process called decidualization of the endometrium.
It helps attract more blood vessels and does facilitate some change in the lining, but the majority of the growth is driven by estrogen.
I really like Dr. Jen Gunter's analogy: estrogen is the bricks and progesterone is the mortar between the bricks.
Progesterone stabilizes the lining, changes the local immune response, promotes vascular changes and helps mature that lining in case pregnancy occurs.
That decidualization process stops if pregnancy doesn't occur and continues if pregnancy does occur.
Victoria
Amazing.
I know there's some variation in what we'd consider a normal cycle.
I've had patients say their cycle is irregular, but then when we look at their app, their cycles are between 27 and 32 days.
I think people assume that if it isn't exactly 28 days every month, it's irregular.
What is considered normal in terms of cycle length, and when should we be concerned?
Dr. Anne Hussain
The textbook definition of a normal cycle length is generally 21 to 35 days.
During the primary reproductive years, we may look at a somewhat narrower range—something closer to around 24 to 35 days.
But if you've recently entered puberty, you're approaching menopause or you're breastfeeding, cycles may be more irregular.
That's because skipping ovulation can naturally happen more often during puberty, lactation and perimenopause.
Cycles do not need to be exactly 28 days.
Twenty-eight days is an average.
Being a few days off here or there isn't necessarily a problem.
Ovulation is really what dictates much of your cycle length.
If you ovulate, you're generally going to get your period around two weeks later.
So if you're very stressed before ovulation and ovulation is delayed by seven days, your next period can also be delayed by around a week.
If the stress happens after ovulation, the period may still arrive on time, although it could potentially be more symptomatic.
That's why ovulation is so important when we're thinking about cycle length.
Victoria
That makes sense.
Sometimes your app says your period is late, but the app doesn't actually know when you ovulated.
It's estimating.
Dr. Anne Hussain
Exactly.
For somebody with a 35-day cycle, ovulation may be around day 21 rather than day 14.
Victoria
When do we raise a flag?
If a patient has one 37-day cycle and then everything goes back to their usual pattern, are we looking more at trends?
Dr. Anne Hussain
Yes, exactly.
A one-off cycle can happen for many different reasons.
I'll use myself as an example because I know when my cycles tend to get disrupted.
Any time I travel—especially if I'm travelling before ovulation—my cycle is usually delayed.
If I have a lot going on, it may also be delayed.
And it isn't just stress itself.
It's what we do or don't do when we're stressed.
When I'm stressed, maybe exercise goes out the window.
My diet may change.
My sleep may be disrupted.
It's usually a combination of factors.
What becomes more concerning is when cycles are consistently shorter than around 21 days or they're truly all over the place.
And by “all over the place,” I don't mean sometimes 31 days and sometimes 37.
I mean sometimes 21 days, sometimes the period disappears for two months and then something completely different happens.
That's when we want to look at previous cycles, track what's happening next and investigate why.
Jeanette
Can you get a period even if you didn't ovulate that month?
Dr. Anne Hussain
You can still bleed without ovulating.
If you don't ovulate, you won't make progesterone in the typical post-ovulation pattern because progesterone production largely comes after ovulation.
But estrogen may still stimulate the uterine lining.
If estrogen then drops, that can destabilize the lining and lead to bleeding.
So yes, bleeding can happen without ovulation.
Jeanette
A lot of people say they feel their best around ovulation and worst right before their period.
Do normal hormone fluctuations affect things like energy and mood?
Dr. Anne Hussain
Yes, both directly and indirectly.
Hormones naturally fluctuate over the menstrual cycle—that's the whole point of the cycle.
But you can't separate hormones from everything else happening in someone's life.
When we're stressed, habits may also change.
We know stress can worsen PMS and make periods feel more difficult.
Hormonal fluctuations can create normal physiological changes.
For example, some water retention before a period can happen because of changes in fluid dynamics and electrolyte balance.
There's also an inflammatory response associated with menstruation.
Digestive function can change.
But then we have to ask what else is happening.
Did you eat enough vegetables and potassium-rich foods?
Did you consume a lot of sugar, caffeine, alcohol or salt?
Did you exercise?
Those things can influence how someone feels too.
If we're retaining water, we may feel sluggish, and that can worsen the experience of other symptoms.
There are normal variations across the menstrual cycle, and then there are things we want to investigate more closely.
PMS, for example, can significantly affect quality of life.
When it comes to people feeling particularly good around ovulation, estrogen rises beforehand and there are other natural physiological changes.
Cervical mucus increases around this time too.
Some people feel very good during that phase.
Others don't.
Some people with endometriosis experience pain around ovulation.
People with premenstrual dysphoric disorder, or PMDD, may actually dread ovulation because symptoms begin after ovulation.
There's huge individual variation.
In general, many people enjoy the follicular phase and early luteal phase more, and then struggle during the later luteal phase as hormone levels start dropping.
Other factors can contribute too—nutritional deficiencies, vitamin D status, thyroid health and more.
Victoria
I always joke that I have one good week every month.
Once I ovulate, I'm like, “Game over.”
I have two weeks of feeling angry with everyone and very bloated.
Dr. Anne Hussain
It can be really hard.
You're definitely not alone.
I've had patients say, “I literally have one good week every month.”
That's not okay.
Then we ask what we can do about it.
Victoria
I blame school.
That's when it started for me.
It's a CCNM problem.
We hear a lot on social media about breast tenderness meaning “estrogen dominance,” or cravings and water retention being because progesterone is too high.
Is that actually excess hormone, sensitivity to hormone fluctuations or something completely different?
Dr. Anne Hussain
That's a great question without a simple answer.
That will probably be the theme.
Let's talk about estrogen dominance first.
It's not a term that I use or like.
We could line up 30 people with the exact same estrogen level, even at the high end of the normal range and measured at the same point in the menstrual cycle, and they could have very different experiences.
On the other side, we could line up people who all have breast tenderness on the same cycle day and their estrogen and progesterone levels might vary significantly.
Can people have different sensitivity to their hormones?
Yes.
The brain can also connect previous stress responses with hormonal changes, and those patterns can become reinforced.
Early childhood experiences or trauma around puberty may potentially contribute to how somebody experiences menstrual-cycle changes too.
We can see wide variation in PMS symptoms—both mental-emotional and physical—in response to hormone fluctuations.
We still have so much to learn.
I'm really looking forward to the next five to ten years of menstrual-health research.
Then we also need to look at how behaviours change around those hormone fluctuations.
If somebody isn't getting enough calcium or vegetables and then consumes more caffeine and alcohol before their period, that may worsen breast tenderness.
Caffeine and alcohol may also be coping strategies for fatigue or anxiety.
Food choices may change because of emotional responses or simply because you're busy and trying to get through the day.
All of that can influence how the menstrual cycle feels.
Victoria
Another question we get all the time is: how do I know whether I'm ovulating?
Ovulation is the major event of the cycle, but a lot of people don't know when—or even if—they ovulated.
What signs should people look for?
Dr. Anne Hussain
A regular menstrual cycle is usually a good starting clue that you're likely ovulating.
Is it 100% proof? No.
You can occasionally have an anovulatory cycle while still having relatively regular bleeding.
Then there's cervical mucus.
Everyone produces different amounts of cervical mucus.
It's discharge that originates from the cervix and then mixes with other secretions as it travels through the vaginal tract.
Leading up to ovulation, cervical mucus tends to become more slippery, stretchy and similar to raw egg white.
After ovulation, as progesterone rises, the mucus often becomes tackier, gummier or drier.
That change can help indicate that ovulation is likely occurring.
You can also track basal body temperature, or BBT.
BBT should be taken consistently every day.
You generally want an oral or other core measurement rather than a forehead temperature.
A thermometer showing two decimal places is helpful because the temperature shift is small—around 0.5 to 1 degree Fahrenheit or roughly 0.3 to 0.5 degrees Celsius.
The temperature rise happens after ovulation, so it confirms ovulation retrospectively rather than predicting it.
It also isn't completely reliable in isolation because medications and health conditions can affect temperature.
Then we have LH strips, or ovulation predictor kits.
They're urine tests that detect luteinizing hormone.
LH rises before ovulation.
The limitation is that an LH surge does not guarantee that the egg was actually released.
In PCOS, some people have higher baseline LH, which can also make those tests more difficult to interpret.
If we really need to confirm ovulation, post-ovulatory progesterone blood testing is one of the more accessible options.
Imaging can also be used, but in Canada that's generally more common in fertility-clinic settings.
Victoria
That's interesting.
We see a lot of fertility patients with PCOS using LH strips, and they're not always accurate because of that higher baseline.
And BBT can be exhausting.
Dr. Anne Hussain
It can be a lot.
Using several tracking methods together can increase confidence, but if we truly need confirmation, post-ovulatory progesterone is often the more accessible clinical option.
Jeanette
What are some common conditions or factors that can affect menstrual-cycle regularity?
We talked about PCOS and stress.
What about diet?
Dr. Anne Hussain
PCOS is a common cause of anovulatory cycles.
Another major one is hypothalamic amenorrhea.
That's where nutrition and energy availability often become important.
If you're under-eating for your needs or not meeting your body's energy requirements, the brain can reduce reproductive signalling.
This is common in athletes, particularly younger athletes, and can be part of relative energy deficiency in sport, or RED-S.
I think of hypothalamic amenorrhea as the brain redirecting resources toward survival rather than reproduction.
Reproduction isn't necessary for immediate survival.
It's an adaptive response.
We want it to be temporary because ultimately we want healthy menstrual function to return.
A regular menstrual cycle requires substantial energy.
Going back to the “fifth vital sign” concept, having a regular cycle can tell us that the body has enough resources to maintain this cyclical reproductive process.
Hypothalamic amenorrhea can also occur with eating disorders or excessive exercise.
It can happen at any body weight or body size.
It is often associated with a lower BMI, but a low BMI is not required.
Thyroid disorders can also contribute to anovulatory cycles.
Some medications can contribute as well.
But in practice, PCOS and hypothalamic amenorrhea are two common causes.
Then there are times when anovulation can naturally happen more often: puberty, lactation and the menopause transition.
Victoria
So you don't have to have a low BMI to have hypothalamic amenorrhea?
If you're not meeting your fuel needs or you're over-exercising, it can still happen?
Dr. Anne Hussain
Exactly.
Any physiological stress on the body can contribute.
That could be mental-emotional stress, inadequate caloric intake, excessive energy expenditure or a combination.
Often it is a combination.
Significant psychological stress or trauma can spill over into other areas of life too.
In athletes, low carbohydrate intake may be part of the picture because of overall energy availability.
But generally, we're looking at inadequate overall energy intake relative to what the body is using.
Victoria
When patients start fuelling adequately and address whatever is suppressing the reproductive system, do periods come back quickly?
Dr. Anne Hussain
Sometimes it can take a long time.
Not always, but often.
And it usually requires a multifaceted approach.
If somebody has an eating disorder, we need a healthcare team.
There may be psychological barriers around food and weight that need to be addressed gradually.
If excessive exercise is part of the picture, training volume also has to be considered.
Everyone has a different threshold.
The level of energy intake where one person develops hypothalamic amenorrhea may be very different from another person.
There are also associations with things such as childhood trauma, puberty-related stress and epigenetics that we're still learning more about.
In my practice, hypothalamic amenorrhea recovery tends to be a slow process.
Victoria
Even the conversation of “you need to eat more” can be difficult.
Some patients might honestly think, “I'd rather not have a period than risk gaining weight.”
We run into that.
Dr. Anne Hussain
Absolutely.
I'm strongly in favour of a multidisciplinary approach.
I'm not a therapist.
I don't have that level of psychological training.
So in my practice, that situation comes with referral to other professionals.
Victoria
Let's talk about spotting between periods.
Sometimes patients also say, “I spotted for two days and then my period started.”
Is spotting normal?
Does it need to be treated?
Dr. Anne Hussain
If spotting happens once, note it and pay attention to where in the cycle it occurred.
A one-off can be a one-off.
If it happens regularly, I'm more inclined to investigate.
If there's recurrent mid-cycle spotting, especially with pain or other symptoms, we may think about things such as fibroids, endometriosis or polyps.
If bleeding is triggered by penetrative intercourse, we might ask whether there's vaginal tissue irritation, a polyp, endometriosis or another local cause.
Recurrent spotting does not necessarily mean it needs to be treated, but it deserves investigation so we know what is causing it.
Conditions such as endometriosis are already underdiagnosed and often missed.
I recently had a patient with debilitating period pain whose doctor told her she didn't have endometriosis because she didn't have pain with intercourse.
That's not how endometriosis works.
There's a wide spectrum of symptoms, and some people may have very few obvious symptoms at all.
So occasional spotting may be okay.
Regular spotting should be investigated.
And if you have an IUD, spotting can also occur from that.
Jeanette
Let's talk about light versus heavy periods.
You mentioned average blood loss is around 30 to 50 millilitres.
Are very light or heavy periods always pathological?
Dr. Anne Hussain
Technically, heavy menstrual bleeding is generally defined as more than about 80 millilitres per period.
The problem is that period blood loss is hard to quantify.
An average commercial pad or tampon may hold roughly five to six millilitres, or around a teaspoon, when saturated.
Menstrual cups and discs usually list their volume capacity, which can make measuring somewhat easier.
But with absorbent products, it can be hard to know how saturated they actually are.
If you're losing more than 80 millilitres, it should be investigated.
I would also investigate if bleeding has significantly increased for you, even if it's still technically below that threshold.
For example, if you historically lost around 20 millilitres and suddenly you're losing 70, that's a significant change.
Heavy bleeding can occur with fibroids, endometriosis, adenomyosis, other growths or anovulatory cycles.
In PCOS, for example, somebody might go three or four months without bleeding and then have a very heavy or prolonged bleed.
Bleeding lasting longer than about seven days may also qualify as heavy menstrual bleeding.
On the other side, scant bleeding might be less than roughly 10 millilitres.
If somebody has a hormonal IUD, we don't necessarily worry about very light bleeding.
But if someone without that explanation consistently has extremely light periods, we may want to ask why.
Are they mounting a normal ovulatory menstrual cycle?
Is there a thyroid problem?
Is something else going on?
I'm a big fan of having these conversations with healthcare practitioners.
Unfortunately, time is a major limitation in the conventional healthcare system.
One thing I recommend is writing down a couple of sentences before your appointment.
“This is what my periods have looked like. Is this normal?”
That can be communicated quickly in a primary-care visit.
Patients need more touchpoints around menstrual health.
If you're wondering whether your period is normal, I encourage you to bring it up with a healthcare professional even if you think it probably is.
Victoria
Absolutely.
Another major topic is painful periods.
People say, “It's common but not normal.”
But then we have people who assume calling in sick for two days every month because of cramps is just part of having a period.
Is some pain normal?
Dr. Anne Hussain
Period pain is one of the most common menstrual concerns worldwide.
I would say some discomfort can be normal because a lot is happening during menstruation.
There are prostaglandins and leukotrienes involved.
There's an inflammatory response.
Blood flow changes.
There can be water retention and digestive changes.
People may feel pressure or heaviness.
But pain that causes you to miss work, cancel plans or rely on very large doses of pain medication is not something I would consider normal.
The medical term for period pain is dysmenorrhea.
There is primary dysmenorrhea, where we don't identify another underlying condition causing the pain.
Then there's secondary dysmenorrhea, where the pain is caused by another condition.
Endometriosis is a major cause of secondary dysmenorrhea.
Unfortunately, because endometriosis is so underdiagnosed, it can sometimes be labelled as primary dysmenorrhea for years before the underlying cause is identified.
If period pain is significantly changing your life, it should be investigated.
Some people have already gone through an appropriate workup and may choose to manage pain through a combination of strategies rather than medication or an IUD.
That's a separate situation.
But severe pain should not be ignored.
Victoria
For somebody listening and wondering if they may have endometriosis, how do you approach getting that diagnosis?
Dr. Anne Hussain
Often the patient doesn't come in saying, “I think I have endometriosis.”
I'm usually the one thinking, “This sounds like endometriosis.”
Getting a diagnosis can be challenging.
Often we need the family doctor involved because they can refer to a gynecologist who is knowledgeable about endometriosis.
Those specialists can be difficult to access.
I often direct patients to The Endometriosis Network Canada as an educational resource.
We go through the symptom pattern.
While the referral process is happening, we're usually treating the presenting symptoms such as period pain or heavy bleeding.
But endometriosis doesn't always look like that.
Some patients also have IBS-like symptoms, dyspareunia, painful bowel movements, painful urination or bladder symptoms.
Pelvic-floor physiotherapy may become part of the team because pelvic-floor dysfunction can contribute to pain whether or not endometriosis is present.
A blood test such as CA-125 can sometimes be part of the broader picture, but it is not a diagnostic test for endometriosis.
We may also look at migraines, IBS symptoms or inflammatory markers and start putting together a working clinical picture.
It can be a challenge, especially when access to family doctors and specialists is limited.
Victoria
I remember being taught the “three Ds” of endometriosis:
dysuria, painful urination; dyspareunia, painful sex; and dysmenorrhea, painful periods.
If somebody has all three, is that worth bringing up to a healthcare professional?
Dr. Anne Hussain
Absolutely.
And even period pain that isn't responding to common strategies such as pain medication can be worth investigating.
Victoria
This is not medical advice, but for primary dysmenorrhea, are there strategies you commonly discuss for symptom relief?
Dr. Anne Hussain
There are lots of options.
In adolescents especially, primary dysmenorrhea can be associated with common nutritional deficiencies and irregular eating patterns.
If somebody is eating irregularly, they may not be meeting their nutrient needs.
There is some evidence for multivitamins and mineral supplements in that population, likely because we're replenishing nutrients they weren't getting adequately through food.
Then the queen of herbs for period pain is ginger.
Ginger is used traditionally across many cultures.
I grew up in Pakistan, and ginger tea is very common there.
When we're looking at studies using standardized extracts, the doses can be higher.
Starting before the period begins may be particularly useful, especially when heavy bleeding is also present.
From a conventional standpoint, we have pain medication, birth control pills and hormonal IUDs.
There are other herbs that may be used too.
There are topical products containing ingredients such as castor oil, clove, arnica or chamomile.
They don't necessarily have the same depth of scientific evidence, but some people find topical pain-relief products helpful.
TENS, or transcutaneous electrical nerve stimulation, can also work well for period pain.
Heat works.
Exercise can help.
Then we have nutritional considerations.
That may include reducing saturated fat and alcohol, increasing fibre, eating antioxidant-rich and mineral-rich foods and, importantly, eating enough overall.
In endometriosis specifically, vitamin C and vitamin E are examples of nutrients we may consider.
Ultimately, treatment should be tailored to the individual.
Jeanette
Let's talk about the birth control pill and the phrase “regulating your cycle.”
We're both very pro-birth control when it's appropriate.
But does the pill actually regulate the menstrual cycle?
What is it doing to your natural hormones?
Dr. Anne Hussain
I think we need to take a step back.
The birth control pill is prescribed for many things, including bleeding and pain.
I'm not anti-birth-control pill.
There is absolutely a time and purpose for it.
But sometimes it gets prescribed without investigating the underlying menstrual concern.
Telling somebody the pill will “regulate their cycle” can be misleading because the pill is called birth control for a reason.
It suppresses ovulation.
That means it's suppressing the natural menstrual cycle.
If you're taking a relatively consistent dose of hormones for three weeks and then reducing or stopping them for a week, you'll get a predictable bleed.
That can resemble a menstrual cycle because estrogen and progestin influence the uterine lining and then withdrawing those hormones triggers bleeding.
In PCOS, the pill can be used therapeutically for several reasons.
It gives a consistent dose of hormones and can create regular bleeding.
One risk in PCOS is endometrial hyperplasia, where the uterine lining can overgrow when somebody goes long periods without bleeding.
That can increase long-term endometrial-cancer risk.
Having regular bleeding is therefore important for some PCOS patients.
The pill can also reduce free testosterone and help symptoms such as acne.
So from that perspective, people may say it “regulates” the period.
But because ovulation is being suppressed, it's not regulating the person's natural ovulatory menstrual cycle.
If you stop the pill, the underlying PCOS still exists.
If you had endometriosis or a thyroid disorder, those issues may still be present once you stop the pill.
I prefer having a conversation about what the pill is actually doing and what may happen when somebody comes off it.
And we can't always predict exactly what that will look like until they stop.
Jeanette
We've talked about this a lot because people online will say, “I came off the pill and the pill gave me PCOS.”
But maybe the PCOS was already present.
Maybe the pill was prescribed without a full investigation, and then once you stop it, the underlying pattern becomes obvious.
Dr. Anne Hussain
Exactly.
Often somebody went on the pill for a reason, and that original reason is still there.
Or they were on the pill for ten years and something changed during those ten years.
A lot can happen in one year, let alone ten.
Many people are also using the pill for contraception.
Then they stop because they want to conceive.
If they have trouble conceiving, they undergo a workup and discover PCOS or another condition.
It can feel like the pill caused it because that's when the condition was discovered.
I understand why people conflate the two.
I was part of that group myself.
I was prescribed the pill for PCOS and didn't really understand why I was taking it at the time.
Later I understood more about what it was doing and why some of my symptoms returned once I stopped.
Health is complicated.
Jeanette
That's why literacy is so important.
People have a five-minute appointment and then they're left with Google and Instagram.
Before we move on, we were taught that bleeding on the pill isn't a “real period” but a withdrawal bleed.
What's the difference?
Dr. Anne Hussain
We call it a withdrawal bleed because you aren't having the same natural hormonal fluctuations that occur during an ovulatory menstrual cycle.
In a natural cycle, the hypothalamus and pituitary gland in the brain and the ovaries are all communicating in a hormonal dance.
That ultimately creates what we think of as a natural period.
On the pill, ovulation is suppressed at the brain-ovary level and you're receiving a relatively consistent dose of synthetic hormones.
When those hormones are withdrawn, the uterine lining bleeds.
We use the term withdrawal bleed to distinguish that from a naturally ovulatory menstrual period.
Do we need to aggressively tell somebody, “That's not a real period”?
Probably not.
But from a mechanism standpoint, it's useful to understand that the pill suppresses ovulation and the natural menstrual cycle.
Interestingly, even in a natural cycle, a drop in progesterone is part of what triggers the period.
So there is a similar concept of hormone withdrawal.
The major difference is whether ovulation and the natural hormonal cycle occurred.
Jeanette
We have a slightly random question before rapid fire.
There was a recent study that detected lead and other heavy metals in tampons.
People are concerned.
Should people stop using tampons?
Dr. Anne Hussain
Right now, my short answer is that I wouldn't change anything based on that study alone.
Science is slow, and we're watching science happen in real time.
Anything involving reproductive and women's health creates understandable concern because women's health has historically been under-researched and reproductive health is politically contentious.
Those feelings are valid.
But heavy metals are also ubiquitous in the environment.
They're in soil.
They're in groundwater.
They can be detected in food.
What we don't know from simply finding a heavy metal in a tampon is how much gets absorbed through use, what portion of the tampon actually contacts tissue, what the exposure looks like over time or what the clinical significance is.
Finding something does not automatically mean the finding changes practice.
We may receive more exposure to some of these metals through food and water.
So for now, I'd say stay tuned for more research.
Science should create more clarity over time.
Jeanette
That was explained so nicely.
I saw someone comparing the findings with other sources of exposure—for example, arsenic in brown rice.
I understand why people are concerned, though.
Dr. Anne Hussain
Totally.
It's a sensitive area with a lot of blood flow, so it's understandable that people have concerns.
We just need more information before jumping to conclusions.
Victoria
We asked our Instagram audience for menstrual-cycle questions.
Before full rapid fire, let's do a mini version with short answers.
Somebody asked: what does brown or oxidized period blood mean?
Dr. Anne Hussain
Usually it means a small amount of blood is coming out more slowly.
We commonly see brown blood at the beginning or end of a period.
It's generally older or slower-moving blood and usually isn't something to worry about on its own.
Victoria
What about ovulation pain?
Can it be normal, or is it always concerning?
Dr. Anne Hussain
Some ovulation discomfort may be normal because there is a physiological event occurring.
But if the pain is severe or accompanied by spotting, getting assessed is a good idea.
Victoria
Why do people get weight changes and water retention around their period?
I think I wrote this question.
Dr. Anne Hussain
There are lots of potential contributors.
Fluid dynamics change as hormones shift.
That can cause water retention.
Then we have behavioural changes.
Maybe somebody is eating fewer potassium-rich vegetables, consuming more salty foods or drinking more alcohol.
Sleep changes.
Digestive motility can change.
During the period, there's also increased blood flow and fluid in the pelvic region.
Genetics influence how much water different people retain under different circumstances.
Carbohydrate intake can affect water storage too.
It's multifactorial.
Victoria
Speaking of carbohydrates, can we control cravings before our period?
Also my question.
Dr. Anne Hussain
That's a loaded question.
If we're talking about luteal-phase or premenstrual cravings, one major thing to consider is overall energy intake.
A common eating pattern is under-eating earlier in the day and then eating much more later.
Sometimes your physiology is simply nudging you to eat because you haven't eaten enough.
Metabolic needs may increase slightly premenstrually—perhaps by around 20 to 200 calories depending on the person.
So cravings can partly signal that you're not getting enough energy.
There can also be habits and conditioning.
Sometimes your body wants quick, accessible fuel.
Sleep deprivation can disrupt appetite cues too.
Eating enough throughout the day, particularly protein-rich and fibre-rich foods, and eating more adequately earlier in the day may help reduce—not necessarily eliminate—some later cravings.
Victoria
Do you have a favourite period-tracking app?
Dr. Anne Hussain
I personally use my calendar because it's what I already use every day.
I recommend using whatever is easiest and most sustainable for you.
Patient favourites include Clue.
I also like supporting The Period Purse, which is a Canadian charitable organization focused on menstrual equity and education.
They have the Menstruation Nation app, which is designed not to store user data.
I've also heard people on Reddit really like Stardust, although I haven't personally looked into it much.
Victoria
I use the one with the flower.
I don't know what it's called.
Dr. Anne Hussain
Period Tracker?
Victoria
I think it's literally Period Tracker.
It does the job.
You get little flowers when you're supposedly ovulating.
Who knows?
Jeanette
Okay, let's move into rapid fire.
We'll give you a statement and you answer myth, truth or “it depends.”
First:
A healthy cycle has to be 28 days long.
Dr. Anne Hussain
Myth.
Jeanette
You burn more calories before and during your period.
Dr. Anne Hussain
It depends.
The more likely time for a small increase is before the period rather than during it.
And it's relatively small—perhaps around 20 to 200 additional calories depending on the person.
Jeanette
It's normal not to get your period back for several months after stopping birth control.
Dr. Anne Hussain
It depends.
Usually there shouldn't be a major prolonged disruption, and cycles should resume.
But if you had something such as PCOS before starting the pill, your previous pattern may eventually return.
Interestingly, some people with PCOS initially have somewhat more regular cycles after stopping the pill because of lingering effects on androgens, and then gradually return to their previous irregular pattern.
Jeanette
Is there a certain point where someone hasn't gotten a period back after stopping the pill and you start investigating?
Three months? Four months? Five?
Dr. Anne Hussain
I often use around three months as a practical point to start investigating—not because there's one perfect scientific cutoff, but because by then we have some information about what the body is doing.
And in the meantime, take a pregnancy test to make sure pregnancy isn't the reason the period hasn't returned.
Jeanette
Everyone ovulates on day 14.
Dr. Anne Hussain
Myth.
Jeanette
PMS is normal.
Dr. Anne Hussain
Myth.
Minor fluctuations in how you feel before a period can be normal.
But PMS, by definition, refers to symptoms that are disruptive to day-to-day life.
Jeanette
Last one:
You should get your hormones tested if you have an irregular period.
Dr. Anne Hussain
Yes, you should have a proper assessment.
That includes a conversation, a review of symptoms and, where appropriate, hormone or other laboratory testing when your cycles are irregular.
Victoria
I'm glad we clarified that.
Sometimes patients want their hormones tested because they have PMS.
But two people can have equally severe PMS and completely different hormone levels.
With irregular cycles, though, we're asking whether there's PCOS, hypothalamic amenorrhea, a thyroid disorder or another identifiable issue.
Dr. Anne Hussain
Exactly.
If all the hormones are low, or certain hormones are higher or lower than expected, or thyroid function is abnormal, that information may actually help us understand why the periods are irregular.
Victoria
At the end of every episode, we ask:
What is one myth in the period-health space that you want to bust once and for all?
Dr. Anne Hussain
Can it be more of a piece of advice?
Victoria
Absolutely.
Dr. Anne Hussain
Watch out for the term “hormone balance.”
We can often be more specific.
There may be an actual diagnosis, or what somebody is experiencing may even be a normal variation.
“Hormone balance” has become a buzzword that is often used to sell things to people.
Sometimes it's simple misinformation.
Sometimes it can become more exploitative.
So watch out for that phrase and have conversations with qualified healthcare providers instead.
Jeanette
That's an important conversation that could be a whole episode on its own.
Victoria
That's our sound bite.
Jeanette
Thank you so much for coming on today.
Can you let our audience know where they can find you, whether you're taking patients and where people can buy your book?
Dr. Anne Hussain
Thank you so much for having me.
This was a great conversation.
As I said at the beginning, I love talking about periods.
You can find me on Instagram and through my website.
I run a hybrid practice with a location near Newmarket, Ontario, and I see patients virtually as well.
I accept patients on a rolling basis depending on my schedule.
My book is available through most major online retailers.
Amazon is probably the easiest place to find both the ebook and paperback.
The audiobook is coming later this year.
Victoria
Amazing.
I'm excited to read it.
Even as somebody who works with patients asking these questions all the time, it's helpful to have a refresher and stay up to date.
Dr. Anne Hussain
Honestly, writing it was valuable for me too.
I learned, relearned and unlearned so many things as I wrote it.
And I'm sure if I rewrote it two years from now, parts of it would look different.
Victoria
Absolutely.
We'll have all of your information and links in the show notes.
Thank you so much for coming on.
Dr. Anne Hussain
Thank you so much for having me.
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Do you remember when you got your first period?
I remember mine: I was 13 years old and I thought something was really, really wrong with me.
You see, I knew absolutely zilch about periods when I ran to my mum with tears streaming down my face because I had some horrible disease that made me bleed from the inside. I grew up in Karachi, Pakistan, and learning about periods wasn't part of the curriculum (or the culture).
My period woes continued as I got older: irregular cycles. My family doctor prescribed me what's offered to most of us for period problems: the pill. Those little pills led to a downward spiral into feeling (more) tired, having migraines for the first time in my life, getting acne, and just feeling downright crummy.
And then came the research studies and textbooks (I was studying biochemistry at McMaster University at the time), coming off the pill, a slow journey to getting apolycystic ovarian syndrome (PCOS) diagnosis,regulating my cycles, becoming a naturopathic doctor, and helping others make informed decisions for their health - a journey, I'm happy to share, I'm still on to this day.
Now, I get to help others with PCOS, painful periods, endometriosis, infertility, PMS, PMDD, perimenopause, and hormone health in general.
I can't imagine doing the work I do today, or have the capacity to dream big, feeling the way I did when I was younger.
I don't want period problems to stop you from living your life. I believe that when you take care of your health, you can show up for yourself, your dreams and goals, and the people who matter most.
You deserve to feel well. You deserve healthcare that is uniquely tailored to you, your lived experience, your values, and your goals.
If you're ready to take the next steps, I'd be honoured to support you.