The Case:  Amelia is 39 and dealing with heavy periods. She was also experiencing extreme PMS including headaches, bloating, and uncomfortable breast tenderness. It got so bad, she started to plan meetings, social gatherings and vacations around her cycle. The only solutions doctors offered was to take the birth control pill but a previous blood clot made that a risky proposition. The Investigation Every menstruating woman experiences her period differently but it was hard to hear about what Amelia was going through. I completely understood her predicament and resistance to start taking the pill again after having suffered a blood clot the last time she was on it. I knew there was still hope and that there had to be something else going on that we could address that would help make her periods more bearable. My first hunch was to look more closely at her hormones.    Joining me to discuss this case is Dr. Anu Arasu. She’s the founder of London Bioidentical Hormones clinic and was one of the first doctors in the UK to train in functional medicine.     What’s Actually Happening with Hormones During the Menstrual Cycle? Having your period is the result of cyclical release of hormones. In the first day of your period, both estrogen and progesterone will be low. At the end of the period (about 7 days later), the estrogen begins to rise. In an ideal world, we would then get a LH (luteinizing hormone) surge. This triggers ovulation (and the peak of our estrogen cycle). If ovulation does not result in a pregnancy, then the corpus luteum breaks down and produces progesterone. Soon, both estrogen and progesterone levels drop triggering a bleed.    What is a Heavy Period? It’s tricky to quantify what is a heavy menstrual flow and what is “normal” and a lot of women don’t know where they fall on the spectrum. It is difficult because we often only have ourselves to compare it to. Dr. Arasu says that if your menstrual flow is affecting your quality of life then it might be outside of ‘normal’. For example, if it stops you from doing things, going to work, socializing - or in Amelia’s case be able to go on vacation. Or, if there has been a dramatic change, then it is worth speaking to someone to find out what’s going on and what can be done about it.    Potential Causes of Painful Periods or Heavy Menstrual Flow There are a variety of things that can affect the menstrual cycle. Heavy periods could be caused by endometriosis or fibroids. Heavy periods can also be the result of not having a regular menstrual cycle (which could be caused by hormone changes or Polycystic ovary syndrome (PCOS). Hormone imbalance can also result in heavier periods. And, some women are just naturally prone to heavy periods.    Testing for Hormone Imbalance If pathologies like endometriosis, PCOS, and fibroids have been ruled out, a hormone test might provide a clearer picture of what’s going on. Dr. Arasu suggests doing both a urine test and a blood test to get the full picture of what’s going on. The DUTCH test (a type of urine test) is recommended because in addition to showing hormone levels, it also gauges metabolization efficiencies. However, this test will not reveal the follicle stimulating hormone levels which can indicate if someone is premenopausal. She also uses daily saliva tests to track what is going on over a period of time with regards to your progesterone and estrogen levels throughout the month.    Estrogen Dominance Estrogen dominance happens when estrogen and progesterone are not balanced. This can be determined through the DUTCH test which looks at all of the potent estrogens. Specifically, experts will be looking at estradiol, estriol, and estrone - the total estrogenicity.    Estrogen Clearance Metabolization of hormones is another important piece of the puzzle. If these dominant estrogens are not being metabolized, this can cause issues with the gut (which lead to other issues). A gut test will confirm this, particularly if there are ano