[INTERVIEW]
Ronda Nelson: If you’re still treating menstrual migraines like a hormone problem only, you may be risking missing the real driver. This patient had debilitating migraines every month for five years, and the breakthrough came when I finally looked at her liver, gallbladder, and bile — because in this case, the migraine wasn’t really the story.
The story was, why could her body no longer handle the monthly estrogen shift without completely falling apart? Let’s talk about it.
Well, hello and welcome back. Here we are over here on YouTube, and it’s going great. Thanks for following me all the way over here. I like this so much better than being on just the podcast streams and then having YouTube secondary. So today though, we are gonna talk about a case. This was a good one. I think you’re gonna really enjoy it.
So I had this patient who came to me by referral — you all know that I only take them that way. And she came to me from a really good patient, great patient, and she said, “I think you can help her.” And her biggest complaint was menstrual-related migraines. And she’d had these for five years, every single month — debilitating, like 10 out of 10 migraine.
And no one could help her. She took the medications, nothing was helping. They lasted two full days. She couldn’t get up, she couldn’t care for her family. She literally had to hire someone to come in during the day to take care of her young children because she was completely disabled. A 10 out of 10 migraine. I cannot even — I had migraines before, but I can’t even imagine that. That’s gotta be just wicked. So I kinda like migraines because it’s always a challenge. Like no one ever seems to be able to fix them. I shouldn’t say no one — I’m sure all y’all are real good at it, but medically, I should say.
You know, they put them on bioidentical hormones — but you know how I feel about that. That is a hill I will die on. I don’t think the bioidentical hormones are the answer. But it’s not so much what would I give for the migraines. You know, you might think about pain relief or reducing inflammation or having her put her feet in hot water and, you know, all the things that we could do otherwise. But because it was hormone related, obviously we have to go look at the deeper issue, which is going to have to do with hormones. But the question I always ask — and I don’t think I’ve ever really articulated it this way to you all — is: when there are cyclical symptoms that happen around the cycle, whether it’s PMS or whether it’s migraines or whatever it is, the question is, why is her body unable to tolerate normal hormone shifts? That is the question right there. Why is it that her body cannot tolerate the normal hormonal shifts in her monthly cycle that results in these symptoms?
So the conversation I wanna have with you today isn’t so much about the migraine, although the migraine is definitely part of the thing. It’s really more about discovering what the underlying issue is. And I believe it has a lot to do with what’s happening with her liver and gallbladder. So let’s dive in.
I’m gonna show you why this got my attention. So she’s already tried — just a little bit of history on her, not a ton — but she’s super healthy. Like she’s one of those people that does everything for her health. And why shouldn’t she, because she’s been dealing with these migraines. So she’s gonna do everything she possibly can to get rid of them. She’s done all the cleanses. She’s done detox protocols. She’s done cortisol support, adrenal support, light therapy, acupuncture, chiropractic, coffee enemas. She tried progesterone cream for a little while. She took digestive enzymes. She’s used castor oil. I mean, you name it, this girl is the poster child for “I’ve tried everything.” So this was not what I would consider a low or no effort case. I mean, she really has done all the things.
But when I started to dive a little bit deeper into her history, I realized that there were some chronic liver and gut complaints that she said she’d not felt well about for about the last three years. My ears kind of perked up. I was like, hmm, maybe this is the “never been well since” moment. Because that means there’s an underlying driver, right? We know her migraines are cyclical, they’re very predictable, they’re severe, and we know that they have to do with her hormones. So yes, hormones are involved — but do we need to give hormones to make the headaches go away? I argue no, no, no. This is not a just-give-progesterone-and-make-this-go-away situation. We’re not gonna do that.
Here’s her history. And this is where it got really interesting. I wasn’t surprised. In my brain, I’m reading through her history and I thought, “Yep. Oh, yep. Yep, that checks. Oh, there’s another clue. Yep, yep.” It just kept building a case for why I wanted to do what I already kinda thought was gonna be the issue — but she just confirmed it.
Here’s the number one thing. Are you ready? Number one — she had a cholecystectomy in 2017. That is nine years ago as of 2026, and she’s a fairly recent patient. She had her gallbladder out in 2017. Previous testing — because she’s done all the testing, right? She’s been to all the practitioners, done all the things — her previous testing showed she had some fat malabsorption. So what does that tell you? Just stop right there. What does that tell you? The gallbladder is having trouble, and she has fat malabsorption, which means there’s no bile. Bile is missing. Bile is majorly low.
When she drinks coffee — or had a coffee enema — she had diarrhea. When she drinks alcohol, it makes her headaches far worse and can even provoke vomiting. So now I’m like, wow, this is getting saucy over here. I asked her about bloating and pain. She has bloating — she gets bloated premenstrually. She has some pain between the shoulder blades. Are you tracking with me here? Like, it’s all stacking up, stacking up. She has a history of waking up at night, unprovoked, between 1:00 and 3:00 AM. She does have heavy menstrual bleeding. She has no ovulatory mucus discharge. Key, key, key, key, key — no mid-cycle egg white discharge. None. Sometimes cold hands and feet, sometimes a little bit of mood and irritability, not always.
And so all of those things individually, if you just looked at them as individual symptoms, you’d say, okay, well, she needs something for mood support and we’re gonna increase her circulation to get her hands and feet going. And then maybe she needs chiropractic and massage because she has back pain. And it’s easy to start piecing it apart and treating it almost allopathically. But what do all those symptoms have in common? What they all have in common is that this is a digestion, bile, fat-handling hormone case. That’s what this is.
So here’s what happens. And I’ve talked about this before, but it’s been a long time. I’m gonna break this down for you slow. You ready? Here we go. Here’s the physiology. First of all, estrogens — we know this — they are metabolized in the liver. And then those metabolites are excreted in bile. Do you see the first problem? If she doesn’t have bile, how are those metabolites gonna get excreted? They’re not. They become more problematic when they can’t be excreted like they’re supposed to. Some of those conjugated estrogen metabolites can be deconjugated in the gut and reabsorbed through the enterohepatic circulation back up to the liver. So sometimes what happens is when that liver — I call it the liver-bile-gut axis — that whole part of how estrogen is being handled becomes burdened and inefficient. And when that happens, her estrogens are not going to maintain their proper level because A, she doesn’t have enough bile to grab onto those metabolites and get them out. They’re back in circulation. They get broken down again. And now we have a problem with maintaining estrogen balance.
So bile isn’t the only factor. There are other factors, but it’s a key piece of this — as far as the infrastructure for her, and for every woman, in order to tolerate hormone shifts well. Because we women have a lot of hormone shifts. I mean, there is a lot happening. I read a thing one time that said — and we know their hormones are different and I pick on them sometimes, but this is not what I mean here — but if men’s physiology was the way that it is and they had to endure, or experience is a better word, the dramatic hormone shifts that a woman’s body has to go through, it would make them suicidal. That’s what this research paper showed. Yes, but we handle it. We’re meant to handle those huge, big swings. But when you have a bile issue, a gut issue, and a liver issue all stacked in together, she’s not going to handle those swings well.
So most menstrual migraines are tied to lower amounts of estrogen or an estrogen withdrawal. It’s not just a hormone imbalance. And then we throw progesterone at it and we’re like, “Oh, that fixes the problem.” Well, sometimes it does and sometimes it doesn’t. It’s not a need for bioidentical hormone. I would argue that it’s often corrected when we get to the underlying cause, which in this case — and very, very often — is tied directly to bile. So the question is, how can we help her navigate these natural hormone shifts in her cycle so that she doesn’t have to have a migraine? So instead of it looking like neurological chaos and us blaming the migraine on some neurological deficit, it’s really more that she just has an inability to tolerate the hormonal shift.
So let’s talk more about how bile fits into this. We know that estrogens are processed by the liver. They’re conjugated, excreted in the bile, and then some of those conjugated estrogens can be deconjugated and reabsorbed back up — and they just kind of stay in the loop. They’re not going out and getting used. And the conjugated intermediates are often more toxic to the woman’s body than the original estrogen would be as well.
Estrogen doesn’t just depend on bile, either — but interestingly, estrogen affects bile physiology. So this is now a two-way street. It’s bidirectional. There is literature that shows that excess estrogen — and I’m gonna put a little pause before I finish that sentence — where do women get excess estrogen? Well, one of the most common places exogenously is their skincare products. There are three types of estrogen, E1, E2, and E3, and they all move back and forth. And at the end of the day, all roads lead to E3 — that’s where they all lead, in the liver. So the liver plays a role. But when estrogen gets high — and the woman is putting skincare products on, eating hormone-fed food, dealing with plastics and environmental chemicals — those disrupt estrogen. Copper IUDs influence estrogen. There’s a lot of different places. But what happens is when we have too many estrogens, it causes a reduction of bile flow. Isn’t that interesting? The very thing we need the bile for is also the thing that reduces the bile.
So how do we work our way out of this? You also have to know that when you’ve got patients with sluggish bile, they’re not gonna have that enterohepatic recycling happening effectively. Or if it does, it’s taking those broken down hormones and putting them back in the liver where they just go round and round. It can be both. It can be an and/or situation. They can have too much estrogen impacting bile, but also low bile where the estrogen can’t get cleared. So the easiest way to think about this — and I know it’s kind of confusing — is that estrogen influences bile, and bile handling influences estrogen metabolite disposal and ultimately recirculation. So when the gut-liver-bile axis is overwhelmed or burdened, the body becomes less resilient to the hormone withdrawal because nothing’s working right. But we need bile. Bile is crucial, crucial, crucial for women in their reproductive years.
So when you have someone who comes to you and they’ve had a gallbladder removed, or they have fatty stools, or pain between the shoulder blades, or cyclical migraines in this case — whatever the symptoms are that point you toward a possible bile stasis situation — insufficient bile production or just congested bile — believe it. For her, it fit perfectly. So as I’m listening to her symptoms, I’m like, oh my gosh, this is so perfect. This literally explains everything.
So once she obviously had the gallbladder out, bile doesn’t get stored. It doesn’t have the same storage and release rhythm. The liver produces bile, it stores it in the gallbladder for use later, it concentrates it. But even if the gallbladder’s gone, the liver still produces bile. And I always explain it like this: the liver will produce it and it just — drip, drip, drip — it just drips into the common bile duct and then out through the sphincter of Oddi into the small intestine. But what happens when there’s food that we’re eating, or we’ve got hormones that need help? When we’re eating something that’s a fatty meal and CCK gets released, that triggers the release of bile. If there’s no gallbladder, the only thing we have to rely on is not a nice bolus of concentrated bile to help emulsify and deal with the fat. Now we just have drip, drip, drip. That’s all we got. Just dripping, not a nice squeeze from that gallbladder, not a nice contraction.
So instead of it being stored and concentrated, she now just has a drip, drip situation. That’s going to change, absolutely change, not only bile acid circulation in the body, but it’s also gonna impair downstream digestive signaling and so on. It kind of creates a big problem. And women that have gallbladder problems — I have seen this over and over and over, it’s not across the board for sure — but women who have bile or gallbladder problems almost always end up, more often than you would think to connect the dots, with hysterectomies. Nobody puts those two things together. But it’s because it messes up the availability of estrogen, and then the hormone cascade starts to get crazy. Heavy bleeding starts to happen because the endometrium is overbuilding, we’re not shedding, the signaling isn’t there — and then they end up having a hysterectomy or they go into early menopause and it’s just a disaster.
So for her, this bile conversation mattered because she had the gallbladder out. She already had a history of fat malabsorption. She has alcohol intolerance. What does that tell you about the liver? She has diarrhea when she drinks coffee. What does that tell you about the liver? Her digestive system is a little bit wonky, and then we’ve got migraines. So it’s all pointing back. All roads lead to the liver. If the body tells you a signal and it says, “This is what’s happening” — believe it.
Now there’s another thing I wanna point out. There’s an older study — and I had to go hunting for it, it took me a little bit to find it, but I remember reading it years ago — and it shows that estrogen inhibits sphincter of Oddi motility, and that’s one way that estrogen contributes to biliary stasis. The sphincter of Oddi is just that little muscular valve in the duodenum — it’s where the common bile duct flows in, where everything kind of comes together, mixes up, and moves into the small intestine. When it doesn’t relax normally, the flow gets impaired. And that means pancreatic enzymes would be affected, bicarb release would be affected, and most certainly bile release would be affected. Those are kind of the three primary things that run through the sphincter of Oddi. So if it doesn’t relax normally, then flow becomes impaired, and that pressure can build upstream.
The research is older, so sometimes it’s harder to find that current stuff, but I think some of the older research is better because it’s not influenced by pharmaceutical interests. So when you think about it — if estrogen reduces the contractility or the flow of bile, then when estrogen starts to back up, that upstream pressure builds and the sphincter of Oddi stays contracted. So now we’ve got a big problem.
So the prevalence — this is what the researchers said, I’m gonna read it: “Estrogen inhibits sphincter of Oddi motility, concluding that the effect of estrogen on the sphincter of Oddi may contribute to the higher incidence of gallstones and sphincter dysfunction seen in premenopausal women.” There it is, my friend. That’s why we have to make sure that estrogen and bile are right.
So how do we do that? Well, I didn’t chase the migraine with her. I knew the migraine wasn’t the issue. And I just told her, “Yes, we’re gonna get this fixed for you. No problem.” I did not give her anything for her migraine.
The number one thing I did — if you’ve been around me for a while, you know what I’m gonna say — I 100% started with detoxification. My tried and true, and you all do what you wanna do, but for me my tried and true is the 21-Day Purification from Standard Process. I have seen — not literally, but — the dead raised to life with that thing. It just works every time. So that’s what I use. You use whatever you wanna do, but that’s what I do. So I started her on that — 21 days — and I gave her some extra liver support. For the liver gallbladder support you could use Beta Food from Standard Process, GB Support, TUDCA, there’s options from CellCore — there are lots of different ones you can use. But I gave her specific bile support, and then I just let her go. I said, “Okay, just do this.”
She was getting ready to go out of town and she knew she was gonna have another migraine, but she couldn’t help it. So when she got back, she said, “I’m gonna start the cleanse.” Great. So she did it. And I said, “No alcohol, no coffee, no grains.” She was already off those. No sugar — already off that. No dairy — already off that. And then I said, “Hard cheese is fine, but nothing like cottage cheese, yogurt, milk, ice cream, nothing like that.” And this type of patient? She was gonna follow it to the letter. And she did.
So the first month, she did the 21 days — the first month, she had a migraine. But here’s the kicker. Remember, the migraines were 10 out of 10 or higher and they lasted for two full days. She was completely debilitated. One month after this — all I did was a 21-day cleanse and I added in a little bit of bile support. That’s all. Super simple. I didn’t give her anything for stress. I didn’t give her digestive bitters. I didn’t do any of that. Right now, this is all I’m focusing on.
In her very next cycle, she still had a migraine — but it was a four to five out of 10. And the kicker was that it only lasted one hour. From two days to one hour. She said, “It’s no longer this piercing ice pick stabbing over my right eye. It’s much more tolerable.” Her brain was clearer, her body felt better, she was beyond excited.
And I said, “Okay, now we’ve got the liver moving. Now we need to support a normal reproductive cycle — hypothalamus, pituitary, ovary, et cetera.” We’ve gotta get the signaling fixed because it couldn’t — the signal gets all disrupted because estrogen got all screwed up because the bile is insufficient. Now, definitely she needs to stay on bile salts. Of course. So the 21-day cleanse, or whatever you wanna use, fixed or improved her bile flow, improved the liver function, and now we’re starting to deal with these estrogens better.
I put her on Cholacol — of course, why would I not? — or any kind of bile salt, it doesn’t matter, you choose. And then what I did was I added in a really small protocol to start to reset the HPO axis. Because now that I have the junk cleaned out — think about the liver like the TV show Hoarders, you know how it collects all the things — well, what I did was I just brought the dumpster in. With the 21-day cleanse, I just cleaned all the trash up, or at least a good part of it. Now, there’s no way her liver is magically fixed in three weeks. So I kept her on some liver support, just very gentle and a low dose, just to keep things moving. I said, “I want you to eat beets every day. I want you to focus on cruciferous veggies, eat some liver — either cooked liver like pate or something like that, or take some kind of liver support.”
Alright, so this was kind of phase two. We finished the liver, then I go to phase two. I said, “Now we’re gonna restore this HPO axis.” I gave her chaste tree because that acts on the pituitary and it also helps with cycle timing and progesterone-estrogen balance. I gave her tribulus during days five to 14 — those of you that know, you know. And then I gave her OVEX. You could do OVEX, you could do a bovine ovary product, there are lots of things. I just use OVEX because I was already using Standard Process anyway and she liked those products, so I just stuck with them.
That’s literally it. Just those three things. The tribulus acts on the hypothalamus, the chaste tree acts on the pituitary, and the OVEX is targeting the ovaries. Win-win-win, super simple protocol. So the tribulus is only days five to 14. The other two I said, “I want you to stay on these for three to four months.” And then I gave her something for her liver, and of course she’s on the Cholacol for bile support.
Now, she messages me about two weeks in and she said, “I have an 8 to 8.5 out of 10 headache.” And I thought, oh no. What happened? Wait, I’ve done this so many times, this is not supposed to happen. And she said — I said, “Well, what did you do?” She said, “I had a glass and a half of red wine.” There it is. So it confirmed that the liver isn’t all the way fixed. The alcohol is still a trigger for her. And I said, “Was it 8.5 better than it would’ve been?” She goes, “Yes, likely it probably would’ve been a 10 out of 10.” I said, “Okay. Well, that confirmed to me that I need to continue with the liver support.” It didn’t feel random. It was just good information to have.
So then the next cycle she had after the 21-day purification — the three simple supplements plus the Cholacol plus the liver support — zero migraine. Zero. Like six to eight weeks, no migraine, that’s it. And she said, “I literally cannot believe it. I have been everywhere trying to fix this, everywhere, and no one has been able to fix it.”
But here’s where it gets a little messy. Finances became a problem for her — which I completely respect — and she ran out of her OVEX, tribulus, chaste tree, Cholacol, and liver support. So she was on five things, and she ran out. She messaged me and said, “I just took my last chaste tree yesterday.” And I started to think, wait a minute, she should have reordered long before now. And I wasn’t paying attention, I wasn’t watching in FullScript. And sure enough, she had not ordered in like a month. And I said, “This isn’t gonna work. You’re gonna undo everything that we’ve done. Consistency is essential. I don’t care if you gotta go get a part-time job — you gotta figure this out, girl. This is your health. We can’t not do this.”
I said, “I’ll try and substitute something out, but the one I’m absolutely not willing to compromise on is the tribulus. No way, no how, not doing it.” So I said, “We will keep the tribulus and I’ll see what I can do.” Fussed with her protocol, ended up being able to save her about $30 or so, and she placed a really simple order and got back on it. I’m hoping we caught it in time so that I don’t have to redo the cleanse or do more aggressive gallbladder or bile support.
And so the end of the story is she’s gonna get better and she’s gonna be fine. At this point it’s really just a financial thing for her. But I said, “Look, if you can just stick this out for four months, then you don’t have to do as much. The only ones you can stay on are chaste tree, liver support, and Cholacol. Just those three things, and the chaste tree dose is two per day. So it’s easy. No big deal. You just have to get through these four months. Where there’s a will, there’s a way.”
And I heard back from her and she’s got it figured out — she’s found the budget room to be able to order the supplements. This is where, as a provider, I had to contend for her because she doesn’t see what I see. She doesn’t know what’s at risk and what’s gonna cost her if she lets the ball go now. I can’t stand by in good conscience and let that happen. So my big takeaway from this one was: I’m so happy that I knew about the bile and the estrogen and I knew right where to go.
And that’s why I thought this would make a great podcast for you. Because I wanted to share with you about the role of estrogen — if you deal with these types of patients. And really think about it this way: it’s with almost every patient, but especially when you think there’s estrogen involvement, which is always gonna be the case with migraines in the first couple days of the cycle. The patient’s not tolerating the shift well. But that’s because something else is driving it. And it’s almost always going to be involved with the liver and the gallbladder.
That’s why I start every hormone case — whether reproductive, menopause, perimenopause, it doesn’t matter — if you have a woman and you have hormone dysfunction, the first step, no matter what, is going to be liver detoxification. Choose how you wanna do it, but it always is that way. So practitioners will ask me, “What should I do? Should I give them chaste tree and this and that?” And I say, “Have you done the cleanse yet? Have you done any kind of detoxification? Have you improved the way phase one and phase two are working? Are you improving bile? Are you getting things moving? Are you clearing the trash out of the hoarder house?” “Oh no, I haven’t done that yet.” “Well, then you’re wasting money. Your protocol is not gonna work.” I can’t tell you how many times I’ve seen this.
There was a period of time where I thought, well, let’s just try and see what happens without the 21-day cleanse. Bombed. 100% bombed every time. So the migraine wasn’t really the problem. The problem was, why was she not handling the hormonal shift? And the answer was clearly liver and bile.
Remember, five years she’d had these migraines, and we got them under control in six to eight weeks. And after the first four weeks, she had her next cycle and it was already down to 4.5 and only lasted one hour.
So to wrap up — anytime you start a protocol with a woman that has hormone-related symptoms, the challenge is that you can only see the evidence of your work once a month. Unless you’re looking at mid-cycle changes: changes in discharge, changes in libido, et cetera. And then how the symptoms show up when there’s that dramatic shift at the end of the cycle. So we’re gonna see symptoms around the mid-cycle ovulation period, then you’ll get the PMS that can occur during the luteal phase, and then the symptoms that show up during the first few days of bleeding. Wherever those are, I can almost guarantee you that the liver, bile, and gallbladder are going to be part of the whole process.
So when you see changes as you’re working with her month over month, write this down because it will save you and it helps you communicate more effectively with your patient: look for changes in frequency of the symptom, duration of the symptom, and intensity of the symptom. You know you’re headed in the right direction. Frequency — how often does the symptom happen? Well, for her, we know it happens every time at the same time. Duration — huge change in that first month. It went from two days to one hour. I would call that a win. And then intensity — it went from a 10, to an 8.5, to about a two. We’re not done. We still have to get the HPO axis cleaned up. There are still other things to do. But there’s no reason why we need bioidentical hormones. We don’t need them. We just fix the underlying issue.
Unless somebody’s had a hysterectomy or they’ve gone into early menopause because of a trauma or surgical removal for whatever reason, there’s always an underlying cause. And that’s why I’m not getting on the bioidentical hormone train. I’m not doing it. I never have. And I have thousands of patients that I’ve helped. So you can’t talk me out of it. I’m just gonna say, “What is the underlying problem?” And in almost every case, it’s gonna tie back to the liver and the gallbladder.
So there you go, friends. That is your take-home clinical case and clinical nugget for the week. I’ll see you next week on the podcast. On YouTube, don’t forget to like, subscribe. Come back. See you next week.
[CLOSING]
Ronda Nelson: All right, listen — if you love this episode and it was of interest to you, especially if you love female hormones, you are gonna really wanna listen in for what I’m about to tell you.
I am teaching a live online seminar all about how to support women from perimenopause all the way through to postmenopause and up into their senior years. We’re gonna dig into the physiology, all the clinical patterns, the protocols — the way that I normally love to do it. I’m gonna leave you with lots of clinical pearls and lots of next steps that you can take with your patients right away to help them get over some of the really uncomfortable symptoms and help them transition into menopause really gracefully.
So mark this down. The day is Saturday, May 30th from 8:00 AM to 3:00 PM Pacific. It’s on a Saturday, 8:00 to 3:00 — we’ll take a little break. The cost is $249. You can go to rondanelson.com/menno2026 and you can register. There will be an early bird registration the week of May 10th — so if you wanna get $50 off, you’re gonna wanna register that week of May 11th. Mark your calendar, it’s coming right up. You’re gonna love the seminar. It’s always good, always fun to be together. I’m going to break down this whole process — perimenopause, all the way through menopause, postmenopause. You’re gonna be a master by the time you’re done. All you have to do is go to rondanelson.com/menno2026. And I’ll see you next week.
[END]