Podcast Episode 31 Transcript – Hypothalamic Amenorrhea

Leah

00:00:07 – 00:00:29

Welcome to the ideal nutrition podcast. This is Episode 31. I am Leah Hagel, and I’m here with my co host, Aidan Muir. And today we are talking about hypothalamic Amenorrhea or HA, which I will definitely be referring it to as a HA. Because that word gets me every time. Um, but Aidan is going to get us kicked off on what it is. 

Aidan

00:00:29 – 00:01:25

Amenorrhea stands for absence of the menstrual cycle. Hypothalamic is referring to the hypothalamus, so that’s an area of the brain that controls hormones and stuff like that. So obviously just putting those together, lack of menstrual cycle due to hormones and basically the mechanism is that in this condition, the hypothalamus is suppressing the production of gonadotropin releasing hormone, which leads to follicle stimulating hormone, lionising hormone and oestrogen all being reduced, which then results in ovulation and menstruation ceasing. So it’s pretty complex, so that’s the simplest way I can put it out there and like you don’t really like. Basically, it’s just like a lack of period or lack of menstrual cycle due to weight loss over exercise or stress or probably a combination of those things. Is that a fair assessment? 

Leah

00:01:25 – 00:01:26

I think that’s a good description, for sure. 

Aidan

00:01:26 – 00:02:09

And it is a diagnosis of exclusion in terms of you obviously got to rule out other stuff like an obvious one. But like pregnancy, like if somebody was pregnant, they wouldn’t be menstruating. So, like you’ve got to like anybody who’s diagnosing this has to rule out any other possible cause of the lack of menstruation, Um, as well. And another thing, I was just going to touch them very briefly, but like stating the obvious but like oral contraception can mask this, as in, you could be in a situation where you have the condition and have the downsides associated with the condition. But you wouldn’t know if you’re getting that, um, fake bleed, so to speak, due to contraception. 

Leah

00:02:10 – 00:02:22

Yeah, and I always think about it as well, as well as like, the withdrawal bleeds. But when you have things like the depo shot or the marina and you don’t have a period at all, this can still be present. But you wouldn’t know because you don’t get your period anyway. 

Aidan

00:02:22 – 00:02:24

Yeah, exactly. Exactly. 

Leah

00:02:24 – 00:03:12

Um, so there’s a lot that goes into why this matters. It’s definitely a deeper rabbit hole than I first thought. Um, I always used to think that the two biggest things that can go wrong if uh, HA is present is obviously issues with fertility, so difficulty conceiving. If you don’t have a regular menstrual cycle, becoming pregnant is going to be quite difficult. Um, the second thing that I’ve always known exists is the impact on bone health. So when HA is present, there is an overall reduction in oestrogen, very similar to what you would see in like postmenopausal people have that low oestrogen level. Um, and what happens there is there with the low oestrogen. 

Leah

00:03:12 – 00:03:56

There’s an increase in bone resort option, but there’s also so that’s like the breakdown of your bones and your bone cells. Um, but there’s also a decrease in calcium absorption, and there’s actually something to do with vitamin D as well. Like that’s not the in terms of like the system in regards to vitamin D and bone health. Something does go awry at that point as well, so it can definitely impact your bone health. Long term. It is estimated the mean bone mineral density of a young woman with just six months of low oestrogen that’s seen an F H has, like an equivalent to that of a 50 year old woman, 51 year old woman. Um, and I thought that was just insane because in six months you can do so much damage to your bone health. 

Aidan

00:03:56 – 00:04:28

That’s such a short period of time. Yeah, and like I even had a client the other day who had a check for 10 years, for example. So it’s like if this happens in six months, like what happens over 10 years and I suppose that amongst a few other things we’re going to talk about, is part of why this is so important. Like it’s not just about fertility. It’s not just about the menstrual cycle. It is about bone health as well. And it is about a few other things, and a lot of people like I’m jumping the gun on this, but like a lot of people get this due to being athletes, for example, and that can contribute to it being caused and over a long athletic career.

Aidan

00:04:29 – 00:04:42

If you are in this state for a long period of time. You lose a lot of bone mineral density, and that can increase your risk of stress fractures and stuff like that while you’re an athlete. But then, obviously it has implications for later in life as well. 

Leah

00:04:42 – 00:05:27

So in addition to the difficulty conceiving and the bone mineral density, there’s also a higher rate of, um, illness like frequency getting cold and just a lower immunity level. So if you’re an athlete and you’re having, you’re getting ill more often and it’s of a longer duration that’s really going to impact you as an athlete. So it’s definitely something that I’m sure nobody wants, so that can be a part of a J as well. Um, and then it’s also going to limit your ability to recover and make training adaptations, so that includes muscle growth that could include things like being injured more often. So as an athlete, you don’t want to be sick. You don’t want to be injured. You actually want to make training adaptations. 

Leah

00:05:27 – 00:05:58

And just like brushing that off and not taking too much notice of it can really hurt you as an athlete. So it can hurt you as an athlete, and it can hurt your long term health as well. I think where I struggle with HA is like a lot of people with it will kind of go, Oh, I don’t want kids and I’m not interested in getting pregnant, So it’s fine and I actually don’t like having my period anyway. But there’s all these other things that can happen from a long term perspective that you need to be worried about as well. 

Aidan

00:05:59 – 00:06:20

And I think that’s the piece of the puzzle that a lot of people miss and like, I don’t know if this is because I said from a male perspective or whatever, but like, I think that trend is changing a little bit, and that definitely exists like it still exists. 100% don’t get me wrong, but I feel like 20 years ago that would have been a much more popular opinion. Whereas like now, like I see women who are like stoked to get their period back.

Leah

00:06:20 – 00:06:32

Yeah, the conversation is changing and it’s really awesome because we’re more aware of these other factors that impact your long term health and impact your performance in regards to HA. And it’s not just about if you can get pregnant or not. So it’s a lot more than that. 

Aidan

00:06:34 – 00:07:10

And I also do think I’m in a bubble as well because I did have a conversation with another client the other day who, like, mentioned that they’d have to catch A and I was like, I was anyone ever spoken to about this? Do you know anything about it? And they’re like, Yeah, nothing. And yeah, so it’s like, I don’t know. I do live in a bubble where I’m just like surrounded by people who talk about this day in day, out, day and down. Um, I suppose when we’re talking about a lot of these factors, including, like the muscle protein synthesis or muscle growth, injury, recovery, all those kind of things, it’s interesting to think about the mechanism as to how HA often occurs beyond just the hormones and stuff like that. Like why? Why does this happen? 

Aidan

00:07:11 – 00:07:48

I talked about the training, the stress and the nutrition side of things, but like another big factor, which is part of most of those things, is what we call energy availability, and the simplest way to think about energy availability is you burn a certain amount of calories while training. How many calories do you have left over so you eat a certain amount. You burn a certain amount through training. Your body still needs to use calories for other functions. How much is left over and like for the sake of simplifying? Let’s pretend you don’t have body fat stores and stuff like that. Like I feel like that’s the fact that it’s left a little bit out of the energy availability discussion. But it’s like oversimplifying once again for the sake of keeping it simple.

Aidan

00:07:49 – 00:08:24

Say you eat 2000 calories per day and you burn 1000 calories through training 1000 calories through training like a decent training. That’s quite a bit of training. Um, you would only have by that kind of mathematics 1000 calories left over for all the rest of your body’s functions. And once again, I started keeping it overly simple. But like most people, their basal metabolic rate is over 1000 calories. Pretty much everybody’s basil metabolic rate is over 1000 calories, and your basal metabolic rate is the amount of calories required just for your like daily functions when you’re doing nothing, so obviously like you can bring back the body fat into the debate and stuff like that.

Aidan

00:08:24 – 00:09:01

But that’s also another thing. Why HA often occurs when people get leaner as well. In terms of there is less of these bodies stores of calories for the body to draw on from their body fat and stuff like that. But like low energy availability, is basically this concept of hi exercise or high calories burned through exercise. Not really a high calorie intake. There’s not really this abundance of calories to go around to be useful of these functions. The menstrual cycle is an energy intensive process. It requires calories, and if the body doesn’t have a lot of calories to go around for all of the body’s functions, it has to start down regulating or shutting off certain functions. 

Aidan

00:09:01 – 00:09:42

And that is one of the functions that will be shut off. But that’s also why muscle growth is harder and stuff like that as well, because there’s not many spare calories to be going around to be put towards muscle growth and injury recovery and all of these other things when the body doesn’t really have enough calories available just for basic functions. So talking about level of Leanness, you don’t need to be super lean to get it. We see it more commonly with people who have low body fat. But you can’t have a low energy availability at a higher body fat percentage as well. Like if you’re training a lot and stuff like that, particular, If you’ve been in even a significant calorie deficit while training a lot, a lot of these things can occur.

Aidan

00:09:43 – 00:09:53

I don’t I don’t know your experience, but, like do you see people get HA at significantly different levels of Leanness like you see, some people were quite lean without it, and stuff like that.

Leah

00:09:53 – 00:10:12

Definitely have quite a number of athletes who you would consider quite lean, Um, and don’t have a choice. HA. But they are also typically the athletes that naturally sit quite lean anyway. But on the flip side of that, I definitely have athletes who are in slightly larger bodies, Um, that have HA on both spectrums. 

Aidan

00:10:12 – 00:10:47

Yeah, and like putting like body fat percentages on it and stuff like that. Like I do see people in the kind of 10 to 13% range where a lot of people will lose their menstrual cycle around like by that stage who don’t have it just like you kind of said. And I see other people who are like every time they dipped below 20% they lose it. So it’s very, very individual. I think part of it is what you said about how, like some people who naturally are sitting at lower body fat percentages, I’d also say, like how you get there is probably another factor as well in terms of like what you do if your colour is what you do with your macros, um, stress in your life you’re training all these other variables as well. 

Aidan

00:10:48 – 00:11:10

So looking through the research and also just because I have spent a lot of time like listening to like experts and what their thoughts are, um so many commonly comes up is people with HA typically have a lower proportion of their diet coming from carbs and fat. Do you have thoughts on that in terms of like, is it specifically to do with those or is it to do with other factors? 

Leah

00:11:10 – 00:11:36

I feel like that’s not going like I don’t think just having a high protein diet that’s low in fats and carbs would necessarily lead to hatred on its own. But I think it can be part of the puzzle. Yeah, that’s kind of my opinion on it. I mean, Fats will definitely go into it because I think you can definitely go too low. In fact, you’re regardless of everything else and end up with a change. But I don’t know, I think it’s a smaller piece of the puzzle than a few other things. 

Aidan

00:11:36 – 00:12:08

I agree. One way I view it is like if you were in the pursuit of like if you were doing a lot of other things that put you at risk of HA and you went on a very low fat diet, I’d say you’d been increasing the risk of versus doing all those other things and having quite a higher fat diet in comparison. But like when I say that I actually do mean quite low, like I mean below, say, 30 grams of fat or something like that, depending on the snow may be slightly higher for people a little bit larger as well, but quite a lot. You have to go quite far out of your way to do that. I just put that caveat out there because I don’t want people listening to this and 

Aidan

00:12:08 – 00:12:44

having a decent amount of fat in the diet and stressing about that. We only need a certain amount to cover these kind of hormonal functions. The carbs thing people talk about collection and the role that players having this abundance of these, um, basically types of fuel available on a consistent basis. But I I do think maybe a small factor. I think the other things factor significantly more. And when we’re looking at those studies and everything talking about that, the people who are having higher protein as a percentage of the total calories and higher fibre intake because that’s another common theme and lower carbon lower fat intakes are typically consuming less calories, 

Aidan

00:12:44 – 00:13:01

and that could be a far more significant factor than those individual things so they can matter. I still do encourage increasing carbs and fats like that’s still part of my kind of treatment, so to speak or intervention or whatever you want to call it, but it’s just one piece of the possible. Basically, 

Leah

00:13:01 – 00:13:21

it’s hard for me to wrap my head around about how Cobb’s themselves would play a very specific role in that you can see Fats clearly like you need fats to make hormones. Therefore, it’s going to affect that, but carbs to me like you’re increasing those because you’re increasing calorie intake. But the argument there, I don’t know. I’m great on it. 

Aidan

00:13:21 – 00:14:05

Yeah, I’m speaking of grey areas like this next one, we’re going to talk about fasting and fasting exercise and how they play roles. So something I’ve noticed. Just as the trend is like most people who are h A experts so speakers and that that’s what they do, that’s their career. They’re not necessarily nutritionists, dietitians or anything like that. They just work in the H A space. Um, well, pretty much exclusively say, from what I have seen, it’s not everybody’s generalisation but will say that with a you should never fast and you should never do fasted exercise. And the mechanism that’s often proposed is due to the fact that cortisol, which is a stress woman, plays a role in HK and during fasted exercise seems to increase cortisol more significantly 

Aidan

00:14:05 – 00:14:19

than if you are doing fed exercises. And you’ve eaten even like 20 grams of cops or something like that before that. And they might even talk about other hormones and stuff like that, like kiss pepper and stuff like that. Do you have thoughts on fasted exercise or anything like that with a 

Leah

00:14:19 – 00:14:41

I mean, I think generally, if you’re trying to increase energy availability in the system, I think it makes sense to not have a lot of fasted cardio as part of your routine. Um, yeah, I say even let’s say there’s a chance it plays a role in undoing HA. I think it’s worth just checking in there as part of it as part of your protocol, just in case 

Aidan

00:14:41 – 00:15:24

I see the same. Like I do the exact same thing. Like I would not be fasting. Um, the main study that is quoted or referenced when people are making this statement is the 2018 study called Within Day Energy Deficiency and Reproductive Function in Female Endurance Athletes, and it was a pretty wack study design. I’ve got to be honest. I think that one group fasted for 23 hours of the day and only had a one hour eating window. And the other group, like spread their figured out across the day. And they had similar calorie intakes, which is what people point to. But the group that bastard was in a 659 calorie deficit. The other group was in a 313 calorie deficit. They were both in deficits, but the fasting group was in double the deficit. 

Leah

00:15:29 – 00:15:34

I feel like that would compound the problem. Surely it would cause you think, almost 700 calories, especially for a smaller female. That’s yeah, that’s a big deficit.

Aidan

00:15:34 – 00:16:02

Yeah, quite aggressive. Yeah, exactly. So I take it as a useful information. It’s a piece of the puzzle. That’s a factor. It’s something that I consider, but I wouldn’t say that’s now on the coffin. Being like you cannot fast if you’re if you have a chair. If you’re at risk. Like I also think the other dilemma we have is like you. Probably we’re going to talk about this, but we’ll probably want to increase calorie intake and stuff like that, too, Um, manage or get out of a change. But if you’re fasting, it’s gonna be hard to eat enough calories. 

Aidan

00:16:02 – 00:16:16

So it’s kind of a bit of almost a self fulfilling prophecy that’s like if you are fasting, you’re probably gonna be eating less calories. It’s harder to address the situation. If you do not fast, you might be able to find it easier to consume more calories, and it’s easier to get out of the situation and the point of fasting.

Leah

00:16:16 – 00:16:26

For most people, it’s typically to reduce your weight, and you wouldn’t want to be actively trying to reduce your weight whilst addressing anyway. 

Aidan

00:16:26 – 00:16:30

Yeah, so I suppose that is a good lead into How do you address what a good lead in.

Leah

00:16:30 – 00:17:02

Okay, so there’s a few things that can play into addressing HA. So the first one I’m going to talk about is reducing exercise. So I think a lot of different professionals have different stances on how much you reduce exercise by. I’ve seen professionals say, Oh, I want you to completely stop exercising and training at all. Um, and I’ve seen other people say, Oh, let’s just reduce the volume and intensity of that exercise. Do you have a protocol that you do?

Aidan

00:17:02 – 00:17:22

I don’t have a protocol like I do see people say what you said. Another one I see is like no high intensity interval training or just high intense exercise Ever, Um, and that’s where they do and be like You can do gentle exercise. I just think the blanket thing is like you go to decrease exercise, probably significantly, assuming that was a factor, like assuming you were at a decently higher level to start off with. 

Leah

00:17:22 – 00:17:32

Yeah, if you’re someone who is just kind of exercising half an hour a day like walking, you probably and you have HA. You don’t necessarily need to reduce your exercise because it probably wasn’t one of the main factors.

Aidan

00:17:32 – 00:17:56

I suppose I want to jump in on that in terms of like, we’ve other factors, like there’s one thing is for that, and I don’t normally talk about animal studies and stuff like that. But it’s been like they’ve looked at monkeys and they’ve moved them into an environment that’s uncomfortable for them. Just a new environment and the female monkeys will lose their menstrual cycle, even though they got adequate food. That exercise doesn’t change all these things, just the stress factor. 

Aidan

00:17:57 – 00:18:14

And I think that’s relevant in terms of when we’re talking about this being like, Okay, this accessing relevant for most people with HA. But what if stress was such a driving force that it wasn’t a factor? That’s where I think it’s worth considering being like maybe 90 plus percent of people this is relevant for, but there can be, like a 10% where it’s not. 

Leah

00:18:14 – 00:18:23

Yeah, 100%. I think a good preface to this part of the discussion would have been that what you do to undo HA is really going to be dependent on what caused it.

Leah

00:18:24 – 00:19:03

And that’s going to take a little bit of an assessment of your lifestyle and your diet and all those kind of factors that were previously talked about. Um, so for for a lot of people, reducing exercise or stopping exercise could be a piece of this puzzle and help, um, but others maybe not so much, um, one thing that often goes into it. There is increasing calorie intake because it’s outside of those cases where it’s just stress related. Usually it is because of low energy availability, so increasing calorie intake would definitely make sense for most people who have HA, particularly in the athlete realm of things. 

Leah

00:19:03 – 00:19:37

Um, there is one study that actually saw the sports dietitian post quite a while ago. Um, and I hadn’t seen it before this, but it was the refuel study, and they found that an increase of just 300 to 360 calories per day, um, is enough for many people with HA to resume their period. So putting that into context of food like that’s just a decent sized snack extra debt. So it doesn’t mean you have to increase it by a tone, but just even 3 to 400 calories could really move the needle on it. 

Aidan

00:19:37 – 00:20:15

I like that because that’s also so much less overwhelming than certain other numbers that I see thrown out, especially one It’s individualist. And it makes sense like when you actually think about it does make sense like, um, that that would probably undo it like a number that I see thrown out there and, like people obviously can’t be at this point like this is an average this isn’t like for everyone, but number often see is 2500 calories and putting myself in the shoes of most females. That sounds like a scarily high number to somebody who spent their entire life trying to diet, for example, or stay lean or whatever it is, Um, that can be overwhelming, and that can scare people off. 

Aidan

00:20:16 – 00:20:38

But then we also factor in that if you are doing a high amount of exercise, you do have high calorie requirements, and maybe that is only 300-150 calorie increase for a lot of people. But if you think about in terms of 300-150 calorie increase, that’s not a large increase from where you’re at. It is just an increase. There probably is a requirement to increase calories to undo for most people. 

Leah

00:20:38 – 00:21:18

Yeah, and I think it’s a hard one because I think for fa lot of people, going up just 3 to 400 calories would help them resume their period. But they could definitely be a benefit to going a little bit higher than that people like for a lot of athletic women. 2500 calories is a pretty standard maintenance amount, to be honest, like I work with a lot of female athletes, and that’s a pretty standard amount of calories for maintenance. So I kind of see why that number has thrown out a lot because it’s a good average. But I’ve also got a lot of athletes that that would be quite a significant surplus. So it just needs to be more individual, I think, than that one number to another number that’s thrown out.

Aidan

00:21:18 – 00:21:54

There is a 45 calories per kilo of lean mass, which is another way of individualising it. But like I think the short answer is, it just needs to be more than where you’re currently at. Another number that’s thrown out there is getting back to a similar body weight to were to what you were before you lost. Menstruation is not one of people check out there, but statistically speaking, that doesn’t even seem to be accurate. In terms of it seems like most people get 12 kg heavier, then where they lost a menstrual cycle on average before they resume it. 

Leah

00:21:54 – 00:21:56

Yeah, interesting. I didn’t know that 

Aidan

00:21:56 – 00:22:01

and I don’t think that’s not a mandatory thing, like it’s just like that’s just like what seems to happen on average. 

Leah

00:22:01 – 00:22:43

I think a lot of the time when you do see someone to address, like you see a dietician, uh, aggressive in their approach so that we would make sense that maybe you do gain a little bit of weight in that time just to speed up the process of actually resuming your period and maybe going into a calorie surplus. And it’s a good thing to mention, um, so another way to address H A is we kind of have already addressed this, but eating frequently and adequately just in general. So I think it makes sense to definitely try to get to a point of maintenance. Whilst you could probably still be in a deficit and resume your period. I don’t think it’s the quickest way to fix this problem 

Leah

00:22:43 – 00:22:51

And maybe not the best way, Um, so eating adequately and eating frequently and not fasting part of this for sure.

Aidan

00:22:51 – 00:23:00

Another one on that kind of stress kind of standpoint is cognitive behaviour. Therapy has a pretty high success rate. 

Leah

00:23:00 – 00:23:06

Yeah, that’s what I find so interesting going back to that stress. And obviously for a lot of people, it’s a big part of this.

Aidan

00:23:06 – 00:23:46

There’s one so that you don’t have 16 people. It’s not crazy large or anything like that. But they got one group to just be the control group. Just continue. Continue doing what they would have done without the study, and the other group did. CBT so kind of behavioural therapy for 20 weeks. And 87% of that group resumed a regular menstrual cycle, and in the other group, only 12.5% resumed it. So it’s like That’s really effective, Yeah, so it’s something to consider. Particularly, you’ve been trying other lifestyle factors or whatever, and you don’t seem to be making the progress that you wanted to make. Whatever. It’s another option that could be considered or thrown in there or anything like that, too. 

Leah

00:23:46 – 00:24:14

Definitely. And I think a lot of women do have that experience of losing their period just because of stress. Like I feel like we’ve all been in a point in our lives where there’s been depression or anxiety or loss of loss of a loved one or something like that, and you lose your period. And I think something like CBT and are just generally managing mental health could be a very big part of the puzzle for those people, especially if they’re not someone who’s like exercising like crazy or trying to diet aggressively. 

Aidan

00:24:15 – 00:24:45

I’m going to skip to a little bit later in what we had planned just due to time. And I want to go through what happens if you’re in a sport. That pretty much requires this because, like using marathon runners, for example, I don’t think many great female marathon runners at the peak of their performance have their period. We know from the bodybuilding world that very few bodybuilders on stage have a regular menstrual cycle by the time they get to the stage at the end of their calm prayer. 

Aidan

00:24:46 – 00:25:21

uh, it’s hard to talk about because it’s kind of like choosing to pursue some sporting pursuits is not always the same as pursuing health. Obviously, like some people are going to do this with the knowledge, all those kind of things, and I think I think that’s fine. Um, it’s like, but if you’re going to do that, that’s where I come back to the whole like long term thing like there’s a great example that a guy named Trance dealing with. So here’s a Here’s a nutritionist and he’s done a case study on his wife, who he basically showed the leaner she got, the better her marathon performance was, um, and they’ve done it over a 12 year cycle, being like every time she gets leaner, her performance improves, which is hard because he knows that she loses her period in this process.

Aidan

00:25:22 – 00:25:58

And basically they do this single nutritional periodization, where she intentionally against body fat after competitions and bases on the four year, kind of like Olympic style cycle, where she peeks for that kind of most important event against body, felt intentionally to get back to this healthy state. So that way, she is not in a state of HA for 12 years straight, which would come with all of these other kind of negatives. Um, but she is able to perform at our best when the time comes. Same thing for bodybuilding, where it’s like, Okay, you get into that condition for the show, but then you undertake a recovery diet to kind of undo things.

Aidan

00:25:58 – 00:26:19

and get hormones back and check and everything like that post show whenever you can, in terms of how long that takes for bodybuilders, it’s at least a six month journey. But on that topic for H A recovery seems to be somewhere in that kind of 3 to 6 month range for most people, anyway, statistically speaking, so that’s something to consider as well. 

Leah

00:26:19 – 00:26:30

Yeah, I think I don’t go down that road with my athletes. To be honest, I don’t need them losing their period. It’s not something I’m comfortable with, but if you have to, I think that’s a approach. 

Aidan

00:26:30 – 00:26:49

It’s something to think about because it’s like if you are choosing a situation where you have to do, it’s like, Well, how best can we manage this? I don’t encourage or anything like that, Um, but it is something to consider that there are people who are going to put themselves in that position. If they are, it’s probably going to be better to period ice it than it is to just be in a state of HA year round, year after year after year

Leah

00:26:50 – 00:26:56

This has been Episode 31 of the ideal nutrition podcast. Thank you for tuning in.