Hypothalamic Amenorrhea Recovery: Eating, Exercise, and Mindset (Episode 429)

Full Transcript: Episode 429

Lisa Hendrickson-Jack: Welcome to the Fertility Friday podcast, your source for information about the fertility awareness method and all things fertility. I’m your host, Lisa Hendrickson-Jack. I’m the author of the fifth vital sign and the fertility awareness mastery charting journal. I’m a certified fertility awareness educator and holistic reproductive health practitioner with nearly 20 years of experience teaching women to connect to their fifth vital sign through menstrual cycle charting, balancing hormonal health, and optimizing the menstrual cycle without hormones. I’m outspoken about hormonal birth control and its impact on fertility and overall health, because you have the right to know how your body works and how artificial hormones disrupt that natural process. I teach women’s health professionals how to utilize the menstrual cycle as a vital sign in their practices, and I host live coaching programs to help you achieve optimal fertility and health, because it’s important to have healthy menstrual cycles regardless of whether or not you want to have babies. I’m also a wife and mother of two beautiful boys. I know, I’m a busy girl, but I managed to fit it all in. This podcast is designed to empower you to take full control of your cycles, your fertility, and your overall health. And I’m so excited that you’re here with me today.

Today I’m sharing an episode exclusively about HA. I’m sharing my interview with Nicola Rinaldi, author of the book No Period. Now What? Excellent resource for PCOS, understanding the dynamics, and really going into some of the challenges that women face. And so in today’s episode we really go through the steps and what is necessary to recover from HA. And I always say in some ways they’re quite simple to understand, reduce exercise, eat more, make sure that you’re eating a sufficient amount to cover your activity level and/or reducing that activity level. But it’s easier said than done. There’s significant challenges for many women with implementing what needs to be done in order to restore normal cycling. The good news is that it’s possible but it can take time especially to work through the mindset shifts and changes that need to take place to make those types of changes to both your exercise routine and dietary habits. Today’s episode also wraps up my short series where I wanted to dive into PCOS and HA so kicking off with episode 425 where I dived into the difference between PCOS and HA and culminating with today’s episode where we get a really strong understanding of HA and some of the challenges that are associated with it. So without further ado, let’s go ahead and jump into today’s episode with Nicola Rinaldi.

And today I’m so excited to have Nicola Rinaldi back on the show. For those of you who’ve listened to the show for a while, you may remember our first episode together back in episode number 141 where we talked all about hypothalamic amenorrhea. And just after having researched more about the topic, and Nicola and I have had many exchanges over the past year, I really wanted to have her back on the show to talk about some of the emotional aspects of it, because HA is quite different to many of the other disorders that can affect menstruation and ovulation and all those types of things. So welcome back to the show, Nicola. Thanks so much for coming back.

Nicola Rinaldi: Thanks so much for having me. I have really enjoyed listening to your podcast over the last year, so I’m really glad to be back on and sharing more with your audience. So thank you.

Lisa Hendrickson-Jack: Well, thank you so much for being here. And for those of you who may not be familiar with Nicola’s work, she’s the author of the book No Period. Now What? And so now that I have my own copy it is a massive book. One of the things that I wanted to talk to you about with regards to the book is the research that you did for the book. I thought that was a really interesting part where you actually had participants kind of go through different aspects of treatment, different things. So did you want to talk a little bit about that aspect of it? Kind of like the clinical aspect?

Nicola Rinaldi: Sure. So the book had its genesis in a forum that I posted on for many years on hypothalamic amenorrhea. And so I got to know a lot of the women that had experienced it and sort of saw them come through, you know, sort of arrive on the board very new to the idea of, “Oh my gosh, my eating and exercise habits could actually be having this negative effect on my life and fertility,” to sort of, okay, I’m going to try this eating more and exercising less thing and see what happens to, oh my god, I can’t believe how much more free I feel and how much more better my relationships are. And getting pregnant, which is, you know, which was a part of it for a lot of women, it’s, you know, they don’t really think about the fact that there could be a problem with the missing period until they want to get pregnant. And so, you know, that was the main reason that many of them were on the board was trying to get pregnant. And so I realized that I had this huge sort of dataset in my head based on the stories of all these women that I had followed through their journeys. And I wanted to kind of quantitate that so that I could share it more widely because there’s so much misinformation out there about HA and sort of the effects of under-eating and exercise on people’s fertility. And so I wanted to, you know, I’m a scientist. So I wanted to put numbers around that and be able to say, like, what is the effect of all this exercise? You know, how much do you really need to eat? And so I put the survey out to that whole group and I ended up getting over 300 responses. And so that is sort of the data set that I had in my head and now I can put real numbers around it to share more broadly. And so that was a big part of what I put in the book and why, you know, I think it’s quite unique.

Lisa Hendrickson-Jack: Well, and I think for any woman who has experienced HA, which we should define in a second, but I think for any woman who’s experienced it or knows someone who has, they’ll know that it seems like there’s just few places to get really reliable information about it in depth. And so I feel like your book is one of the very few, if there are others, resources that really go into it in depth. I mean, that’s, it really occurred to me as I was going through it, because there’s so much misinformation about that, just about it in general. So for the listener who’s like, this is their first episode that they’ve ever tuned into, they’re brand new to the podcast, welcome. Maybe you could define for us what is hypothalamic amenorrhea and how would you know if you had it?

Nicola Rinaldi: So hypothalamic amenorrhea is a condition where the part of your brain that controls many of your systems including your reproductive system, the hypothalamus, has been suppressed and is basically shut down. That can come from a number of different factors. So it’s not like you do this one thing, you know, if you weigh x, your hypothalamus will not work and you’ll not have your period. It’s not like that. It’s a whole combination of how much you or how little really you are eating and that can be in terms of just your overall food intake, number of calories, and also if you’re restricting particular food groups. It can be how much exercise and the intensity of the exercise that you’re doing can play a part. If you’ve lost weight in the past, that can have an effect on your whole, you know, on so many of your body systems that can sort of set you up to have HA in the future. Stress, psychological stress plays a role. You sort of hear about women who miss a period for a month if they’re going through a divorce or if a parent dies. And that’s an extreme case, but a lot of stress on a daily basis can play a part. And then genetics is a factor, obviously. I mean, there are so many hormones that are involved that, you know, you might have a receptor that’s different or a hormone that’s different. And so all of those things together make up somebody’s unique recipe. So you can have two women who on the surface seem to be exactly the same and one has her period and one doesn’t. But it’s like, there’s so many other, there’s so much interplay between all those different factors that it’s a very unique thing. So basically, your hypothalamus controls many of your systems, it sends out the signals that encourage you to eat or tell you you’re full, it helps keep your body warm or cooler, and it controls your reproductive system. It sends out a hormone called gonadotropin-releasing hormone, and that then leads to your pituitary gland, which is another part of your brain, sending out follicle-stimulating hormone, which basically starts the whole process of a follicle growing and the egg inside maturing. So if your hypothalamus is shut down, those pulses of the gonadotropin releasing hormone that it sends out are much slower or smaller, and so you don’t have enough of the follicle stimulating hormone and basically you end up not ovulating and therefore not getting a period. So, that’s my spiel.

Lisa Hendrickson-Jack: Well, and you mentioned something a little bit earlier that’s really important. And I mean, it’s one of the central messages of the podcast, just in general, which is that your period, your menstrual cycle, regular ovulation is important regardless of whether you ever want to have kids. So I think with hypothalamic amenorrhea, it’s a really interesting example of why it’s really important to have regular menstruation. So maybe for the listeners who aren’t as familiar, just with some of the actual effects. So for a woman who experiences hypothalamic amenorrhea, so her ovulation stops, she stops getting her period, what are some of the health effects that are associated with this condition, especially if prolonged?

Nicola Rinaldi: So there are actually a ton of effects. And for somebody who’s interested in this, if you look into relative energy deficiency in sport, that’s sort of the new name of the whole syndrome that encompasses all the effects. So you can have problems with bone density because estrogen and progesterone are both necessary for sort of the cells that build our bones on a regular basis. There are potentially heart effects. There are studies that show that the elasticity of your arteries can be decreased if you don’t have the rise in estrogen that you normally get around the time of ovulation. Thinning hair, brittle nails, problems with your immune system, problems with digestion, I mean there’s a myriad of effects sort of short-term and long-term. I think one of the most important ones is the long-term effect of brittle bones. So if you aren’t menstruating regularly, if you’re not getting that ovulation and the associated rise in estrogen and progesterone, that can lead to weaker bones and that can have serious consequences as one gets older. So there are a ton of reasons to work on getting your period back, even if you are not interested in getting pregnant now or ever.

Lisa Hendrickson-Jack: Well, and this may be a little bit controversial, but you know, whatever. But there’s a number of different diets, like I’m not going to list them out or anything, there’s a number of different diets that involves restricting different food groups. And I’ve actually seen a lot of information online where women will say things like, “It’s actually good when you stop menstruating. It means that your body is so clean that it doesn’t have to anymore,” and things like that. So I know that it sounds outrageous, but it’s a real thing. And there’s a lot of women who do subscribe to those types of beliefs. So what, if anything, would you want to say about that regarding regular menstruation?

Nicola Rinaldi: There is so much evidence in the medical literature of the benefits of estrogen and progesterone and the negative side effects of amenorrhea and, you know, however one gets to that point, I think that anybody who says they believe that they don’t need their period, that belief is not based in anything factual that I am aware of. I’ve certainly seen that same statement thrown about as you have, and there’s never any scientific evidence to support it. So I would encourage anyone who has been told that their period is not important to really go and look for statements by doctors, read through some of the stuff that I have on my website. I assume you have information also about why your period is so important and the rise in estrogen and progesterone. Just because we want something to be true doesn’t make it true. So, our periods can be messy, yes, but that doesn’t mean that they’re bad for us. Aside from the whole reproduction thing, there are just so many benefits to the monthly changes in our hormones. And we don’t even necessarily know what they all are. I mean, we talk about estrogen and progesterone, but there’s also follicle-stimulating hormone and luteinizing hormone and inhibins and prostaglandins, and there’s so much that actually changes on a monthly basis that to say that, “Oh, your body’s fine without all of that,” it’s like, well, you know. Our bodies were designed to work this way, and certainly if you look at women who are in menopause they have a lot more, you know, there tends to be a lot more health issues that arise after one is no longer regularly menstruating. So to just say that that’s okay when you’re in your teens or your 20s, I think is really, there’s just really nothing factual to support that in my opinion.

Lisa Hendrickson-Jack: Well said. One of the things that struck me about hypothalamic amenorrhea, HA, I’ll just start saying HA, but one of the things that struck me is that it’s quite different from some of the other conditions that affect menstruation and affect ovulation, in that there’s a significant behavioral component to it. So maybe you could talk a little bit about this. I mean, I suppose I’m thinking of kind of like a broader context. As women there’s quite a bit of pressure for us to look a certain way, have a certain body type, and it would seem as though HA is kind of like this wild wild west of what happens when it all goes too far. So I’d love to hear your thoughts on that.

Nicola Rinaldi: That’s a great way of putting it. So yeah, I mean, you know, we get told every day in all types of media, from women’s magazines to the news, about how unhealthy it is to be in the larger body, which, you know, I’ve looked at some of the evidence for that, and there’s a lot of stuff that’s very correlational, not causative. So I think that whole idea of a larger body equals unhealthy is very questionable. And I encourage people to look at the health at every size movement and kind of read some of the research that’s been done in that area. But, you know, we’re always told being in a larger body is bad, it’s unhealthy. Being in a smaller body is great. And it seems like that we’ve gotten to a point where the smaller your body is, the more quote unquote attractive you are and the more quote unquote healthy you are thought to be. And so, and then there’s the whole fitness aspect as well. And it kind of goes in the same way. You know, we’re told you should exercise every day. And there’s always this idea that the more you exercise, the healthier you are. And I think that both of those messages have led a lot of women to take those things too far. And when you do take them far enough that you end up with a missing period, that is your body kind of screaming out to you. This is not healthy. You know, we’ve been told you’re healthy, quote unquote, but your body is not agreeing with what society tells us. So I think that we really need to kind of pull back from some of those pressures and ideals and remember that our bodies are, they’re not meant to be the smallest they possibly can be. Our bodies have a size that they prefer to be and if we have to constantly under eat whether that’s in terms of restricting the amount of calories or restricting food groups in order to keep our body at a lower weight than it actually wants to be at, that’s not actually as healthy as we’ve been sort of told that it is. Because as we’ve just discussed, all of the side effects of amenorrhea and everything that goes along with that, I really fail to see how that is healthier than being in a slightly larger body or a much larger body and getting the benefits of that estrogen and progesterone and having the stronger bones. And then there’s also the whole emotional side when you’re constantly under fueling. I don’t know about you, but I get really — when I’m hungry, and I know that’s a really common response — when we’re hungry we’re not as patient, we’re more anxious. You get so focused on your eating plans and your exercise plans that you can lose your relationships and lose sight of what’s actually really important in life, which is not what your body looks like or how many pounds you can bench press, but it’s your connections with your spouse, your friends, the work that you do, the impact that you’re having on the world, your kids. I mean, it’s so easy to get so wrapped up in this idea of being quote unquote healthy that you lose sight of so much else that’s really important and beneficial and makes our lives worth living.

Lisa Hendrickson-Jack: I kind of want to go there a little bit more. I mean, part of the spirit of the questions I’m asking is that I’ve personally never had kind of like a challenging relationship with food. So I feel like I’m pretty in tune with my body. I eat when I’m hungry. And I can’t imagine overriding my hunger cues for long enough to — so I suppose let me try to formulate this into a question, Nicola. So if a woman has HA and it’s related to under eating, does that mean that she’s continually overriding her hunger cues to the point that, like, is she hungry all the time? Because from what I read in the literature, she would have to be hungry all the time.

Nicola Rinaldi: So this is something that I did to myself. I decided when I was at the end of grad school, I decided I needed to lose a few pounds. I thought it would make getting pregnant easier because you read so much in the literature. Lose weight to have an easier time getting pregnant. Lose weight to have a healthier pregnancy. So I was like, “Oh yeah, so you know, I want to do it for aesthetics and I want to do it to make it easier for me to get pregnant.” And so I cut my calories significantly and I kept up with all the exercise that I had been doing, which at the time was just, I loved the things I was doing. I was playing ice hockey and volleyball and biking and squash and playing golf on the weekends. It was all for enjoyment. It was stuff that I loved doing. Then I decided I’m going on this diet. To start with, yeah, I was hungry, but I was doing this diet. I was going to lose weight. I did exactly that. I overrode my hunger signals. I found that over time, I didn’t feel as hungry anymore. I think that your body kind of shuts some of that down. You know, I would drink a diet soda if I felt hungry and then that would fill up my stomach and so I wouldn’t feel those hunger signals anymore, or you know I might have a couple of jelly beans and that would give me a little bit of energy but it wasn’t too many calories, quote unquote. And so I think there are a lot of ways that we can actually override our hunger signals. And another thing that I found really interesting in the research that I did for the book was there was a study where the researchers took a group of men — sadly always men — and they had them two separate experiments, one where they just kind of had them live their day and put them in a room with an unlimited buffet and said, “Eat as much as you want, stop when you’re full,” and they ate x number of calories. And then they had them do 800 calories worth of exercise on a different day, and then put them in the same buffet. And the men did eat more, but not enough to make up for those 800 calories that they had burned through exercising. So I think that’s something that a lot of people don’t even realize. So sometimes it is the intentional overriding of the hunger signals, as we just talked about. Sometimes it’s unintentional. You’re doing a lot of exercise, and so your hunger signals are suppressed a little bit, or your body just doesn’t feel the need for as much fuel as you actually do need to support all that exercise that you’re doing. So I think that’s actually a place where a lot of people get into trouble. “I eat when I’m hungry, I eat till I’m full, but I still don’t have my period.” It’s because they’re doing a lot of exercise and the amount that their body is sort of naturally telling them to eat is not actually enough to support everything that it’s doing — breathing, heart beating, brain using up energy — as well as all the exercise they’re doing. So I think it’s kind of often a little bit of both: the intentional ignoring the hunger and then also this completely unintentional component.

Lisa Hendrickson-Jack: Because that’s helpful. I mean, so I was never like a serious athlete beyond high school or anything, but I did a ton of activity. So I was in ballet, which is hard. So for anyone who’s like, it’s just people dancing on their tiptoes — it was a legitimate workout. And basketball, track, like all this stuff. And I ate so much food because I was so hungry all the time. So the thought of working out, you know, five to seven days a week, and eating less — from the perspective of a person who has never really had like a strained relationship with food, I kind of don’t know how you would do it.

Nicola Rinaldi: Yeah, I mean, it’s so much of it comes from the societal pressure to be smaller. And women with HA tend to be sort of type A, very controlling. You give us a goal and by God we are going to make that goal no matter what it takes. And you know, that’s actually been found by researchers in the field of HA as they have found that women with HA tend to be exactly as I just described. And so if I’ve decided I need to lose 10 pounds, then I’m going to do what it takes to lose 10 pounds. That’s my goal, that’s my focus. And so it almost doesn’t matter if I feel hungry because that’s getting me away from my goal. And so, you know, I just stick through it and I make it to my goal. And then oftentimes, you know, what I found was when I was losing the weight as I was on this, you know, caloric restriction, it got really addictive. And I think seeing the number on the scale going down and getting the accolades from people as my body began to look more and more like it’s quote unquote supposed to — I could definitely see how it was such a slippery slope. You start out thinking, “Oh, I’ll just lose a few pounds,” and then all that happens, you see the scale go down, you get the praise, and it’s like, “Oh well, I can go a little bit further. I can go a little bit further.” And interestingly, the further you go, the harder it is to back away from it, because you kind of end up focusing so much more on your food and this goal, and it gets harder and harder to pull back. The further you go down that slope — I was lucky in that as I was going down there, I had a friend that was kind of experiencing the same thing. And she posted on a blog everything that she was going through and about the Minnesota Starvation Study. I don’t know if you’ve ever heard of that. It was a study done in the 1940s where they basically took a bunch of healthy men and severely calorically restricted them. And so then there was a lot written about how their experiences and how they were feeling when they were on this restricted diet. And I read some of that and was like, wow, that’s me. I’m waking up hungry at night, you know, I can’t sleep very well anymore, all these others, I’m thinking about food all the time. And so that for me really helped me to pull back from the brink, I think. And I can see how it was basically luck for me that I went there and that I saw the blog post and thought about it. And I can definitely see how I could have gotten a little bit further into the hole and ended up with a full-blown eating disorder. Just, you know, the caloric restriction really messes with our brains I think. And so, yeah, it can be really hard to pull back from once you’ve started down that path.

Lisa Hendrickson-Jack: Well, and what role does our societal obsession — and I say that purposely with emphasis — with calories in and calories out? I mean, I’m a child of the 80s, like I grew up in the 90s, and it was all this — that’s basically the whole thing. There’s Weight Watchers, there’s Jenny Craig, there’s just everything is based on this assumption that a calorie is a calorie is a calorie, right? Doesn’t matter if it comes from a jelly bean or grass-fed beef liver, right? Not, but beyond that, the concept that this is just a math equation. So when you want to lose weight, it’s literally just math. So you could like pull out your agenda and make a goal like you would to run — you pull out your agenda to make a goal and do it like a math exam where it’s like, okay, this is how many calories I’m going to eat, this is how much I’m going to exercise, and then subtract or whatever. So tell me how you feel that that incorrect portrayal of food impacts this whole issue with HA.

Nicola Rinaldi: So that’s an interesting question. For me, it very much was a math equation. And I know that’s not true for everybody. I mean, I know that so much of whether that calorie in, calorie out thing applies to a particular individual depends on so much else about them, like, you know, conditions like PCOS for example, where your hormonal structure is not set up so that it’s a calorie in, calorie out thing. But at the point I was in my life, it did work out that way. So I had an Excel spreadsheet where I was tracking my in and out every day, and I was aiming for an incredibly low number, because I didn’t understand all of the things that our bodies actually do on a daily basis that take energy. So there’s this thing that researchers talk about called energy availability. So basically, the amount of energy that you’ve consumed in a day is the total amount that’s available to your body. And then off the top comes your planned exercise because your body doesn’t have a choice about moving your muscles when you’ve decided, “Okay, I’m going to exercise and I’m going to burn x number of calories through exercising.” And then whatever is left over from that is what your body has to work with for digesting your food, breathing, pumping your blood, your brain working. I mean, you have hundreds of millions of cells in your body that are all using energy constantly through the day, you know, rebuilding things, all of that. So with the calories in, calories out thing, you’re basically saying to your cells, to your body, “You don’t get as much energy to work with as you need, so figure out what to shut down.” And when one has HA, your body has already shut down — it’s already decreased the temperature that it keeps you at because that takes energy. It might have decreased your heart rate because that takes energy to pump your heart. It might have decided to stop producing as many immune cells. It’s kind of not building the bones anymore. It’s not repairing your muscles as well. And then it shuts down your reproductive system. So it doesn’t even do that — that’s not even necessarily the first thing that happens. So when you get to the amenorrhea, the no period, that’s such a strong signal that things are not right with your body because it’s used up the extra fat that you have. I mean, your fat actually produces hormones, so it’s not a bad thing to have body fat. That’s another thing that society tells us is this awful horrible thing. It’s like, no, it’s actually one of our organs, we need it. So yeah, I mean, I think that we think about it as calories in, calories out without considering all of the other things that our body actually does with all of that energy.

Lisa Hendrickson-Jack: Well, now thank you for taking us through that. I’m kind of going down this road because in many ways HA is a problem with a solution, right? I mean, so when I was looking at the research about HA, women with HA who’ve lost their periods have like a lower body mass index, they are eating too little. I mean, there’s no way to simplify it because every woman is different. And as you mentioned, stress can play a factor. Just there’s all these different factors and genetics and all those things, but there are common threads. And so for the most part, if you organize your caloric intake and organize your exercise accordingly and manage your stress, at some point the period will come back. So tell me just a little bit about — because this is not so easy, and I think that’s why I wanted to focus on the emotional aspect of it, because it’s really not so easy. So for a woman who’s in that rabbit hole — you said that you were on the brink, like she’s fully there. And what we’re talking about here, correct me if I’m wrong, is a spectrum somewhere on an eating disorder or a disordered eating. So maybe that’s a better way to say it, but it’s somewhere on a disordered eating spectrum, an indefinitely disordered way of thinking about food and your body. And I mean, it makes perfect sense to me why this happens because of the world that we live in. So how then do we interrupt this and try to get her healthy again so she doesn’t develop osteoporosis at the age of 30?

Nicola Rinaldi: You put it all perfectly. I think it’s a great way to think of it — all of it is on the spectrum. I mean, as you said, it does tend to happen in women with lower body weights, but there’s certainly women who can have HA no matter what their body size. And I think that’s a really important thing for people to understand. A lot of doctors will say, “Oh, you can’t be missing your period because of that, because you don’t look like x, y, z.” And so, you know, it’s really important for people to know that this can happen no matter your absolute body size. In terms of interrupting the pattern, I think knowledge is power in this case. I think there’s just so much out in the media about how great it is to be smaller and what have you without really covering the negative impact. So I think once women learn about the negative impacts, it makes it a lot easier to make changes and also understanding all of the things that our body uses the fuel for. I think that’s why people really like my book so much, is because it lays out all the science behind what your body is doing with all these calories, this energy that you’re taking in, how exercise is impacting your missing period. And evidence for — I say generally — that one should eat about 2,500 calories a day to recover. I don’t like to really encourage thinking about calories because the end goal is always not to track. It’s to listen to your body. But it can be helpful to kind of have that as a number in your head because for many women, that’s almost double what they’re eating on a regular basis. And can be like, whoa, that’s where I need to get to. So it’s really hard to interrupt the rabbit hole, as you say, but I think that what helps start the process is the knowledge. And then also finding support from other women who are going through the same thing. I think it can be very isolating if you have this feeling, “Oh, I should probably cut my exercise. I probably need to eat a bit more. I probably need to gain some weight.” But when you’re doing that in a world where everybody else is doing the opposite, it can be very, very difficult to move forward. So I think support of other women going through this is really key, and that’s, you know, I have a Facebook group that I started for that purpose. So I think the knowledge starts the process and some people can just be like, “Oh my god, I had no idea. I need to fix this right away.” That tends to be the case when one is looking to get pregnant. When pregnancy is not on the table right now, I think it’s often a longer process. It’s sort of like, okay, I have this knowledge now, but it doesn’t really apply to me. I’m different. I can’t cut my exercise for x, y, z reason. But the kernel of knowledge is there. And so I think sometimes it takes women a year or two years to kind of be like, okay, now I’m ready to make these changes. My health has become more important to me. I’m not in college as a college athlete anymore and I can take some steps towards this. So I think knowledge is the beginning, and then for each person it’s sort of her personal journey to coming to a place where she can be like, okay, I can make these changes and I need to make the changes.

Lisa Hendrickson-Jack: Well, and tell me a little bit about — so more about the relationship with food. So I’ve spoken with women who’ve been on this disordered eating spectrum who don’t even like food. They don’t enjoy it. It’s a chore. It’s something that they have to do. Eating is a thing that has to happen or I’ll die, so I have to do it. But there’s no pleasure or enjoyment. And even in terms of the variety of foods that they will allow themselves to eat, may be very, very small. So for someone like me, I mean, I love food. I love the taste of food. I love all kinds of different types of food. And I’ve never really restricted. I mean, I have certain things that I do and certain habits that I follow and things like that. But at the end of the day, there are very few things that I would ever actually say I would never under any circumstances eat. So talk to me a little bit about that because I personally, Nicola, I have a hard time understanding what that would be like. Food is one of the wonderful pleasures of life, in my opinion, and so to not even like food — help me understand.

Nicola Rinaldi: So that’s also somewhere that I didn’t go. I sort of never went to a place where I didn’t like food. It was always like, this is the amount that I’m going to allow myself to have. And so that’s, you know, I get to that number and I stop and that’s it. I think some of it is sort of psychological. We’ve decided this is all I’m going to allow myself to eat and so therefore I don’t like it. And so you know, there’s a term that I learned about when I took psychology in college. It’s like you come to think about something in a way that helps you to justify your decisions. I know there’s a term for it. I can’t remember what it is. But I think a lot of times that kind of happens with our food choices as well. We’ve decided I don’t want to eat this. So then you go and look for reasons why it’s quote unquote unhealthy. And so then you’re like, “Oh, I’m not eating that because it’s unhealthy.” And then you get to a point where you’ll just say, “I don’t eat that anymore. I don’t even like it.” It’s kind of confirmation bias almost. You kind of go to a place where you tell yourself you don’t like it because you don’t want to like it and you don’t want to eat it. That’s one way that makes sense to me from what I’ve seen with people that I work with. And then as they sort of recover and start to add back some of these foods that they are scared of or that they didn’t think they liked, you know, a lot of women will find they actually do enjoy and appreciate them. So I think so much of it is mental, and there’s also the aspect of food intolerances. So as women reduce their caloric intake and cut out food groups, they can sometimes start to find that they are less tolerant to some of those foods when they try them. It can be, obviously, there are women that have bona fide allergies, and there’s celiac disease and what have you. I’m not talking about those kind of things. But women who have decided I am gluten intolerant, but have never actually gotten tested for it. It’s just, oh, you know, maybe it makes me feel poorly. Maybe I think it makes me feel poorly. But they find that as they actually increase their overall energy intake, their bodies are much better able to handle those foods they didn’t think they could eat before. So I’ve witnessed this over and over again in the women that I’ve worked with and supported in my Facebook group and on that thread that I told you about earlier. My co-author, for example — I have a couple of women that wrote the book with me — she had an anaphylactic reaction to eating beef. And then over time, as she ate more, she is now able to eat beef with no problem. So she went to the hospital with an anaphylactic reaction, and now that’s not there anymore. So I think when we deprive our bodies of the energy that we need to such a degree that it can actually cause our body to have problems with certain foods, but as we increase our overall energy intake back to what our body really does need and want, some of those intolerances can go away. So I think there’s sort of two aspects. There’s sort of just the purely psychological, and then there’s the physical manifestation of the constant energy deprivation that can sort of rebound after one is no longer in that energy-deprived state.

Lisa Hendrickson-Jack: Oh, yeah. No, it makes total sense. It’s fascinating. Well, and one of the aspects of overcoming HA is something that would make certain dietitians cringe or for women who are really focused on this quote unquote eating healthy thing. So for example, when I’m doing groups with women and we’re talking about something like chemical exposure, so like xenoestrogens and things like that, I always make a point of stressing that there’s no clean. Your body will never actually be clean because we live in this world and the world is polluted. So what we’re aiming for is a reduction of harm. Because there’s no, like, if you if you actually are trying to go for like my body’s perfectly clean and there’s no toxins in me, then you’re going to have to go to another planet because that’s just not the reality here, right? So the concept of this healthy food thing and like good food and bad food — frankly, I don’t believe that there is such a thing as good food and bad food. I feel like there’s food that may be more beneficial or less, but I don’t think that anything is good or bad. So tell us why it’s important then in terms of recovery, especially because we’re talking about this whole disordered eating spectrum, for non-restriction.

Nicola Rinaldi: That’s such a great point, Lisa. I think there has been so much fear-mongering around food recently. Sugar is being demonized, carbs are being demonized. And I think that the problem is that those media articles and whatever make everything black and white. And we don’t live in black and white. Our bodies don’t live in black and white. Our bodies live in shades of gray. And so, yeah, if 100% of your calories are coming from sugar, you’re probably not going to be very well. But if 100% of your calories are coming from broccoli, you’re also probably not going to be very well. So I think it’s really important to realize that our bodies are great at handling so much of this stuff. Food is not a toxin. Food is energy. Our bodies need food. And so often with HA recovery, we have to kind of pull ourselves back from some of these ideas that x food is really, really unhealthy, and if I eat it I’m going to get diabetes and I’m going to get heart disease and I’m going to balloon to four times my size overnight. You know, all this stuff is just unrealistic. It’s not the way our bodies work. But that’s kind of the thing that we have in our heads. So you know, a lot of women that have HA tend to eat very quote unquote clean, which means a lot of fruits and vegetables, often very low fat, often low carb, and it’s hard to recover on a diet like that. I’m passing no judgment on that, you know, whatever people want to eat, that’s fine with me, I don’t care. But that type of diet makes it very difficult to actually get enough energy in a day because fruits and vegetables fill you up without having a lot of energy content, which is why a lot of people eat them because they want to be in smaller bodies. But when you’re trying to recover from HA, I really find that cutting fruits and vegetables for the time being and adding in things that often tend to be more processed foods, because they have a lot of energy in them and they’re easy to eat. Like, ice cream is a great HA recovery food. I mean, you know, ice cream is good in general, but for somebody who’s been restricting calories — it’s got fat, it’s got full fat dairy. And I’m not talking about the Halo Top or those kinds of low-calorie ice cream, but stuff like that. And French fries. I mean, objectively, if you ate French fries all day every day, yeah, you’re not going to be healthy. But if you throw them in as a way to increase your caloric intake on a day or two days, you have a hamburger, you have some pizza, you know, none of it is sort of quote unquote healthy food. But when you’re not menstruating, you’re not healthy. So you have to kind of rework your ideas of what’s healthy and what’s not healthy. And healthy is eating and increasing the number of calories. And often it takes some of those less desirable maybe foods. I call them fertility foods in my book, because that’s the idea — instead of thinking of them as being junk and bad for you, that’s one way for women to increase their calories and then recover from HA.

Lisa Hendrickson-Jack: Well, it’s so interesting because I mean, I’ve interviewed a ton of people. So I can actually picture like a boardroom table with different guests that I’ve had on the show to talk about this. And I think what’s hard about this particular situation is the emotional aspect of it. Because what you’re doing is you’re trying to get in the calories and you’re also trying to address the emotional aspect of it. So then like if we’re debating about a French fry, like, yeah, we could talk about all the issues with like is it nutrient dense and whatever, but we’re also addressing an emotional issue by kind of shattering our ideas that food can be good or bad. So I feel like it’s a very interesting conversation because you could argue, like, you could do this on a whole foods diet and blah blah blah, which you could provided that you were eating enough food, but it may be like easier for you to just eat the French fry so that we can move on.

Nicola Rinaldi: I think the other thing that’s really important for women to learn about eating that French fry is that we kind of have this idea like if I eat this one French fry, oh my god, everything’s the world’s gonna end. And it’s like, no, you can eat a French fry and you’re going to be fine. And I think that for some women, sort of taking those scary steps and eating those foods that they are afraid to eat right now can just open up so much of their life. Because it means you can go out with friends and family and co-workers and not have to check the menu beforehand. You can go wherever they’re going and just enjoy spending time with them and not be so focused on “this food is bad and so therefore I can’t eat it” and missing out on all of those interactions. So I think that’s where I love to see the food freedom coming in, is that it doesn’t just give you freedom around what you’re eating, it gives you freedom in so many other aspects of your life.

Lisa Hendrickson-Jack: Well, so let’s switch gears a little bit as we kind of draw near the end and talk a little bit about one of the topics. And we may have covered this in our last interview together. But I mean, the common treatment for HA, unfortunately, is hormonal birth control at least with a certain percentage of practitioners. So tell us your thoughts on that. I mean, I think my thoughts — if anyone’s listened to the podcast, they’re going to know my thoughts — which is that it’s not doing anything. In HA you’ve got this very clear issue where you know it’s leading to all these other health problems so we don’t want to cover that up. So maybe talk about the pill — like why it’s used, but why it’s not necessarily the best option.

Nicola Rinaldi: Oh, I would 1,000% agree with you on that, Lisa. I think the pill is a band-aid. It does nothing to address the underlying issues. And unfortunately, it’s very, very common for a woman to go to her doctor and say, “I haven’t had my period for three months or six months,” and the response is, “Here, take these pills. They’ll give you a period, and they will quote unquote protect your bones.” More and more research is coming out showing that while the pill can keep your bone density stable, it doesn’t allow it to increase in the same way as your natural menstrual cycle does. So giving it to women because they quote unquote protect your bones — I think is really not quite accurate. Well, some doctors will say, oh, take the pills and it’ll jumpstart your period. That does not work because, again, you’re not addressing the underlying cause of the missing period. And there’s nothing in fake estrogen and progesterone that is going to cause your body to make follicle-stimulating hormone. They’re completely unrelated. So this idea that the pill or progesterone alone or even estrogen plus progesterone is going to jumpstart anything is just not based in biology. So it really takes working on the underlying cause, looking at your life, your habits, your thoughts, and figuring out where can you make changes. Eating more, eating more food groups, cutting out high-intensity exercise, because not only is that a caloric drain, as we talked about, it also can increase stress hormones, which suppress your hypothalamus. So taking a look at your life and your lifestyle and thinking about ways that you can make changes sort of along those lines — that’s what needs to happen. The pill, it’s a band-aid. And a lot of research in the relative energy deficiency in sport or female athlete triad have come out and said it’s not good to put women on the pill because it gives you this false sense of security that things are okay because you’re bleeding every month. I think it’s really important for women to understand that this is not a bleed that comes from ovulation. It’s a bleed that comes simply because you’re putting artificial hormones into your body. It is not the same thing and it is not as good for you as your natural period is.

Lisa Hendrickson-Jack: Well, and one of the topics as well that you had mentioned in our pre-chat was for women who are trying to conceive. So this is complex, so we won’t be able to go into a ton of depth because we don’t have like another hour to talk about it. But I suppose just briefly, I mean, I’m thinking, okay, so woman’s trying to conceive, hasn’t ovulated for however many months, she’s given all these drugs to force her body to ovulate, but meanwhile — I mean, would you say that HA is like a your body’s response to starvation on some level?

Nicola Rinaldi: Absolutely. There’s no doubt. The main driving force behind HA in most people is chronic energy deficiency — not getting enough fuel for your body. And so that can make getting pregnant more challenging, no matter what drugs you put into your body. There are many doctors who will say to women with amenorrhea, “Oh, go on the pill, and when you want to get pregnant, come back and see me again.” And then they’ll put them on the injections of FSH and LH, which make one grow a follicle and probably ovulate. Sometimes it works, sometimes it doesn’t. And then the woman gets pregnant — and now she’s, if it even works, I certainly know many women for whom those fertility treatments don’t work until they have made the lifestyle changes that we’ve been talking about. But, you know, if she gets pregnant, then it tends to be a pregnancy that’s very focused on, “I don’t want to gain too much weight. I want to be this perfect pregnant woman with just a little belly and I want to come home weighing the same thing as I did when I got pregnant.” And you know, it just leads to not nearly as pleasant a pregnancy experience. I mean, you know, pregnancy can be pleasant or unpleasant in and of itself, but just having that emotional restriction and those feelings of worry about what your body is going to do while you’re pregnant, one of the aspects of recovering from HA beforehand is allowing yourself to feel so much more freedom around that whole aspect of changing body. And it really just makes for a much more pleasant and enjoyable pregnancy. Not to mention, like I said, it can be very difficult to get pregnant if you do have HA no matter what the fertility treatments. I know many women who have gone through multiple rounds of IVF and have failed and then found me in my book, started eating more, exercising less, and gotten pregnant naturally, or had a frozen embryo transfer that has now finally worked. So for somebody in that situation, I really, really encourage you to take some time off from fertility treatments and look at those lifestyle changes and make them. I mean, it’s just, I’ve now seen thousands of women go through this and just the freedom — from being kind of so stuck into food and what your body looks like and not being able to focus on as we’ve talked about the much more enjoyable parts of your relationships and your baby and all of that — it’s so worth putting in the time and energy to recover.

Lisa Hendrickson-Jack: Well, towards the beginning of our chat today, you mentioned something about how it’s important for women to understand what’s happening. So on a fundamental level, you know, I think this is the bigger problem. Like, this is bigger than both of us, Nicola, because it’s like, you know, we grow up not really understanding anything about our bodies or our cycles. And we’re not really taught that our ovulation is important. And it’s like they didn’t know what to do with us. So they just put everything that’s different into a box and pretend like it’s not important. But as a woman, as a biological woman, ovulation is an essential part of it. And without it, you just are not functioning the way that you’re supposed to function. So when your body has taken ovulation off the table, your body is telling you, “This is not a good time to get pregnant.” It’s telling you, “We don’t want you to get pregnant.” Your ovaries are protecting you because if you are starving, a pregnancy could be catastrophic. So as a mom — and you’re a mom as well — when you’re healthy, when you’re good, when you’re going into pregnancy with a good weight, you’ve taken time to replenish your nutrients ahead of time, you’re going into it in a really good place. It’s still hard. But after the baby comes, it’s no easier, because there’s no other time in your life that’s going to take as much energy out of your body — macronutrients, micronutrients, energy, the whole thing. There’s no other time in your life that’s going to be as taxing on your body. So it actually terrifies me the thought of a woman who hasn’t fully recovered from HA, hasn’t regained that body mass, let alone eating in a proper way, just to replenish the nutrients. Because I’m actually worried for her after. I would be worried about the postpartum after. Because it’s going to be rough.

Nicola Rinaldi: I couldn’t agree more. And that actually is one of my very big pet peeves — that during pregnancy, a woman who is not gaining, you know, sort of an appropriate amount of weight, which is in my mind a minimum of 20 pounds for the whole pregnancy, 25 is much better, because you have to consider the baby weighs 7 or 8 pounds. There’s the increased weight of your uterus, the amniotic fluid, blood volume, breast growth. That all adds up to about 20 pounds. So a woman goes to her doctor and she’s on track to gain 10 or 15 pounds, which I’ve seen, and the doctors will do an ultrasound and say, “Oh, your baby’s growing fine. You’re all good.” And it’s like, but what about the woman? Just what you were talking about — the postpartum period is so challenging. If you’ve been essentially losing weight while you’re pregnant, you go into that postpartum period with so little reserves for breastfeeding and just for the emotional challenge of having a baby. So I really get so upset when OBs will say to a woman, “Oh, you’re fine.” I mean, I know there’s some people that just simply can’t gain weight, they try and try, and that’s a bit different. But I’ve also seen women who are actively restricting while pregnant. And for their doctor to basically tell them, “That’s fine, your baby’s good, so no worries” — I’m like, but what about the mom? Like, they’re just not even considering that aspect. And that really makes me really sad.

Lisa Hendrickson-Jack: Yeah. Well, I mean, that’s something hopefully within our generation we’ll see that shift. Because I get it, I get that we have to be focused on the baby, but at the end of the day, since everyone else is focused on the baby, let me focus on the mom. Because I think that’s the part that’s missing. Like when you go into pregnancy in a really bad place, whether it’s that you are like way too skinny, like you don’t have the reserves as you were mentioning, or if you have not taken any time to really replenish those nutrients and store, stock, deposit into the bank account, like really build that up, then yeah, you’re setting yourself up for a really, really rough, because when the baby comes, that’s just the beginning — then you have to be a mommy. Well, we could totally go down this rabbit hole because of course it’s so much fun chatting with you. But after everything we’ve spoken about today, I feel like we’ve really covered a lot. If you could leave the listeners with one takeaway, what would you want?

Nicola Rinaldi: Okay. Can I say one thing first before we talk about this? So there are women who put in the work to recover from HA. They sort of gained back to their set point. For many of us, we’ve lost a bunch of weight, and that’s kind of led us to HA, and many women will recover their periods at around the same weight that they were when they started the whole weight loss journey, which was the case for me. But for some women, they get to that place, they’ve stopped their high intensity exercise, they’ve reduced their stress, and they wait some amount of time, and they still don’t get their period. At that point, I feel okay with recommending some of the oral medications for encouraging ovulation, like Clomid or Femara. I feel like that’s a much better — if one needs fertility treatments, that’s a much better way of going about it than doing the injections or the IVF. In a woman with HA, like, obviously there are many other reasons for using the injections or IVF, but I really like those, the Clomid and Femara, just in somebody who’s made the lifestyle changes and done the work toward recovery, but her system just hasn’t quite gotten that message to start up again. So I just like to throw that out there. Lots of information in the book about that. I do recommend Femara over Clomid, if doctors will prescribe it, especially for getting pregnant, but a lot of them won’t, unfortunately.

Lisa Hendrickson-Jack: So for women listening, maybe she tuned in because she’s looking specifically for information for HA. I actually had a woman in my Facebook group not that long ago who posted something along the lines of, “I haven’t had my period for a while. I’m not sure what it is.” And of course, everyone’s jumping in telling her what it is. And so I gave her a couple of episodes to listen to, and she listened to a few on PCOS and then a few on our episode. So if anyone’s listening and they’re not sure, like, what’s the difference between HA and PCOS, I feel like we really covered that in our previous interview together. So I would direct you back there. But in her case, it was apparent to her based on our conversation — okay, I think it’s probably more in this category. So with that in mind, what is kind of the big takeaway that you’d want the listener to leave with today?

Nicola Rinaldi: I think really the most important thing is to make sure that you are nourishing your body appropriately. Forget about what society tells you you should look like. Forget about your appearance. In the end, what we look like — it doesn’t matter that much. And nourishing your body so that you can live your life as a human being and support another life inside you if that’s your choice — I think that just, if you’re well nourished, there’s so much more that you can do, that you can imagine, that you can accomplish, than if you’re super focused on “my body has to be like this and I have to do this much exercise.” And so I really — that’s one of my favorite parts about helping women recover from this — is just seeing the butterflies that they turn into.

Lisa Hendrickson-Jack: Oh, well, thank you. This is such important stuff, so I’m really glad that you’re out there in the world supporting women with HA, because without information like this, it’s kind of like, where would you go? Especially if you go to your practitioner and your practitioner happens to tell you just go on the pill and it’ll be totally fine. So thank you so much, Nicola, for being here with us today.

Nicola Rinaldi: Thank you so much, Lisa, this has been really great.

Lisa Hendrickson-Jack: Thank you for listening. If you enjoyed today’s show, please share it with a friend. You’ll find the show notes page for today’s episode over at fertilityfriday.com/429. I hope that you enjoyed today’s episode with Nicola. I feel like it gives a really good insight into what I would call the HA phenotype — common characteristics of women who have lost their period due to under nutrition, over exercise, rapid weight loss, and/or stress — and I really feel like it sheds light on the path that is necessary to get your cycle back, to resume normal cycling, and ultimately work towards having overall normal cycle parameters. And so the good news is that there is hope, there is a proven strategy to achieve this goal. And I guess the challenging part is that it does take work, and it’s not overnight that these things shift. Women often have to work at this for quite some time. And I would say the bigger aspect of it is shifting your mindset around diet and exercise and overall even the conversation about calories in and calories out, shifting the mindset around food and what it does for your body, from food as fuel and it’s just calories and they’re all the same, to really looking at food as nutrition and nourishment and bringing the conversation to what is necessary to nourish your body and to achieve optimal menstrual cycle health, hormonal balance, and all those great things. So with that said, I hope you have a wonderful week — weekend, whenever you’re tuning into the show. And of course, as always, until next time, be well and happy charting!