Thanks for joining us for episode 125 of The Ancestral RDs podcast. If you want to keep up with our podcasts, subscribe in iTunes and never miss an episode! Remember, please send us your question if you’d like us to answer it on the show.

Today we are answering following question from a listener:

“Is there a case for taking oral birth control if you have amenorrhea? I have hypothalamic amenorrhea and early onset osteoporosis, so the supplemental estrogen would be for bone health. I lost my period at 16 and was put on birth control, but went off it a year ago to try and get my period on my own, but no luck. My bone density never improved while on birth control, but the doctor’s argument is that it could have been worse. Can post birth control syndrome last longer than one year, and is trying to get my period back with diet and lifestyle foolish considering bone loss risk? Some details” I’m 26 years old, 5’ 8”, 125 pounds. I’m 100% Paleo for 2 years, no refined sugar and moderate/low carb, for example, one piece of fruit and about a cup of starchy tuber tubers most days, slowly upping it.”

In an effort to treat amenorrhea and reduce the risk of bone loss in young women, many doctors prescribe birth control as the solution. But did you know that using birth control to regain your period and improve bone density is actually counterproductive?

If you’re on the pill for amenorrhea or considering starting, join us for our conversation today to hear diet and lifestyle modifications to get your period back and improve bone health.

Today’s discussion is packed with information and tips on how to regain hormonal and bone health such as key micronutrients and the importance of appropriate caloric and macronutrient balance. We also talk about the female athlete triad and other lifestyle factors that affect amenorrhea and bone density.

And be sure to listen as Laura introduces her new “Get Your Period Back” program for more in depth guidance in dealing with amenorrhea. You’ll hear an overview of the program and learn how to get started!

Here’s what Laura and Kelsey will be discussing in this episode:

• [00:04:53] The lack of evidence in research that birth control improves bone density in pre-menopausal women with hypothalamic amenorrhea
• [00:07:59] How bone loss in young women is most likely related to malnutrition
• [00:08:56] Diet and lifestyle factors that are the most likely causes of amenorrhea and bone loss in pre-menopausal women
• [00:12:09] The female athlete triad and how disordered eating is a main component
• [00:15:31] How a woman’s period is a barometer for health
• [00:18:45] The prevalence of post birth control syndrome
• [00:21:32] How ensuring appropriate caloric intake with balanced macronutrients in relation to activity levels is key to help improve bone density and regain periods
• [00:32:25] How a moderate level of exercise is key for hormonal and bone health
• [00:35:12] Micronutrients that are important for bone and hormonal health
• [00:37:39] Lifestyle factors such as sleep and stressors that affect amenorrhea and bone density
• [00:45:09] An overview of Laura’s new “Get Your Period Back” program and how you can sign up

Download

Links Discussed:

• This episode is sponsored by Paleo Rehab
• Laura’s program “Get Your Period Back”
• Amenorrhea In Athletes: 5 Tips For Athletic Women To Get Their Period Back
• How To Keep Your Bones Healthy On A Paleo Diet
• An Update On Calcium: Are You Getting Enough?
• The Ancestral RDs Podcast Episode 110: How The Pill Affects Your Thyroid Health With Dr. Jolene Brighten
• The Ancestral RDs Podcast Episode 88: Fresh Insight Into Women’s Hormonal Health With Dr. Lara Briden
• The Ancestral RDs Podcast Episode 121: The Relationship Between Food And Sleep With Dan Pardi

TRANSCRIPT:

Kelsey: Hi everyone! Welcome to episode 125 of The Ancestral RDs podcast. I’m Kelsey Kinney and with me as always is my cohost Laura Schoenfeld.

Laura: Hi everybody!

Kelsey: We are Registered Dietitians with a passion for ancestral health, real food nutrition, and sharing evidence-based guidance that combines science with common sense. You can find me at KelseyKinney.com, and Laura at LauraSchoenfeldRD.com.

Over the next 30 to 45 minutes we’ll be answering your questions about health and nutrition, and providing our insights into solving your health challenges with practical tips and real food.

Laura: If you are enjoying the show, subscribe on iTunes so that way you never miss an episode. And while you’re in iTunes, leave us a positive review so that others can discover the show as well. And remember we want to answer your question, so head over to TheAncestralRDs.com to submit a health related question that we can answer on an upcoming show.

Kelsey: Today on the show we’re going to be discussing the role that birth control plays in recovering bone density in women with hypothalamic amenorrhea. This is an incredibly important topic and we’re excited to tackle it today. But before we get into our question for the day, here’s a quick word from our sponsor:

This episode is brought to you by Paleo Rehab, a five week online program designed to help you recover from HPA axis dysfunction, also known as adrenal fatigue. Is your perfect Paleo diet and lifestyle leaving you exhausted? Now is the time to start feeling the health and wellness you know you deserve. If you’re sick and tired of feeling sick and tired, and are ready to take back your health, then head over to MyPaleoRehab.com to get your free 28 page e-book on the 3 step plan for healing from adrenal fatigue. That’s www.MyPaleoRehab.com.

Kelsey: Welcome back, everyone. Here’s our question for today’s show. This question is from Katie. She asks:

“Is there a case for taking oral birth control if you have amenorrhea? I have hypothalamic amenorrhea and early onset osteoporosis, so the supplemental estrogen would be for bone health. I lost my period at 16 and was put on birth control, but went off it a year ago to try and get my period on my own, but no luck. My bone density never improved while on birth control, but the doctor’s argument is that it could have been worse. Can post birth control syndrome last longer than one year, and is trying to get my period back with diet and lifestyle foolish considering bone loss risk? Some details” I’m 26 years old, 5’ 8”, 125 pounds. I’m 100% Paleo for 2 years, no refined sugar and moderate/low carb, for example, one piece of fruit and about a cup of starchy tuber tubers most days, slowly upping it.”

Laura: This is a great question and I picked it because I’m knee deep in the research on hypothalamic amenorrhea right now. Just the question that she asked about whether or not it would be foolish to try to make diet and lifestyle changes to get her period back rather than taking taking birth control, I just thought that that was a really important question becuase I think this is something that a lot of doctors unfortunately make their patients feel like they’re in danger if they don’t take birth control in that situation.

A lot of women don’t necessarily develop osteoporosis at this age if they have amenorrhea, but it is possible that that can happen. A lot of doctors will say if you’re not getting your period, you’re at higher risk for bone density loss, and here, take this pill to get the period back.

We had done a really awesome couple of podcasts with Dr. Jolene Brighton and Dr. Laura Briden on this topic. I just wanted to continue the conversation because I think this is something that it’s really unfortunate that this is the message that women are getting from their doctor that if you don’t have your period and you want to protect your bones, you better take birth control.

When I was doing the research for this question, I actually could not find any evidence that taking hormonal birth control actually improves bone density in pre-menopausal women with hypothalamic amenorrhea.

Actually there was some research showing that women in the 19 to 30 year old age group that their mean bone density was actually lower when they had longer birth control use. The bone density that they measured was lowest in women who had been using low dose birth control pills for longer than a year.

Kelsey: Wow!

Laura: Yeah. There really hasn’t been any research to support the idea that using birth control, or these synthetic hormones in general, that it would make any difference in bone mineralization in women that are pre-menopausal.

I feel like this is something that I wanted to get out that information to our listeners because that’s a main sticking point for a lot of women who basically get convinced to take birth control for amenorrhea is they’re worried about their bone health. But honestly, there’s really no evidence to support that it makes any benefit.

If your doctor is suggesting that you take birth control to recover your bone density, according to the research this isn’t actually going to help. Not only are you masking the problem that’s going on so you’re essentially covering up the symptom that you’re having of not having a period from potential diet and lifestyle reasons, but based on that research at best if it’s not doing anything, there’s no point of taking it. And at worst, it could actually be causing reduced bone mass in those women.

Using the pill to prevent bone loss in women, I think it’s kind of just crazy. What do you think about that Kelsey?

Kelsey: I’ve always been kind of mind boggled by this whole idea of oh you don’t have a period, here take this hormonal pill that will make you “have a period.” But it’s not a real period as we’ve talked about in our other interviews that you mentioned earlier.

And then this whole idea about bone density to kind of scare women into taking it to get their period back, yeah, it’s utterly crazy to me because as you just said, there’s no evidence that it does anything to help that situation.

Honestly, to me it does really feel like kind of a scare tactic when women are questioning like should I really do this? Is this really going to help anything? Or like you said, or is it just masking what’s really going on and I’m not going to be able to heal anything because I’m not seeing these symptoms and I’m not able to notice if any sort of diet and lifestyle changes help me to recover my period? I think it’s totally insane.

Laura: I feel like this girl, Katie, or woman I should say. I don’t know how old she. Oh, we do know how old she is. She’s 26. Obviously her question being would it be foolish try to do it with diet and lifestyle, I’m not saying that there aren’t other things that she could try doing on top of that, but I actually think it would be foolish to not change her diet and lifestyle to try to get her back.

Kelsey: Yeah.

Laura: Honestly, like I said, from the research that I’ve done and just the other type of conditions that can lead to bone loss in women that are younger, my feeling is that bone loss is far more likely to be related to malnutrition, especially in Katie’s case, than it would be low estrogen levels.

There’s a lot of evidence supporting the connection between eating disorders like anorexia and bone loss and osteoporosis in women that are in the 18 to 30 year old range. That’s not a normal disease for women at that age to be getting.

Like I said, if you’re getting it and you don’t have your period as well, it’s a pretty good sign that malnutrition is likely at least part of the problem. That’s why I think diet and lifestyle not only isn’t foolish to think about, but it’s probably actually the most important thing that this lady could be doing to get her period back and to recover her bone health.

Kelsey: Yeah. I have a question for you, Laura.

Laura: Sure.

Kelsey: When I see women who aren’t having their period, typically the most common things that I notice across the board with them is, like you said, malnutrition. A lot of times there’s tons of stress and then potential over-exercising. Are there any other factors that encompass diet and lifestyle that you tend to see that people should be considering here?

Laura: Yes. The ones that you mentioned are definitely going to be the top factors. The calorie balance piece is probably one of the biggest. I just wrote a blog post on the female athlete triad, which I can talk about in a second, but that’s a super common cause of amenorrhea especially in the populations that I work with, I’m sure in the population you work with as well where it’s a combination of over-exercising and under-eating. It’s that calorie mismatch of burning too many calories and not eating enough that actually leads to the loss of the cycle. That tends to be one of the bigger ones.

And like you said, stress is definitely involved. I don’t often see women that lose the period for more than a month or two from just stress.

Kelsey: Right.

Laura: Certainly you can be irregular because you’re stressed out, but to develop amenorrhea without some other factors is I would say less common. We’ll talk about other things that affect bone health because I wanted to give Katie some ideas about how to improve her bone density. But a lot of those things actually make a big impact on the amenorrhea issue as well.

There’s things like circadian rhythm entrainment, which I’ll talk about in a few minutes. Stress definitely is going to impact both the menstrual function as well as actually bone density because cortisol directly acts on bone. Stress and sleep. I mean it’s kind of all the major things that we normally talk about on our show. But essentially malnutrition, appropriate training, stress management, sleep, and circadian rhythm entrainment.

And then there are some things that can also trigger amenorrhea that maybe aren’t as obvious. I’ve seen things like SIBO that was maybe not causing a amenorrhea directly, but perhaps preventing somebody’s period from coming back especially in a post-birth control syndrome type situation. That’s I think largely to do with the impact of the bacteria in SIBO blocking estrogen clearance in those women.

Kelsey: Yeah.

Laura: That’s one that can cause amenorrhea, which that tends to be more of a PCOS type amenorrhea for those women. It’s not always, but it seems to be whereas this kind of low bone density hypothalamic amenorrhea tends to be in those women that are over-training and under-eating.

There’s so many different things that can help with getting someone’s period back, but ultimately the foundational stuff for most women is really going to be their food intake and their exercise routine.

Kelsey: Yeah, got it. Cool. I just wanted to sort of overview that for people who maybe weren’t sure if there were other factors they should be considering here.

Laura: Yeah, absolutely. Like I said, I just published a couple of weeks ago an article which I’ll link to that in the show notes so people can check it out if they want. But again, it’s about the female athlete triad and specifically athletes who lose their menstrual cycle.

The female athlete triad is three different symptoms or situations that come together to form this syndrome essentially. It’s defined as disordered eating, menstrual dysfunction or amenorrhea, and premature osteoporosis. The osteoporosis they believe is caused by a drop in estrogen production. I do think that some of that is directly impacted by malnutrition during that disordered eating.

Women don’t have to have a diagnosed eating disorder to be defined as disordered eating. They may just be under-eating or a little bit overly conscious about their diet. They may have some level of orthorexia. So it’s not that they have to have anorexia, or bulimia, or anything like that. They just have to have some level of inadequate food intake that’s kind of purposeful. I mean accidentally under-eating can happen, but that doesn’t usually happen unless somebody is purposefully restricting certain types of foods, so that would be disordered eating.

Kelsey: Yeah. I see that a lot. I don’t work with generally people who are currently dealing with an eating disorder, but I deal with tons of people that have sort of more minor issues with disordered eating but still lead to really big symptoms and problems like hypothalamic amenorrhea. I assume you do as well. Do you work with people with eating disorders as well?

Laura: I would say I’ve worked with women who had been through treatment for an eating disorder and still had some disordered eating. I don’t normally work with women who are in the midst of a serious eating disorder because I think those kind of issues really need one on one in person or even like inpatient treatment at an eating disorder clinic.

But if somebody has a history of eating disorder, I’ve worked with those kind of women before. A lot of them have made big strides, but they don’t necessarily have everything under control or they still have some lingering problems that are affecting their hormonal function.

I actually feel like this female athlete triad is an issue that’s really under-recognized in the Paleo community. I know Steph Gaudreau from Stupid Easy Paleo has brought it up a couple of times. She has like this women’s strength summit group that I’m a part of and she’s mentioned it a few times. I’ve seen it in some circles. Probably the Paleo For Women Podcast talks about this kind of thing.

But honestly, I feel like it’s something that probably doesn’t get as much attention as it should and one of the reasons is likely because of these women who are using these hormonal contraceptive options that actually masks the symptom. So if you don’t get amenorrhea because you’re taking birth control, you wouldn’t even know if you were getting the female athlete triad. Most people are not aware of disordered eating in their own situation unless it’s really severe to the point where they seek help.

And osteoporosis, I mean honestly unless you’re fracturing bones or you’re getting bone scans, you’re not going to know if you’re losing bone density. So really the menstrual cycle is the only thing that most women can have as a direct sign that they’re developing this female athlete triad, and using birth control totally takes that out of the picture. You’re masking the symptom.

I like to say that having a period is sort of a barometer for young women’s health. So if you’re not having a period, you can assume something’s going wrong.

Kelsey: Right.

Laura: I don’t want to scare women. I’m not trying to say this to be like freaking women out, but it is something that I think is not taken seriously enough. And again, a lot of doctors, the solution they give you is birth control pills and we’ve already established that that’s not actually going to solve the problem. It’s just going to mask the symptoms.

Kelsey: I think periods, they kind of suck, obviously. I think a lot of us would be happier without them generally. But I think because of that many women view a period as kind of just this like nuisance thing that we have to deal with rather than having, like you said, a barometer of her health.

I think that’s a really important point to bring up because it is such a marker of what is going on inside your body whether your body is happy and in a non-stress state enough to the point where it can think about longevity and the future of bringing children into the world. That’s what your body needs to feel to be able to create a period basically. That’s a really, really good marker to pay attention to. Yes, periods are annoying, but they give us a lot of really great information that we should be paying attention to.

Laura: I think the other issue is women who aren’t planning on getting pregnant any time soon, or maybe at all, they don’t really tend take it seriously. I find that a lot of the women that come to me with amenorrhea, it’s because they want to get pregnant and obviously that’s a huge barrier to getting pregnant if you’re not menstruating. So that’s when it becomes serious for them where it’s like, okay, I really need to do something about this because it’s preventing me from getting pregnant.

Whereas a lot of women that are younger, or again, if they are looking at the menstrual cycle as being an annoyance or a nuisance, then they probably don’t care if it’s missing. I don’t blame them. Like you were saying, having a period can be kind of annoying.

Now if you’re having bad periods, that’s a sign of something going wrong, too. So if they’re like super painful, or really heavy, or just like you feel awful on the day of, that’s another sign that there’s stuff going wrong. I’m not going to touch on that because that’s like a totally different issue than amenorrhea. But it is something where if you’re not having relatively comfortable menstrual cycles, then that’s potentially a sign of some hormonal imbalances or other issues going on.

But like we said, amenorrhea for sure is a sign that something’s not working. And like you were saying, with energy reserves and your body being comparable with the possibility of getting pregnant, if it’s not, if there’s anything going on with the energy intake, or if you’re under a lot of stress, you’re not sleeping, whatever’s going on that your body perceives as something that would be dangerous to pregnancy, it’s going to slow down or stop your menstruation. That’s why it is such an important indicator of overall health for women and not something that you should just like not care about if it’s not happening or if it’s super regular.

Kelsey: Right.

Laura: She had asked about post-birth control syndrome. That was something that Dr. Brighten….It’s funny because it’s Brighten and Briden, and I’m like which one is it? Maybe Dr. Briden and talked about it, too. Honestly, both of these podcasts are ones that women should listen to.

But I remember Dr. Brighten was mentioning that if a woman goes on birth control for irregular periods, that she has I believe it’s a 37 percent chance of not getting her period back on its own when going off birth control.

There’s a lot of stuff that can be done to help that post-birth control syndrome, but that lasting longer than a year is not unusual. It’s not great and if you haven’t had your period and in three to six months after stopping the birth control pill, you need to be figuring out what’s going on. Is it amenorrhea? Is it a gut infection? Is it detox issues? But definitely not unusual to see that happening for longer than a year if nothing’s being done about it, which it sounds like Katie is at this point where she’s not even sure if she should be doing diet and lifestyle changes for this issue.

I’ve definitely seen quick recovery of menstrual cycles in a post birth control syndrome state when things were put in place to not only support health, but also to support hormone detox, that kind of thing.

I did want to address Katie’s concerns about her bone density since I know that’s what her main question was is how to not only get her period back, but to help with this osteoporosis since it is somewhat of a dangerous condition especially at her age.

Osteoporosis is generally an older woman’s disease. I think the stat I saw is that 1 in 2 women at some point in their life when they’re post-menopausal will develop osteoporosis. So it’s very common in older women, not that it’s healthy or normal. I think osteoporosis probably develops in later life due to a lot of things including hormone balance when we’re younger, malnutrition, that kind of thing, not exercising enough, all that.

But if you have it when you’re in your 20s, that’s pretty scary because you’re not supposed to have a major loss of bone density in that time. In fact, you’re really supposed to be putting your peak bone density on in your 20s up till basically age 30 is when women get their peak bone density. Setting yourself up for good bone density by your 30th year is going to help with your bone density across the rest of your lifespan. I’m not saying this to scare people who have low bone density. I just want to make it clear that this is something that’s important for long term health as well as short term health.

With bone density, there’s a couple different things that can really help with young women that have amenorrhea to not only get their periods back, but also to improve their bone density. I do have an article on Chris Kresser’s website that I’m going to link in the show notes that talks about general strategies for improving bone density if you’re on a Paleo diet. That one is just general for all ages. It’s not necessarily specific to women who have the female athlete triad level of osteoporosis. But it is relevant because it’s similar in terms of the types of nutrients that help, the types of issues that cause it.

Again as I was saying before, eating enough calories to match your physical activity levels is probably the number one thing that I would say women need to figure out. For some women that means they need to simply just eat more and they can keep doing the activity that they’re doing. For other women, they actually really do need to reduce their activity levels significantly to be able to match the calories in/calories out.

That’s just because if you’re eating a Paleo diet or any sort of whole foods diet, it’s really hard to get enough calories without supplementing or without doing some kind of non-food option to match really high activity levels. I’m thinking about women who are like training for marathons or doing CrossFit 6 days a week, something like that where you might need like 3,000 calories a day to support your activity.

Kelsey: I even seen people who maybe they’re not even doing that level of activity, buy maybe they’re doing like 4 or 5 days of CrossFit a week or something like that, and otherwise they’re fairly sedentary so they feel like they’re not moving all that much and not expending that many calories.

But for somebody who feels like they literally can’t get 3,000 calories in or 2,500 calories in, I find that sometimes the better option is to actually bring down their exercise at least for a time until they get used to eating more that’s a little bit higher than where they are right now. But they don’t have to go all the way up to like 3,000 where that feels totally ridiculous to them at that time.

Laura: Right. I mean really it’s just about the balance. So if somebody is able to eat enough to support their activity levels, then great. And if they’re not, then the activity has to change.

Kelsey: Right.

Laura: A lot of women I work with, probably similar to you where they don’t think they’re super active and they’re confused, they’re like I don’t feel like I work out that much. Why would I lose my period? They don’t realize that they’re still just under-eating for the amount of activity that they’re doing.

Kelsey: Exactly.

Laura: That helps with amenorrhea, but it also helps with bone density simply because if you’re not getting enough food intake, you’re just not going to be in an anabolic state in general. And if putting on bone density or bone tissue is your goal, you do need to be more anabolic state for that to happen.

Same goes with muscle. I mean any part of your body that you’re trying to rebuild, you need energy to build it. So if you’re under-eating in any sort of energy, either not eating enough or exercising too much, and then being in the calorie deficit, that’s going to affect your body’s ability to build anything, and bone is definitely part of that.

Another issue, and I don’t know if this has more to do with the amount of calories women get or some specific benefit of balanced macros. I don’t know how it would have an impact bone health beyond getting enough protein, but I do find that most women if they’re too low fat or too low carb, it’s just impossible for them to get enough calories to match their activity levels. So that’s why I think balanced macros can really help with bone density just to make sure you are eating enough. And again, higher protein intake can help with increasing bone density just because bone is made of a lot of protein as well as minerals. So a low protein diet actually can reduce bone strength.

And the other side of the coin there when we’re talking about amenorrhea…and like I said, I mentioned this in this blog post on the female athlete triad…is that insulin signaling actually tells our body whether or not we have enough energy to reproduce.

If you’re eating super low carb and your insulin is always low, you’re actually telling your body even if it’s not true from a calorie perspective, you’re essentially telling your body that your energy stores are low, that you don’t have a lot of food available, and that ovulation wouldn’t be something good to invest energy in. So low insulin levels from very low carb diets, especially if you’re active, that can potentially trigger amenorrhea even if your calories are not super low.

Low fat is the same way where if you’re really low fat or if you’re just eating junky fats and not eating whole food fats, and saturated fats, monounsaturated, some polyunsaturated from whole foods, having any sort of fat deficiency can affect how well our bodies are able to create hormones.

I don’t see that as much in my clients because I feel like we tend to get the Paleo crowd that’s all about the healthy fats, but it is relevant to include that because some people still do avoid fat because they think it’s bad for them.

So just getting balance macros in general is really good for both amenorrhea and bone health. Do you have anything to add about the diet side of things there?

Kelsey: I guess I’ll just put a little hope out there in that I have worked with so many women where like that’s all it takes. And I think we’ve talked about this before, but I think for some women it can feel really overwhelming to kind of start to work on this and get their period back and oftentimes they’re very scared of increasing calories or increasing carb intake, things like that.

But seriously, I’ve had so many women that like the increase in calories, once they’re consistently doing that…and consistency is very, very key here because we want to basically tell the body that it’s okay to ovulate, it’s okay, there’s no stress, we’ve got enough food, things are good. That does so much and I’ve had tons of women who just get their period back with increasing calories or increasing carbs. Oftentimes that goes hand-in-hand with maybe a little bit of lowering of exercise and focusing on stress, but the big underlining key here is that calorie intake.

I just want to throw that out there that I know this can seem really daunting when you’re first starting this and it can be scary to increase your calories and kind of change your macronutrients around, but it makes such a big difference. And it’s often at least from like our end in terms of figuring out what’s going to help people, it tends to be a really, really easy fix for many, many women. Of course there are others where we really need to start thinking about other things that I’m sure you’ll go into in a second, Laura. But for many women it can simply be that they’re not eating enough calories.

Laura: Yeah. It’s funny, it’s fun for me to work with those kind of clients because I’m like, oh yay, don’t have to do like a million functional tests and like rack my brain for what’s possibly going wrong with this person because it’s fairly easy to fix those situations.

Now of course, not everyone is that easy. There are some people who they do this and they don’t see the results and this is where some other factors can come in that can help. But I always like to hammer home the calorie balance piece because I felt like even when we say it, it’s it still doesn’t always translate to people and they still have a really hard time with the implementation side of things.

Kelsey: One other thing just harping back on that consistency piece, I’m wondering if you see this a lot, too, Laura, where like sometimes I’ll have women they get their period back for like a month, but then like it will go away for a little while. And usually once we do a little digging, we find out that you know they were tracking their intake for a while making sure they were getting enough calories every day, and then that sort of went to the back burner. They kind of forgot about the tracking and suddenly like the period is gone again.

To me, I just often see that it’s hard for people to be really consistent with the calorie intake especially if you tend to under-eat unless you’re tracking to make sure that you’re eating enough.

Laura: Right. When somebody gets their period back, I think they’re in a few months’ worth of this somewhat fragile state where they go back to old habits, or something happens that’s stressful, or something like that that they can lose it. So it’s always worth going back and checking what does my food look like right now? What does my exercise look like?

I mean again, not the only things that affect it. I’ve had some clients before that had all that on the right balance and were doing what they needed to do there, and they had a gut infection, or they had hypothyroidism, or they were traveling a lot and they were changing time zones, stuff like that.

It’s not always just the food, but it’s always worth checking back and making sure that you are still being consistent. I don’t want people to think they have to be perfect and get like if you need 2,400 calories every day, then if you get 2,300, you’re screwed or something like that. It’s not that hardcore as far as like every day needs to be perfect, but it’s just an overall trend of eating enough that really makes a big difference for women.

And it all depends on the day. I mean if there’s a day that you’re not really doing much and you eat a little less, should be okay. If there is a day you’re pretty active and you eat more, that might be better for you. So it’s not something that has to be so rigid.

It’s just when I work with clients, a lot of times they just don’t have any idea what they’re supposed to be eating and they’ve never even looked at what they’re currently eating as being a problem. Or they think because their plate is full of food that they must be eating enough. Or the fact that they eat to appetite, then of course I’m eating enough because I’m not hungry.

Kelsey: Right.

Laura: But if somebody has any sort of history of disordered eating or under-eating, their appetite drops and maybe their stomach size shrinks a little bit so they don’t have as much room for food. They feel full and they feel not hungry, but their body is still in a calorie deficit.

It can be really complicated and confusing, but it is something that again, once you’re able to fix the problem, for a lot of women it turns around pretty fast. We don’t want people to feel like it’s impossible, it’s just it takes some level of effort and awareness and not just again eating to appetite or eating what you think is enough without double checking for sure.

Kelsey: Yeah.

Laura: The exercise piece is interesting because I think there’s a lot of information out there that for hypothalamic amenorrhea suggests that women shouldn’t exercise at all. That’s something that I don’t find to be the case for most of the women that I work with. A lot of them do have to reduce their activity levels and that’s usually women who are training a lot or just really, really active and really need to bring it down a couple of notches.

But for most women, a normal just moderate workout routine where they’re doing some strength training a couple of times a week, maybe doing a little bit of moderate endurance….I say moderate endurance, generally that is more short runs, so not long distance running, but maybe a couple of miles at most, longer walks, that kind of thing, cycling. Generally not longer than an hour per activity I would say I would keep in the moderate category. If you’re doing much longer than that every day, that’s getting into the more endurance training type of exercise.

And so if they’re doing a couple of days a week of a combination strength training and moderate endurance, and then they have a couple of days off, for most women that’s perfectly fine. And again, if you’re calorie balance is there and you’re training several days a week, but not every single day, I don’t think that generally leads to amenorrhea for the average person.

And with bone density, strength training is something that’s super helpful for improving bone density. So that’s why I wouldn’t want someone to not exercise at all if they have osteoporosis or if they’re heading in that direction because I feel like even though you might get your period back faster if you just totally cut out exercise, you may have a worsened bone density because exercise in moderation does help with improving bone density.

I just like people to be aware of that because like I said, if you Google exercise and amenorrhea, a lot of times it comes up saying don’t exercise, like just stop exercising for months. I just feel like even if that is helpful, I don’t feel like it’s realistic for a lot of people. I know I would be pretty unhappy if somebody told me not to exercise for a couple of months.

Kelsey: Yeah, I’m sure.

Laura: Which both of us have experienced in the last couple of years with our car accidents where we had to stop exercising for a period of time. It’s like no! So miserable.

That’s something that you just have to get into a routine that is appropriate. And again, that’s going to depend on the person, going to depend on how stressful their life is, what they’re able to eat, any other concurrent issues. But I don’t want people to just lay around all day when they have a memory. That’s usually not helpful for more than like a week or two.

Kelsey: Yeah.

Laura: And then again, I have this article, so I don’t want to go into a ton of detail. But it’s the one that I was mentioning with Chris Kresser and it’s called “How To Keep Your Bones Healthy On A Paleo Diet”. But I do talk in more detail about some micronutrients that are helpful and it’s ironic because these ones are also helpful for amenorrhea.

Calcium and magnesium are two minerals that are…I mean everyone knows that calcium is important for bone health, not everyone knows that magnesium is as well. But both of those are pretty important nutrients for bone health. A high mineral intake in general can be helpful.

I have a post on my website about calcium and how there may be a lot of women doing Paleo, or doing dairy free, or something like that that actually don’t get enough calcium. I think it is a little bit more common than the Paleo community admits and I have some solutions in there for figuring out what your calcium intake is and how to bump it up to what’s appropriate.

But I’m not opposed to calcium supplementation if somebody is not getting at least 800 milligrams a day. I don’t think you need to be taking like 1,000 to 2,000 milligrams of calcium supplementation. But if you get like an average of 500 in your diet, then taking a couple of hundred extra to get up to 800 for most women I think is not a bad idea, especially if they have poor bone density.

You definitely want to combine that calcium with the fat soluble vitamins. Vitamins D and K2 are the ones that help make sure that calcium gets into the bone and doesn’t get into your arteries. D and K2 are more directly involved in calcium metabolism in that way, but I do think vitamin A is another nutrient that doesn’t get quite enough attention in the overall nutrition community. I find A is extremely helpful in an amenorrhea, too. So hormone production, any hormone deficiencies issue, I think vitamin A is a great thing to look at either in your diet or in your supplementation. And then again, the D and K2 is going to help make sure that calcium gets into your bone where it needs to be.

So those are just some basic nutritional guidelines. Again, they’re not complete. There are certainly other supplements and dietary strategies that can help with amenorrhea and bone density, but those are some of the more basic ones that I think are important. Anything you wanted to add there Kelsey?

Kelsey: That was perfect, Laura.

Laura: Okay. And then like I said, there are some other lifestyle factors that will affect both amenorrhea and bone density. Sleep is always important for everything. We just had a great podcast interview with Dan Pardi about sleep and how circadian rhythms in general affect your health. Those definitely affect both amenorrhea and bone density.

Sleeping well directly impacts bone density because it affects melatonin production. Melatonin actually impacts the actions of these cells called osteoblasts and osteoclasts, which are the cells that essentially build up and break down bones. It also interacts with estrogen. If you’re not sleeping well and you’re not producing enough melatonin because you’re not sleeping, that may actually affect how well your body is able to build up its bone.

And again, circadian rhythms, I feel like they impact everything.

Kelsey: Yeah.

Laura: It’s unfortunate because I feel like in my own personal life they’re probably like the least well controlled of any of my health inputs. But they are so important and if you get a lot of disruption there, that can have a huge impact on your hormone signaling, but it also would impact your melatonin.

We did have a bunch of really good tips with Dan Pardi’s interview, so definitely listen to that one. But basically you just want to get your circadian rhythms into an appropriate 24 hour cycle. Lots of different ways to do that. Things like reducing your exposure to artificial light at night, getting daylight during the day, getting out about eight hours of high quality sleep in a cool dark room. Dan talked about meal timing and being consistent there as helping with a 24 hour cycle entrainment. You can do things like camping. If you get out into the wilderness for a couple of days with no electricity or Wi-Fi, you can actually reset your circadian rhythm. These are all things that can make a big impact on both bone health and amenorrhea.

And then as Kelsey was mentioning before with stress, stress is funny because again it can cause women to miss a period if they get super stressed for some reason. That’s pretty typical. I feel like I know I’ve been there before where I had a late period because of stress. I don’t know, Kelsey, if you’ve experienced that before.

Kelsey: Yes, I have actually, weirdly enough.

Laura: Really? Mine was in college. I just was like under a lot of stress and I missed a period. It was a little freaky. But personally I’ll just see irregular periods if I’m stressed. I’m trying to think when this was. I feel like it was either last year or the year before. I was having really long cycles because of stress. I was getting like 36, 37, 40 day cycles, that kind of thing.

Now I actually track using the Daysy monitor that we talked about with Dr. Briden. I think I’m like pretty consistently 32, which is considered normal. I don’t necessarily skip whole periods anymore. I’ve only seen that happen maybe once or twice, but definitely seeing that lengthening of a cycle was pretty typical for me.

That’s pretty common for a lot of women to see an irregularity in their cycle if they’re super stressed. And then again, some people can miss a period or two from stress.

Now stress again also impacts bone density. There’s evidence and it’s pretty well supported that using like drug versions of cortisol actually puts people at high risk for bone loss. So we can kind of extrapolate from that that if you have chronically high cortisol, that you may actually have the same issue with bone density. There is some research suggesting that high cortisol can lead to decreased bone density. Again, all of this is in that article that I have on Chris’ website where I have a little bit more details about that.

But stress management, I mean honestly we talk about that so much with our Paleo Rehab program and in this podcast in general. There’s so many different things that cause stress. I find that in my amenorrhea clients, a lot of times their disordered eating is a main stressor in their life. It’’s not just that you’re not getting enough calories, but the stress of trying to follow this like super perfect, Instagram worthy diet actually is a huge stressor for them.

That’s why when I work with these women, a lot of times I’m working on taking restrictions out of their diet within reason. If somebody has celiac disease, obviously I’m not going to tell them to eat gluten or something like that. But a lot of women are avoiding foods that they really don’t need to avoid.

Katie might be in that situation. She had mentioned that she eats one piece of fruit a day and a cup of starch, and that’s she’s slowly upping it. I’d question if she has a fear around carbs. That’s what it sounds like to me. Of course I don’t know this person and I don’t want to make assumptions, but that’s what it does sound like.

Fear around food is a stressor. Being in a calorie deficit is a stressor. Not sleeping well is a stressor. Having inflammation is a stressor. Gut infections are a stressor. If we have all these stressors that are compiling, and your body, again, when it’s stressed it doesn’t want to do things that aren’t essential to survival. So your period is going to be one of the first things that shuts down.

Kelsey: Yeah. That’s something I see a lot in the type of clients that I tend to work with. Of course a lot of them have digestive issues and I do also work with a lot of women who are trying to get their period back. Or that’s sort of like one thing on their list of many symptoms that they’re having is like, oh yeah, also I don’t have my period and I haven’t had it for like five years.

Laura: It’s like a side note.

Kelsey: I know, exactly. But I am glad that you bring up this piece about just that there’s so many different internal and external stressors that your body can be dealing with. And it’s important that especially if things like just increasing calories or decreasing exercise don’t bring your period back, that you do really start to think about some of these other stressors on the body like infections and things like thyroid issues, just kind of figuring out all the other body systems and how they impact first of all your cortisol levels, but then also your hormone levels is really, really important.

Laura: Yeah. I would say those are going to be the basics for most women. Like we said, there’s going to be some deeper issues that might be going on that might be contributing to a missing cycle. In those situations working with someone one on one really makes a lot of sense because there’s testing you can get done, there’s treatments that can be done. Like I said, I’ve had clients before who had digestive issues or gut infections that once those were treated or resolved, they actually saw their period come back.

There’s a lot of things that can impact the menstrual cycle, but what we talked about today is really just foundational things that most women if they’re not dealing with appropriately, they’re at risk for amenorrhea, or irregular periods, or that female athlete triad syndrome.

That is just kind of like I said, the overview of what I would suggest to Katie. No, it’s not foolish to try to get your period back with diet and lifestyle. I think that’s a really good idea and hopefully these recommendations that we talked about today will be helpful there.

I also wanted to mention since this is right in the thick of my program launch right now that this podcast is coming out, that if all of the stuff that I talked about today sounds overwhelming to you or you’re not even really sure where to start, I actually this week have launched my new online program. It’s called “Get Your Period Back”. Super creative, I know. But that’s what it’s about.

It’s about helping women who have amenorrhea, mostly hypothalamic amenorrhea, but also women who have things like PCOS, or just have irregular cycles, super long cycles, that kind of thing and they don’t want to use birth control to try to fix that problem, which as we said earlier is really not a solution, it’s just masking your symptoms. If you’re ignoring that symptom or if you’re not even experiencing it, you’re not going to be able to get to the root of the health issues that are driving that problem.

I can talk a little bit about it. It’s going to be a six week program. This comes out on a Thursday. We’re going to be starting the program on the Sunday after this period comes out…Ah! This podcast!

Kelsey: You’ve got period on the brain.

Laura: I know, it’s really scary. It’s just all I’ve been doing for a couple weeks at this point. We’re going to be starting on the Sunday, which is October 15th. I think this podcast is coming out on the 12th. So if you hear it and you want to get into this round of the program, you definitely want to jump on that pretty quick because I’m going to be closing registration soon. I’m going to be opening it again later, but I just have a shorter registration period for this launch that I’m doing.

Basically like I said, it’s a six week program and it covers what I have called my 4 R Protocol. The protocol like I said, 4 Rs, so the first R is Refeed. Refeed just means that you’re nourishing your body with the right amount and the right types of food and nutrients. That’s calories, that’s macros, that’s micronutrients, any supplements that would be helpful. That’s the refeed component of the 4 Rs.

Number two is Rest. Rest is funny because I think a lot of people think about sleep as rest, which is for sure. And I’m going to talk about improving sleep, and how to make sure you’re getting enough sleep, and getting good quality sleep so you’re entraining your circadian rhythms.

But also rest is somewhat of a mindset as well. Rest is going to cover resting appropriately during a training regimen and setting up a training regimen that includes enough rest both in the actual workouts themselves as well as the days off that you take. So incorporating rest into your routine, incorporating that restful mindset into your day to day life, giving yourself downtime, giving yourself breaks, that kind of thing. It’s not just about sleep, it’s about giving your body rest and recovery.

The third R is Relax, which is a little different than rest because it’s more about that stress piece, what we were just talking about where you’re getting maybe stressed about food, you’re stressed about your exercise, you have some body image stress, maybe stressing about your career, or finances, or relationships. Anything that can cause stress in your life, we want to just relax.

There’s going to be some talk about food restrictions and how you can relax on those. There’s going to be talk about body image. Again, just anything that’s potentially contributing to high levels of stress needs to be dealt with as part of a period recovery plan.

And then the final R that I’m going to cover in this program is Repair. This is where I’m going to just cover some of the deeper functional treatments. I’m going to just touch on them since a lot of them you really do need to work on a practitioner with. But I like to give people some information about what might be going on for them that is beyond just like the eating enough, sleeping enough, exercising appropriately, all that.

There’s things like gut imbalances or gut infections. There’s thyroid issues, especially hypothyroidism. There’s adrenal dysfunction, which we talk about all the time with our podcast and our Paleo Rehab program. And then immune health so if someone’s got an auto immune disease or any sort of immune issues that can potentially be affecting their menstrual cycles. There’s things like endometriosis, or really any autoimmune disease can potentially affect menstruation.

That’s that Repair part of the 4 R Protocol because again, you want to get your foundation set with all the good habits, and eating enough, sleeping enough, chilling out, treating your body well. But some women, they do all that and they don’t get the results. And that’s because they have deeper things going on that need to be tested and treated. I’ll just cover those briefly and give some tips about what kind of testing to look for, maybe some alternate therapies that can be helpful while you’re making these diet and lifestyle changes just to get the results faster because a lot of times if you’ve not been having a period for a year or something and you’re on a little bit of a rush to get it back, it’s not a bad idea to kind of hit every angle and do things that might help spur on your period a little faster.

That’s the general gist of the program. Like I said, it takes about six weeks to go through all the material.

Kelsey: That’s awesome and so comprehensive!

Laura: It’s funny because it’s one of those things that it came from the type of work I was doing with my clients to deal with amenorrhea. Some of it’s inspired by stuff we did in the Paleo Rehab program, but a lot of it’s also just more specifically for the sex hormone balance and amenorrhea, and the kind of things that women who have amenorrhea are dealing with specifically.

So a little bit of different things like supplements, for example, are going to be different. Some of the food recommendations are going to be a little different, especially because some women who have amenorrhea need to gain weight, some of them need to lose weight, so covering all those issues there.

I’ve been working on creating a guide to figuring out your own meal plan, which was kind of a funny endeavor because on one hand, I do it with my clients all the time so I knew what to do to create meal plans. And when I say meal plans, I mean like meal templates for people. It’s something that I do a lot with my clients. I think you do meal templates, too, right?

Kelsey: Yeah, I do.

Laura: I basically spent a couple of hours trying to figure out how to translate that into a DIY guide. I had somebody test it and she was able to get the results I was looking for. So I feel pretty confident that it will help women who aren’t Dietitians figure out what their general food intake should be. We have some awesome visual macro guides to help women understand what a portion of certain foods look like.

Like I said, I have some specific supplements I recommend. It’s DIY, but it’s very handholding because I think that’s where a lot of women struggle and something that I’m sure you see, too, where they know what they need to do, and they’ve heard it, and they listen to our podcast, and they have all this information, but they really struggle with the implementation side of things. Or they’re really not sure, okay, do I need 2500 calories, or do I need 2000, or what do I need? Helping them figure that out in a way that’s very practical is the goal of my food guidelines for this program. I feel like I did a good job on that.

Kelsey: It sounds great!

Laura: Yeah, I feel pretty happy with the way that came out. And again, I’m trying to avoid getting people into this like calorie counting, macro counting mindset. So giving them a way to create a template that helps them put together meals for themselves that meet their guidelines or meet their goals without having to really count things I think was my hope for this. So again, I’ve put together some resources to help with that.

And then for this launch period, I am offering weekly live Q&As. I don’t know how many times I’m going to do that. I’m sure, Kelsey, you’ve experienced with your group program, it can be a little time consuming if you’re always doing Q&As with every single person that joins the program. So I wanted to offer that as a bonus to the people who enroll with the first round of the program.

That’s something that I think having that support and ability to ask questions really is helpful. I know in our Paleo Rehab program we had a lot of people really enjoy that component and they really appreciated having the opportunity to interact with us. So that’s going to be a part of the launch.

I’m going to have a Facebook group, which again, kind of standard for a lot of these online programs, but it’s just one of those things that helps you talk to other women and get some ideas about things that have been helpful, get some encouragement, see what other women are doing to get their period back faster if there’s any resources that they found useful. I feel like the community aspect is always super helpful to just have that support and to have that communication with other women who are dealing with the same problems so.

I think that pretty much covers the gist of the program. If people are interested and want to get signed up, the website that you can go to is at my website, LauraSchoenfeldRD.com/GetYourPeriodBack. Pretty easy. We’ll link to it in the show notes as well. But that’s where you can register for the program.

And again, we are starting on Sunday the 15^th, so would love to have anyone with me doing that if you are listening to this podcast and you’re in the same situation as Katie was where you don’t have your period and you’re worried about things like osteoporosis or other long term health issues.

I did find it a little crazy when I was doing research for this program that if you aren’t getting your period, you’re at higher risk for things like cancer, so endometrial cancer and breast cancer as well as heart disease and heart attack.

Kelsey: Wow!

Laura: Yeah. I don’t know if that’s the hormone thing or the malnutrition thing, but there are some longer term risks associated with not getting a menstrual cycle. This is one of those things that we were saying before, maybe it doesn’t feel like it’s that important right now, but it’s important for both your short and long term health.

Kelsey: Absolutely.

Laura: I’m hoping that through this program I can help people really get what they need as far as the support and the practical guidelines for going through the process we discussed today. I’ve had some really awesome results with some clients that I’ve worked with. And I have a couple of like baby pictures on my page of the babies that we helped create with these amenorrhea clients. I just love being able to see women who were really freaked out that they were told that they would never have children and all that, and then they’re able to get their period back.

And again, it’s not only for women that want to get pregnant. Personally, I don’t plan on getting pregnant for a couple years. I’m not like trying to force fertility on women, but it is something that if you’re interested in getting pregnant in any time in the future, getting your period back and getting it regular will make a big impact on your fertility levels.

Kelsey: Well congrats, Laura! That’s really exciting, first of all on a personal level.

Laura: Thanks!

Kelsey: But also just I’m really excited to be able to refer people to that if they can’t work with someone one on one to start with and they just want to get through starting this process on their own. I think that’s going to be a really, really awesome resource.

Laura: Thank you. It’s kind of like when I get someone who can’t necessarily work one on one, I’m like go do Kelsey’s Build Your Biome program. It’s kind of the same thing where it’s like it’s not necessarily going to replace working with a practitioner for some women, but I think they can get a lot of really great results from these kind of online programs.

Honestly, I think for this kind of issue, a large majority of women can get results without working one on one with someone.

Kelsey: Yeah.

Laura:  I mean I love working with these kind of women and it’s one of my favorite issues to work with, but I also want to make this more accessible to a bigger number of women. That’s why I’m really excited to have the program launching. It’s my little baby that I’m birthing. It’s the only baby I’ll be having for a while, knock on wood.

But I’m really excited about it. And if you join me, then like I said, this time around we’ll do the live Q&A. I do have a discount on the price for this first round. So definitely if you’re thinking about it, this is the best time to join.

Kelsey: Cool!

Laura: Well, I am done pitching my program. I know we haven’t done updates in forever, so we might have to. I know you were traveling for a while. So next time we do our Q&A podcast, we’ll have to hear about your trip since you were in Colorado and Europe I think.

Kelsey: Yep, exactly. Colorado and Portugal.

Laura: Lots of traveling. Awesome. Well like I said, maybe not this episode just because we’re probably at the end of this hour, but next time we’ll definitely want to talk to you about your travel.

Kelsey: Cool! I’ll talk to you then, Laura. Take care.

Laura: Alright. Thanks. You too, Kelsey.