All Things Amenorrhea with Dr. Nicola Rinaldi


As promised, here is our monthly feature of All Things Amenorrhea with Dr. Nicola Rinaldi. This week Dr. Rinaldi gives us a great perspective on Dr. Chrisandra Shufelt’s study about the relationship between estrogen and heart health (and even an opportunity to participate for those in the local area!).  Following her discussion, Dr. Rinaldi answers our readers’ questions.

Hope everyone has a happy Monday!

It seems like people are talking much more these days about missing periods, the health effects, and how to restore them. Which is *awesome*. If you’re in the LA area and currently not menstruating, please consider participating in this study run by Dr. Chrisandra Shufelt at Cedars Sinai, studying the heart effects of low estrogen.

It is common knowledge and scientifically proven (for example, these three articles 1, 2, 3)  that an absent period can lead to issues with bone density both in the short and long term. In my book, “No Period. Now What?” I also discuss potential heart and brain effects – but the evidence for those is not so cut and dried (based off studies performed in women with surgical early menopause, which in some ways mimics missing periods due to hypothalamic amenorrhea, but in other ways does not). So I think it’s fantastic that Dr. Shufelt is directly studying heart effects in HA!

Recovery from HA absolutely helps increase bone density, and evidence suggests it helps with heart and brain effects as well – along with short term symptoms like hair loss, absent libido, anxiety, lack of patience, brittle nails, constipation, other GI symptoms… the list goes on and on!

The consensus for HA recovery is simple – eat more, exercise less, and reduce psychological stress – but it is oh so hard to follow.

One might think that the hardest part is eating more but actually, for the majority of women with HA it’s actually cutting high intensity exercise that is the most challenging aspect of working toward recovery. As you will see from the questions I received this month. Everyone wants to recover while continuing with the same level of exercise. I know that there are people out there who say this is a possibility… … … but in my experience, both personal and in working with women on recovery, restoration of periods will almost certainly happen sooner, and is more likely to happen overall, with a decrease or cessation of high intensity exercise. (Low intensity is generally fine, although within reason… 20k steps per day, for example, means you need to eat a LOT more to compensate…)

I’ll tell you my personal experience first. Keep in mind this was over ten years ago now and there was about zero information regarding HA recovery on the web at that time so I was really flying blind. I did cut down on my high intensity exercise in an attempt to recover, going from exercising about two hours a day seven days a week (this consisted of a combination of ice hockey, volleyball, squash, biking, weight lifting, and golf) to one hour a day five days a week. I did not get my first period until I went on a three week vacation during which I did nothing but walk a bit and play a few rounds of golf. Coincidence? I tend to think not… (And this was in concert with gaining back almost all of the weight I had recently lost in an attempt to “get healthy for pregnancy”. Psht. I wish I knew then what I know now – that weight loss in someone in a small to medium sized body to begin with is almost never actually “healthy”. Anyway, I digress!

My point is… yeah, it’s possible to restore periods while continuing with high intensity exercise.  However, I cannot tell you personally, if it will work for you. Some of us just have systems that are more sensitive to exercise… and any high intensity exercise is pretty much going to prevent restoration of menstrual cycles (we can however return to exercise after cycles are restored… for example now I play ice hockey, bike, lift weights, and dream about the days when I can play golf again (tough with three small children!) and my cycles are pretty regular). So what I will say is that if you want to continue high intensity exercise and try and recover, go right ahead. You will need to eat a bunch more, take as much rest time as you can, and see what happens. If you restore cycles, great! If not… well, you probably will begin to feel more anxiety about the missing period than you do about not exercising, and it becomes a lot easier to skip those high intensity days, knowing that the long term health impacts of missing periods are surely worse than a few months of being more sedentary.

I would also ask you to do some introspection… think long and hard about why you feel it is impossible to cut out your high intensity exercise? What do you get out of pushing yourself longer, faster, harder? Because it’s not for health… if your period is missing, high intensity exercise is actually more detrimental to your health than being sedentary. Does it help you feel in control by keeping your body at a particular size? Does it help numb you out so you don’t have to experience emotions that are scary or painful? Does it make you feel less stressed?

Once you pinpoint the reasons for YOU, I encourage you to work on other ways of accomplishing the same goals. (Well, aside from keeping your body at a smaller size than it naturally wants to be, that’s a battle I really can’t encourage… too many negative health effects… an endocrinologist I was recently speaking with was telling me how many women she sees in their 60’s and 70’s with low BMIs (<20) and osteoporosis well before their time…) If you’re exercising to avoid experiencing other emotions, work on some different strategies. Feeling emotions is normal and healthy, as is finding ways to work through them… (lots of suggestions in No Period. Now What? and you also might find working with a therapist useful). If you’re using exercise as stress relief know that the endorphins that make you feel good are actually part of what is preventing your period… again, find other ways to manage those negative emotions and anxiety – taking up a new, relaxing hobby that can occupy your body and mind, spending more time with friends who can buoy your spirits, sleeping (so good for you and many of us do not do that nearly enough…)

Ok so this went from being a quick chat about a new study that it would be awesome for you to participate in, to a mega rant… I struggle with brevity in case you haven’t noticed 🙂 So please consider participating in Dr. Shufelt’s study – and if you’re not in the LA area but know people who are, please share with them!!

And now on to the fun part of the post – reader questions! Please feel free to ask more, I really enjoy answering these!

1). Is it possible to regain your period with doing two-a-days?

LOL I had to look up “two-a-days”! Apparently it’s a term that originated with football programs doing two practices a day and just this season the NCAA has disallowed that – it seems like mostly to reduce head injuries that are most common in the preseason (53% of head injuries), but Louisiana Tech coach Skip Holtz commented, “I don’t think you’re going to have the number of injuries that you had, especially the soft tissue injuries — hamstring pulls, quad pulls, groin pulls.”

I’m guessing that in this case though, the question is more about running twice a day than football ?

I will be completely honest with you. Anything is possible. But is it likely? That’s a different story.

If you are missing your period it is almost always a combination of not eating enough to support your daily fuel needs, along with the physical stress of exercise and psychological stress. In theory you could increase your food intake to compensate for the calories burned, and you probably need additional energy beyond that in order to restore the energy deficit from however long your period has been missing. And you can certainly give that a try. But I would suspect that A) it will be hard to actually eat enough (my general recommendation is 2500 calories a day PLUS whatever you use for planned exercise), and B) the two-a-days are too hard on your body for your hypothalamus to turn back on again.

I find myself wondering why you’re doing two-a-days? Are you training for a particular event? If so, go ahead and participate and then scale back (probably way back) on your exercise after the event. If you’re doing two-a-days because you feel you need that in order to be fit and healthy, well, that is just not the case and you are more likely hurting your body than helping it, especially with your “fifth vital sign” (your period) letting you know that your system is not in balance. I would encourage you to run no more than once a day, 3-4 days a week. And eat more. And if you still don’t recover your periods with that level of activity, you may need to cut down further. If you have more questions, please feel free to join my facebook support group!

2). I want to know how to keep a better constant supply of energy because eating more has not helped me gain weight, feel properly energized, or get my period back. It has helped with some energy-but then when trying to put on weight, I feel sluggish. 

It’s a little hard to answer this question without knowing more about your individual situation – so please feel free to join my facebook group where you can share more specifics. It’s interesting that “eating more” has not helped with weight gain. That, along with “feeling sluggish” suggests to me that perhaps you might be restricting what food groups you eat, and perhaps you need to work on incorporating different types of foods? It is common these days to try and avoid simple carbs, but those can help with providing energy that our bodies can access easily. My other suggestion is not going too long without eating, and not skipping meals. Intermittent fasting while trying to recover from HA is not beneficial, and morning and afternoon snacks in between defined meals absolutely helps both as an easy way to increase overall intake and with feeling more energetic. It is sometimes the case that you will feel worse before you feel better, as your body starts to undertake repairs that it did not previously have energy for.

 3). Is it absolutely necessary to cut back on training to recover?

As I said above, it is theoretically possible to restore your system to balance and resume menstruation while exercising/training. However, it is much more challenging and it really depends on your particular system and how much exercise affects you personally.

There are a few options here.

  1. Keep training exactly as you are and make a wholehearted commitment to eating a LOT more. Eating enough to recover while continuing with high intensity exercise is challenging for a number of reasons – our hunger signals do not lead us to compensate naturally for the energy we have burned during exercise so you will have to eat beyond fullness or make a very conscious effort to add snacks in and eat even when you do not feel hungry. And it can also just be difficult to eat enough food for basic metabolic needs and all that exercise. And in my personal experience, I have yet to see someone recover without cutting high intensity exercise to some degree.
  2. Cut down on the amount and/or intensity of what you are doing. If you want to continue with high intensity exercise, I would recommend 30-45 minutes, 3-4 days a week. AND eat more. This is more likely to lead to restoration of your cycles than option 1, but it will still take some time.
  3. Stop high intensity exercise for the time being. The thing is that once you have recovered, you can add back the exercise you love – and often it’s in a much better balance with the rest of your life because taking time off allows you to assess your priorities and figure out what’s really important to you, build and strengthen your relationships, and realize that you do not actually have to run/exercise as much as you thought in order to be fit and healthy. I always like to share an example from my book, where Jen ran a 3:30 marathon when she had HA. Took some time off, gained weight, had two kids, and then ran a 3:03 marathon.

4). How do you know whether you are reaching your caloric needs?

This is a good question and a really tricky one to answer! Easy answer is that if you’re not getting your period and other medical issues besides hypothalamic amenorrhea have been ruled out (e.g., there is no anatomical reason you can’t bleed, you aren’t on a med that prevents bleeding)… and you exercise, you’re almost certainly not eating enough.

Many people think that if their weight is stable they must be eating enough, but it doesn’t actually work like that – if you’re in a chronic caloric deficit, your body will slow down and shut down various functions in order to match your calorie output with input. This is why if you “go on a diet” you might lose weight quickly at first, but then weight loss slows, stops, and sometimes you even gain weight while continuing to eat at the lower intake… usually leading to even more restriction 🙁

It’s also important to know, as I said above, that our natural hunger signals don’t account properly for the energy we’ve burned while exercising – demonstrated in this study where men who exercised ate more than when they were sedentary – but not enough to make up for the energy used for that exercise. So especially if you’re exercising a lot, it can be helpful to check in with a dietitian (NOT one who encourages weight loss, a Health At Every Size friendly dietitian would be great) and make sure you are getting sufficient energy for your basic needs AND exercise. But I’d encourage you to be realistic about the energy you’re using during your workouts and make sure to replenish afterward. (and before too, especially if it’s a longer workout like a long run while training for a marathon).

5). How do I get over the fear of depleting performance when trying to recover?

I think it’s important to understand what performance is important to you and why it’s important. Do you have a short term goal, or do you care more about performance in the long term?

For example if you’re a college athlete with a scholarship on the line, short term performance is definitely what matters for the moment and I would encourage you to work with your coaches to plan your exercise for the most efficiency while ideally taking at least a couple of days a week to recover. And I would *strongly* suggest that you work with a dietitian to ensure you are eating enough—actually, more than enough! If your coaches aren’t willing to work with you or to help you see a dietitian, I know that it might be difficult to go to an outside person for help but I would suggest speaking with the team doctor and stressing your concerns and desires to work with a team. And please check out the guidelines published by the female athlete triad coalition and Relative Energy Deficiency in Sport working group to determine if it is reasonable for you to continue exercising while working to recover or if you really do need to take some time away from your sport (note Jen’s anecdote above where her performance was actually 20% better after HA recovery).  

If you don’t have something like that riding on your near term performance I would definitely suggest taking a longer view – keeping in mind the health consequences of energy deficiency and missing periods. You are more likely to injure yourself, and returning from an injury will likely be much less pleasant, and deplete your performance even further than taking a voluntary break to restore balance (and your cycles).

6). I am a marathon runner who doesn’t get her period when I am training. I actually didn’t have it for over 6 months. What causes me to get my period is by fasting during Ramadan – I know weird bc you would think more food restriction but I actually eat more sugary “fatty” foods during this month and my exercise intensity is less. This is really the only time of the year that I get my period.

It makes total sense that during a time when you are exercising less and eating more nutrient dense foods, your period comes back. I would probably encourage you to try and eat more of those same foods and in a higher amount while training to support your period continuing when you train. My expectation would be that if you cycle normally for at least part of the year both the short and long term effects of no periods would not be as severe as absent periods year round… but I do believe that it would be beneficial to have cycles more regularly including while training.

7). I am recovered from amenorrhea but my cycles vary a bit in length from 4 weeks exactly to 4 weeks and 5 days. Is it normal and healthy to have your cycle vary a bit in length? I already have three kids so I’m not concerned with having more but just want to make sure my health is ok!

Yes, it is TOTALLY normal. I know so many women (myself included) whose cycles vary in length by up to a week and that really is not a problem, especially if you are not trying to conceive. This idea that a normal cycle is always 28 days is just not supported by the evidence. This graph of hormones during the menstrual cycle shows a wide range in day of ovulation, and I know that luteal phase length varies even more… What’s really important is that you are getting the natural increase in estrogen and progesterone and all the other menstrual cycle related hormones (FSH, LH, inhibins…) each month – those peaks in particular are what support your bone, heart, and brain health. Those organs don’t care if your peak is on cycle day 14 or 21, just that your hormones are regularly getting high enough.  

Once again, thank you Dr. Rinaldi for taking the time to enlighten us with further information regarding amenorrhea and the like. We look forward to having you join us again next month!

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