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Hey everyone, Mikki here. You're listening to mini mikkiepdia. And today I'm gonna chat about hypothalamic amenorrhea, which sounds like a bit of a mouthful, I understand. And it's something which I've been talking to a couple of clients about recently. And I thought it would be quite good to highlight some of the, one, what it is, two, some of the risk factors associated with hypothalamic amenorrhea.

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then also the nutritional strategies that one might sort of proceed with if they find themselves in this situation. So yeah, a mini episode for this is quite a good platform to be able to just share with you some of what I do with my clients. So firstly, hypothalamic amenorrhea, for those of you unfamiliar, it's a condition where menstruation stops for several months.

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Often it's defined as three or more months due to a disruption in the normal functioning of the hypothalamus. So the hypothalamus is a region of the brain that plays a crucial role in regulating many bodily functions, including the menstrual cycle. So it controls the release of hormones that are essential for the ovaries to produce estrogen and for ovulation to occur. And as my friend Lara,

01:28
likes to say ovulation is absolutely the main event. And I'll be talking about hypothalamic amenorrhea in the context of an athlete, because I think things can vary depending on whether someone is an athlete or otherwise. So HA is typically triggered by one or more of the following factors which can interfere with the hypothalamus' ability to regulate the menstrual cycle. And the first one is energy deficiency or calorie deficiency.

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and it's a significant contributor to HA, an energy imbalance where the calories consumed are insufficient to meet the energy demands of the body, especially in athletes. And this can be due to either excessive exercise, inadequate calorie intake, or a combination of both. And what I would say is, of course, a large part of the population I work with are looking for a calorie deficit. They're looking to improve body composition and to lean out.

02:26
that energy deficiency is actually a requirement for that. But if you have an excessive calorie deficit, which result in aggressive fat loss or weight drop, or it happens chronically over an extended period of time, then that's when it can cause those menstrual disturbances. So it's a requirement for a calorie deficit and to improve body composition, but it's the...

02:56
either the aggressiveness of it or the duration of the time that you spent in a significant calorie deficit. The second major cause of hypothalamic amenorrhea is actually is distress. This is regardless of calories, both physical and emotional stress can disrupt the hypothalamus' regulation of reproductive hormones. High levels of cortisol can inhibit the release of gonotropin releasing hormone from the hypothalamus.

03:21
and this in turn affects the entire reproductive hormone cascade. So from an athlete perspective, particularly high achieving athletes who are at high levels of competition, you've got obviously the physical stress of training, but also that psychological and emotional stress that comes from competing at a higher level or having a perfectionist mindset. Low levels of body fat.

03:47
So body fat is essential for the production of estrogen and when body fat percentages drop too low, estrogen levels may fall, leading to the cessation of menstruation. A note here is that every body is different and having low body fat is not a necessary element for hypothalamic amenorrhea to occur because you can experience HA at a quote unquote normal or even healthy level of body fat if other

04:16
signs and symptoms or triggers are present. Whereas you might also have quite a lean, or know quite a lean athlete who has very low body fat yet continues to menstruate. So it's more, I think, to do with how your brain perceives your level of body fat actually. So it's an individual thing. There's no sort of blanket numbers. What I will say though is that in a healthy, quote unquote healthy female,

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athlete, when you're getting into body fat levels that drop sort of 15, 14, 13 percent and lower, and I know that these can obviously occur with a number of athletes, then you do run a sort of a greater risk. But again, it's individual. And then of course, the fourth trigger is intensive physical training. So especially those people in endurance sports like running, swimming, or something like gymnastics.

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which again has great demands placed on them with regards to their sport. Dancers as well, they're at higher risk for HA because their training often leads to a significant energy deficit, high levels of physical stress, and low body fat. And I mean, I think everything that I've suggested above, all of the triggers for hypothalamic amenorrhea place athletes at risk because they have high training loads.

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because it's easy to under eat either intentionally or unintentionally due to the higher training loads and not having the knowledge of what you need to support the training load or you're active for vast periods of time across the day and there's not enough time in the day to eat and I can see that happens quite a bit as well. But it's not just calories. Inadequate nutrition.

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whereby you actually have an insufficient intake of micronutrients to support energy metabolism pathways, to support pathways in the brain related to hormone production. That can also contribute to HA. Diet quality is an essential piece of the puzzle as well. Oftentimes it isn't just one trigger, it's a combination of them. It's the stress, the low energy availability.

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and low body fat can all lead to chronic disruptions in hormone levels, particularly the hormones that regulate the menstrual cycle. And this is obviously not an unrelated topic to relative energy deficiency in sport. And it does lead to decreased bone density or risk of decreased bone density leading to osteoporosis or osteopenia, infertility, since ovulation is required for a regular healthy menstrual cycle.

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Women with HA may struggle with infertility if they're not having that regular ovulation. And also cardiovascular issues. So estrogen has a protective effect on the heart and blood vessels as I've talked about numerous times with respect to estrogen's role later in life, perimenopause and menopause. So low levels can increase the risk of cardiovascular disease in women. And then of course, you know, the management and treatment of hypothalamic amenorrhea.

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Generally, it will involve reducing exercise intensity, so either the intensity, duration, or frequency of workouts where possible, increasing caloric intake, and I'll give you some numbers with which to work with in a minute, but not only caloric intake, but certainly also micronutrient intake and ensuring that nutrition is on point, as well as calories. Managing stress is a huge one, and I'll talk about some stress reduction techniques as well.

08:00
And with it comes adequate recovery from training. That's a really big piece of the puzzle. And also where necessary medical intervention to make sure that bones are taken care of and also brains are taken care of, will put an athlete on, not put an athlete, will talk to the athlete about hormone replacement therapy using body identical hormones. A word of caution is if you suspect that you do have hypothalamic amenorrhea,

08:30
One thing you don't want is your GP to put you on an oral contraceptive pill because an oral contraceptive pill will shut down your menstrual cycle and in fact it can mask signs and symptoms of that low energy availability in hypothalamic amenorrhea. And even actually if you go on the oral contraceptive pill you won't get one of the withdrawal bleeds that occurs.

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when you start taking the sugar pill for that particular month. So that is a sign of hypothalamic amenorrhea if you don't have that withdrawal bleed. But I would caution anyone against just taking the oral contraceptive pill to correct hypothalamic amenorrhea because it doesn't do that and it doesn't help bones and it doesn't regulate the menstrual cycle at all actually.

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So from a nutritional perspective, you definitely wanna check your energy availability to ensure that you've got adequate calories on board. What might be adequate for someone who is relatively sedentary is likely far too low for someone who has quite a heavy training load. And this is the brain protecting the body actually and ensuring the body makes a smart decision not to have a pregnancy when there is insufficient.

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calories or energy available, so hence not ovulating. And there are a couple of different calculations that can be used. And I will say that the science isn't settled on this, and this is just based on a range of papers that have been published looking at energy availability, but some other scientists and researchers have questioned these numbers, so I would just like to be transparent about that.

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Your goal is to have between 40 to 45 calories per kilogram of fat-free mass on active days to avoid that low energy availability. And low energy availability is around 30 calories or less per kilogram of fat-free mass per day. And you work out your energy availability by calculating your energy intake for the day, then minusing off the calories used in energy expenditure,

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and you divide that by your fat free mass. And you will know your fat free mass if you do something like get a sum of skin folds done by someone who's very skilled at using skin calipers, or you have a Dexa scan done, or you have an MRI, which I'm not sure many people would actually do an MRI. And of course you could use something like an in-body scanner as well. Those bioelectrical impedance machines are pretty good for trends.

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And look, an in-body is one of the more accurate ones, given that as long as the environment is accurate and you get your test done at the same time on the same day of the week and you're in the same sort of clothing, you've had little to no liquid, et cetera, et cetera. So all of these things have to be true, but that can give you quite a good estimate of your fat-free mass. And then your equation that you'd want to make sure is that you have...

11:39
around 45 calories per kilogram of fat-free mass after you have subtracted the energy required for your exercise for that day. Now, if you don't know your fat-free mass, you can still do a calculation to sort of determine or give you sort of ballpark numbers to work with using body weight as a rough guide. And because body weight is obviously going to be greater, you would use

12:07
the guide of around 30 to 35 calories per kilogram of body weight. So let's say you weigh 60 kilos and you eat 2500 calories a day. And then you run for an hour and your Garmin tells you that you burn 600 calories. And yes, I've talked numerous times about how inaccurate this can be, but it's the only number you've got. So you just go with it. So like I say, you weigh 60 kilos, you eat 2500 calories and you burn 600 calories.

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So to do the math on that, you would do 2,500 calories minus that 600, and that would equal about 1,900 calories, exactly 1,900 actually, and then you would divide that by 60 kilos, and this would give you 31.6 calories per kilogram of body weight, which falls within the guide of 30 to 35 calories per kilogram of body weight, and that would be sufficient

13:05
to ensure you've got enough calories on board and you're not in low energy availability. Now, the other thing to check isn't just the number of calories, it is the timing of those calories as well. So are you going too long between training and eating? Are you doing any fasted workouts? And if you do suffer from hypothalamic amenorrhea, this is not the time to do those fasted workouts. And you wanna make sure you have calories coming in around those workouts.

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to provide sufficient fuel for these. And the other thing is around your energy intake is to ensure adequate fat calories and adequate carbohydrate. And again, there's no scientific data here. There's just a lot of clinical experience of people in this space. And a friend of mine, Kate, who used to do holistic nutrition, she would recommend at least 150 grams of carbohydrate a day. And Lara.

14:04
recommends around 200 grams of carbohydrate a day. And even for women who prefer to keep a lower carbohydrate diet, if you are an athlete, this is still actually quite a low percentage of your calories coming from carbohydrate. So let's say on an active day, you consume 3000 calories, and I've suggested that you have 200 grams of carbohydrate. That's 800 of those 3000 calories.

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coming from carbohydrate because for every gram of carbohydrate you eat, you're getting four calories. So if you do the math on that, that's less than 30% of your total calories coming from carbohydrate which would certainly still place you within that low carbohydrate sort of diet range because it's less than the acceptable macronutrient distribution range of 45%. And it still leaves you.

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plenty of calories that you can derive from fat and protein. So it's a really nice balance of not running short, but also having enough room in your diet for those other really important foods. In addition to that, you wanna make sure that you, obviously protein is key, but just don't go overly high on protein, I would say, that if hypothalamic amenorrhea is something that you're struggling with, then I would probably stick closer to about

15:29
between 1.6 to 1.8 grams of protein per kilogram body weight actually, which is lower than what I would recommend a fat loss population. But now's not the time for fat loss. Now's the time to get your menstrual cycle back on track. And protein is highly satiating. So if you eat too much protein, you run the risk of under eating. That's not what you want to be doing right now. And the remaining calories will come from fat.

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Now timing around training as I've already talked about as well. So this is when I think a good window of opportunity does exist and we do need to think about that. So either always train between meals or have something before training so you're not fasted. And then if your next meal is over two hours later then when you finish training you definitely want that training snack in there as well.

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Another thing to be mindful of is checking your blood biomarkers. So check that your thyroid is on schedule and not just your thyroid stimulating hormone, which is the marker that is almost always tested first. But you do want to check your T3. And T3 is your active thyroid hormone. And you want to make sure it's not at the lower end of the range. And you want it to be at least 4.5 to 5 even. You know, you want to make sure you've got enough of that.

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T3 hormone. And you also want to check your iron panel. So check that ferritin is above 50 and that all of the other markers are well within that normal range. You don't want ferritin to be so high that it's actually more of a marker of inflammation. That's why in of itself it's not adequate just to test ferritin, but make sure you know what your transferrin saturation is, your serum iron, your transferrin.

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have a really good idea of all of your markers and of course hemoglobin as well that comes into your full blood count. You wanna ensure that you've got optimal levels of B12, which is at least 400, if not closer to 500 or above, vitamin D as well, and zinc. So that's another one that's really important for the brain and for your immune system and for everything. And just do, like if you wanted to check cholesterol,

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Often a pattern I see is that in low energy availability, cholesterol can run a bit low actually. So just check to see where that's at. And then of course, what about life? What are your life biomarkers? So I mentioned stress before, and I cannot emphasize enough that stress management is a big piece of this because as I said earlier, unmanaged stress is a big trigger for hypothalamic amenorrhea. So you have to get, you cannot out supplement this, and you cannot.

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out eat it either. So what kind of like walks in nature are you doing? What kind of recovery are you allowing yourself from not just workouts but life? Are you getting in nature? Are you grounding like feet like bare feet on on grass or sand? Are you doing any sort of yoga practice which will help disengage that sympathetic nervous system drive and get into that parasympathetic

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journaling, are you getting therapy? All of these things can help with stress management. And also, of course, what about sleep? Are you getting adequate sleep? And certainly hypothalamic amenorrhea, if there is low energy availability and a highly anxious brain, then sleep can be really challenging. So ensure you have really good sleep routine, going to bed at the same time each night, regardless of whether it's a weekday or weekend.

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and getting up at the same time of day, getting that early exposure to sun, super important, avoiding devices and overhead lights in the evening time, using just lamps and orange toned lights where possible, having blackout curtains, wearing an eye mask when you sleep, looking at things like magnesium and holy basil, ashwagandha.

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for appropriately for to allow that brain to sort of calm down and get into that state to get sleep. And that for a lot of people comes more down to discipline than it does anything else. And then also do take track of your markers associated with ovulation and menstruation. So do you have mucus changing across the course of a month, which indicates that you have changing hormone levels.

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and that these are fluctuating appropriately. And can you take your temperature daily as this can give you insight into whether or not you've ovulated. And after ovulation, you should see temperature increase in 0.5 degrees Celsius. And this is because progesterone increases that body temperature. And whilst this might not be the best tool to use in a research setting, clinically speaking, it can be really a good tool to use.

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And do you have other signs of ovulation, yet you're not getting your period? So sore breasts, abdominal cramps, hormonal acne, a sore back, like all of these things can indicate that your body is preparing for a period, but you might not be there yet. And I mention these things because it does take at least three months if you do have hypothalamic amenorrhea, or it can take at least three months to get back on track.

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with ovulating and then of course having your menstrual cycle. So you do need to allow sufficient time for that. And all of these signs are good signs that your body is sort of on board. And then from a supplement perspective, magnesium 400 milligrams daily, not oxide or hydroxide, so a magnesium biglycinate. And you know I think that I like the Ethical Nutrients mega magnesium powder. It has taurine and B6, which help act on our...

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Gabber neurotransmitter in the brain, which helps calm our brain down. Zinc 25 milligrams a day, taken in the evening time. Zinc picolinate or glycinate again. Take any supplements required to help correct any deficiencies that might come up in your blood biomarkers. And this is definitely when, I mean, all of this stuff you should be working with a health practitioner, but this is just giving you hopefully some insights. And then other supplements, which I would work with a naturopath.

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and just to sort of get their ideas on would be other adaptogenic herbs like rhodiola, which can help manage stress. Vitex is one that's often used to help elongate or help in that luteal phase, but you want to be working with a health practitioner or a naturopath, obviously. A good spectrum multivitamin to get all those little missing trace minerals that you might not have been getting in. Omega-3 fatty acids for reducing inflammation and

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brain and hormone health. So there are plenty of things that you can take but what I will say is that you can't continue to run at an energy deficit, continue to train and continue to ignore your stress and just take supplements. So these really are in addition to what you would otherwise do. And then look finally, seat cycling is something there is absolutely no evidence to support it but a lot of clinicians who work in the natural health space swear

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I don't think you can ignore a lot of that experience. And if you don't have a cycle and you're not sure about your ovulation, you just work with the moon actually. So on new moon day one, include one to two tablespoons of ground flax seeds and pumpkin seeds per day up to day 14. And then in the second half of the moon cycle, aim to include one to two tablespoons of sunflower and sesame seeds each day for the next 14 days.

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And then when the new moon comes around again, you repeat the cycle. This is supposed to have a hormone balancing role, and it might be useful for some. And then Macca powder, particularly red Macca, has been used for eons for hormone balance, and it's pretty easy to pick up. It's got a slight sort of sweeter undertone, and it can go really nicely in yogurt or in smoothies. So including it.

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daily is another potential recommendation. So I mean, look, certainly there are many other things to explore here, likely, but this is just a good sort of start, hopefully giving you some insights into that. Any questions, don't hesitate to reach out. Instagram threads and Twitter @Mikkiwilliden, Facebook @MikkiwillidenNutrition. Head to my website, Mikkiwilliden.com and book a one-on-one call with me. All right, team, have the best week. See you later.