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No Period. Now What? with Dr Nicola Rinaldi

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No Period. Now What? with Dr Nicola Rinaldi

What do we do for a patient who’s periods are absent? How do we peel back the layers and identify what’s causing this aberration in a crucial part of female physiology?

Today we are joined by Dr Nicola Rinaldi who is passionate about raising awareness of HA: hypothalamic ammenorhoea. Nicola’s own journey with HA combined with her background in biology prompted her to dive deep into the research and resulted in her authoring a book “No Period, Now What?” 

Listen in as Nicola discusses some of the causes and contributors of hypothalamic ammenorhoea, as well as her recommendations to help clients recover from this condition. 

Covered in this episode

[00:47] Welcoming Dr Nicola Rinaldi
[02:44] Hypothalamic amenorrhea (HA): diagnosis and aetiology
[09:31] Other causes of amenorrhea
[13:50] Does the location of fat stores matter?
[15:12] Recommendations for recovery
[18:18] Stress and prolactin
[20:45] The set point theory
[23:17] Birth control pills and recovery
[25:33] How exercise affects ovulation
[29:06] Body composition and fat percentage
[32:45] Life after recovery
[35:17] Foods for recovery
[37:46] Personality type and HA 
[39:58] What’s next for Nicola’s research
[41:45] Closing remarks

Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook. Joining us on the line from the U.S. is Dr Nicola Rinaldi who has a PhD in biology from MIT. Since experiencing hypothalamic amenorrhea herself, Dr Rinaldi has been on a mission to spread awareness of the condition and how to recover. 

She published her book "No Period. Now What?" which was updated in March of 2019 to be more “Health At Every Size” aligned. In addition, Dr Rinaldi performed the largest survey to date of women who likewise experienced amenorrhea. Welcome to FX Medicine, Dr Rinaldi. How are you?

Nicola: I'm doing very well. Thank you. Thank you so much for having me.

Andrew: It is our pleasure, and I've got to say, "Wow." So you've got a PhD in biology from MIT. Let's delve into that a little bit. 

Nicola: Sure.

Andrew: We’re talking general biology?

Nicola: So, it's actually in what's called computational biology, which is a combination of biology, statistics, and computer programming. So, I chose that field because I wanted something that would let me work part-time or work from home because I knew that I wanted a family at some point. 

Andrew: Yeah.

Nicola: I actually loved every aspect of it—learning the statistics and the programming as well as the biology. I think all three aspects have really helped me in my career since then.

Andrew: Well, I've got to say the computational part would see you in good stead to look through the mess of some studies and to tease out the wheat from the chaff as they say.

Nicola: Yes, exactly. And that's been very helpful as I've done not only the research for the book but I also really enjoy myth-busting and doing that since then. So, being able to read and really understand the statistics in the science that's coming out is incredibly helpful for that.

Andrew: Okay, let's delve into hypothalamic amenorrhea. We've discussed this on FX Medicine. We like to get various viewpoints so that people can make their own decisions for treatment. Hypothalamic amenorrhea. How's it diagnosed and what's its aetiology?

Nicola: So, it's kind of all in the name. Hypothalamic amenorrhea is amenorrhea or a missing period. Typically, it means 3 months or more is kind of the standard that's used. And it's of hypothalamic origin. So, the hypothalamus is a major control centre in your brain. It takes in inputs from all over your body including information from your stomach in terms of the mechanical receptors that tell it how much you've eaten, various hormones that are generated as you eat. So, if you eat fat or protein or carbs, different hormones are generated. Those travel through your bloodstream to your hypothalamus. It takes in information about your stress levels, in terms of your cortisol levels or it can sense the beta-endorphins.

So, it basically collects all of this information from your body and then sends out signals that basically tell the rest of your body systems what to do. It sends out thyrotropin-releasing hormones to adjust your thyroid. It sends out corticotropin-releasing hormones to adjust the production of stress hormones from your adrenals. It sends out gonadotropin-releasing hormone that then goes to your pituitary and leads to secretion of follicle-stimulating hormone or luteinising hormone, which serves as the two major hormones that control your reproductive cycle. 

Andrew: Yes.

Nicola: It also secretes ADH, antidiuretic hormone, which controls the water balance. It can also adjust where your body is expending energy, so how much energy it's using to keep you warm. So, it's basically a master regulator in the sense that it takes in all these inputs and sends out outputs.

In terms of the amenorrhea, what generally happens is it's usually the strongest criteria...the strongest factor is under fuelling, so not eating enough to support everything that your body is doing. When that happens and your hypothalamus is sensing that it's not getting enough energy, it basically tries to shut things down to conserve energy because it only has a given amount to work with. It needs to do things like pumping your blood and making you breathe and letting your brain work. 

So then it shuts down systems that are not as imperative. Your reproductive system is one of the top things. It's a nice-to-have, not a need-to-have. So, basically, when it senses this lack of energy, it shuts things down including your reproductive system. It can decrease fat storage, which we tend to see in our society as a positive, although it's not always the case. It stops keeping you as warm, so people that are experiencing this often feel really cold. You can have problems with brittle hair and nails because it doesn't choose to spend energy on building those things. One of the major impacts can be issues with bone density because, again, there's not enough energy and the hormones in the reproductive cycle actually play a role in bone density as well. It's kind of a double-whammy there.

It's a hugely important organ and when we're not eating enough...or it can also be suppressed through stress. But it generally tends to be mostly from under fuelling and then with some level of either psychological stress or stress from exercise layered on top of that sometimes in a synergetic way. So, basically instead of just adding those things together, they amplify each other and make things even worse.

Andrew: Normally, these organs are based on a negative feedback. The only one that's based on a positive feedback is really in pregnancy where it just says “Go!”

When we're talking about basically a misread negative feedback, is that what's happening here? So that you've got misread signals between the hypothalamus and the pituitary?

Nicola: So, I think it's actually more that the signals from the hypothalamus are dampened. So, we know that in hypothalamic amenorrhea, the gonadotropin-releasing hormone... in a normal cycle, the gonadotropin-releasing hormone is released in pulses.

Andrew: Right.

Nicola: So, I think it's about every 4 hours and the amplitude of x whatever it is. 

Andrew: Yes.

Nicola: In somebody that has HA, the pulses are much further apart so then the pituitary is not getting the stimulation that it needs to then generate the necessary follicle-stimulating hormone, which is what starts the menstrual cycle going.

Andrew: Right. I'm also very interested in what you said about prioritising, which is really interesting when you think about humans as an animal. We see for instance, and I'm going to talk in the Australian instance, kangaroos will expel even a foetus if famine occurs. Kangaroos can go for years without going into oestrus if the situation is dire in the environment, which will basically waste energy on progeny.

This prioritising, that's really quite a fantastical thing. How the heck does it prioritise fertility at the bottom below survival of other organs and even fat storage?

Nicola: Well, I mean, if you think about it from an evolutionary perspective, it makes sense because, if it prioritises fertility over survival, then yes, you get to have your baby maybe…

Andrew: Maybe.

Nicola: …then you die afterwards. You can't take care of the baby. 

Andrew: Yeah.

Nicola: And I think from an evolutionary perspective as well, certainly our species has experienced many times through the ages of famine. One of the common things that women will hear is, "Oh, you're never going to get your period back," or, "Your hypothalamus is broken." 

But in our species history, like I said, we have famines and then we've managed to reproduce afterwards. So in our history, we actually have people who have been able to get their periods back after a famine, because if they weren't, then we wouldn't be here basically.

Andrew: Yeah, yeah. Just going through some other pathologies, I guess, that we have to be aware of, things like pituicytomas and things like that that can really mess up the actual mechanics of the neural systems. 

Nicola: Yes.

Andrew: Can we go through just a few of those just so that we get them out of the way so that we know that what we're dealing with is an otherwise healthy woman?

Nicola: Yes, yes. So, I think there are definitely other causes of amenorrhea and they should absolutely be ruled out. So there's hyperprolactinemia, which is basically an elevated prolactin level. You can experience this when breastfeeding and that's actually one of the ways that our body shuts down our menstrual cycles when we are breastfeeding so that we don't have too many babies right in a row. It can also come from, oh, it's called a microadenoma which is a small growth on the pituitary gland that can increase the secretion of prolactin that then shuts down your menstrual cycle. So prolactin is definitely something that should be checked when you're doing a workup for amenorrhea.

Other causes can be if your thyroid is totally out of whack, that can also suppress your reproductive hormones. So thyroid hormones are another good thing to be checking if you are missing your period. 

It can be due to something called Asherman's syndrome, which is scarring in the uterus that can come after some kind of uterine trauma. So, if somebody's had a C-section and then is not getting their period or if you've had a D&C for some reason, that can be a potential cause. It's not that frequent but it's definitely something else that should be ruled out.

Andrew: Yea.

Nicola: Diminished ovarian reserve/menopause is another possibility for why someone might stop getting their period. That can also be ruled out by checking the reproductive hormones and hypothalamic amenorrhea can… you can get a stab at it by looking at the reproductive hormones; specifically, the luteinising hormone tends to be quite low. 

Andrew: Right.

Nicola: But that's not always the case. There's no gold standard for diagnosis. 

Andrew: Right, okay.

Nicola: The two other conditions that are quite common are polycystic ovarian syndrome, also known as PCOS, and congenital adrenal hyperplasia or non-classic congenital adrenal hyperplasia. Those manifest with high levels of androgens or 17-hydroxyprogesterone in the case of the adrenal hyperplasia.

So, those are all sort of things that you can look at via blood work and can be ruled in or ruled out. PCOS is an interesting one because it overlaps quite a lot in terms of diagnosis with HA, hypothalamic amenorrhea. I like to abbreviate it as HA because it's a little bit easier to say. 

Andrew: Yes.

Nicola: So, technically the diagnostic criteria for PCOS are three-fold. One is amenorrhea or oligomenorrhea which is cycles that are longer than 90 days, I think, or maybe 35...35 days. Sorry, I'm getting a little mixed up here.

Andrew: That’s okay.

Nicola: And then polycystic ovaries. So, when you do an ultrasound, you'll see lots of follicles in the ultrasound. It's really important when you're trying to distinguish between the two to get the diagnostic criteria correct. The most up-to-date research suggests that, for it to diagnose PCOS, somebody should have 25 or more follicles on one ovary. You can't just look at it and say, "Oh, that's a lot of follicles," because women with HA actually also tend to have multi-cystic ovaries so that's something that's...you can't really use it as a way to distinguish between the two conditions.

Andrew: And the levels of androgens in PCOS?

Nicola: The androgen level is the third one. 

Andrew: Got you.

Nicola: It can either be a physical manifestation of high androgens or biochemically seeing that in your blood work. In women that’s, sort of, been maybe under fuelling, doing a lot of exercise, and has amenorrhea, I really strongly believe that it's imperative to get that blood work done. And if you're not seeing elevated androgens, it's almost certainly HA versus being PCOS.

Andrew: Right. You mentioned earlier fat storage, and I'm wondering if hypothalamic amenorrhea might have a different preponderance for where the fat is stored, the thighs versus the abdomen, that sort of thing. Do we see that? We're certainly aware of, for instance, PCOS and you get… well, the classic picture is the central adiposity, the apple-shaped thing. That's not always the case though.

Nicola: So, I haven't seen anything to suggest a distribution of fat stores in somebody that has HA. 

Andrew: Okay.

Nicola: What I do know is that I was actually very surprised when I did the survey for my book because I asked the question about: have you ever lost weight in the past? 82% of the survey respondents said they lost at least 10 pounds which is just around 5 kilograms. 

And I find that really surprising because many of these women were in small bodies to begin with and having that level of weight loss was way more than I expected. But I think that speaks to the ongoing energy deficit because obviously being in energy deficit can cause weight loss. And then if you're just maintaining that lost weight for a long period of time, you've probably been under fuelling that whole time so that seems to be a very common association.

Andrew: Okay, and so let's go into recommendations for recovery. I mean, it seems like we're jumping ahead here, but I'm going to sort of do a jump back and forth. 

Nicola: Sure.

Andrew: With regards to recommendations, under fuelling seems a bit simplistic to just say, “Oh. Well, over fuel," because there's so many points along the way. You mentioned digestion. We've spoken about stress and how the sympathetic nervous system is activated. So, how do you approach that from a holistic perspective?

Nicola: So, I think it really does have to start with proper nutrition. So, I do have a certain number of calories that I recommend in my book. I don't know how you feel about talking about calorie levels. So, my general recommendation for recovery is eating about 2,500 calories a day. 

It can vary a little bit. Somebody who's quite short can eat a little bit less. Somebody who's tall can eat a little bit more. But that's based on a study done by Anne Loucks and her colleagues where they looked at the energy level based on a body's fat-free mass in order to be, what they called “energy replete.” That turned out to be 45 calories per kilogram of lean body mass.

So, for a woman who is about 5'6", which is about 166 centimetres or thereabouts, that works out to be approximately 2,500 calories if she's active. It gets really complicated. There's a lot that goes into the equation, and I do talk about it in detail in my book. But sort of the general take home message is it's about 2,500 calories. That's a lot more than we're usually told we need. 

Most places say you need 2,000 calories a day and, if you're looking to lose weight, you should eat 1,200 to 1,500 calories a day. So, for a lot women, that can feel a huge jump but it is… So, I've been working in this field for almost 15 years now and I've helped so many women recover their periods through using this level of energy. It may decrease a little bit over time but particularly when you're working to get your period back, you need to really baby your hypothalamus. I think of it kind of like Newton's first law where an object in motion stays in motion. 

Andrew: Yes.

Nicola: An object at rest stays at rest.

Andrew: Yes.

Nicola: So, a lot of times women can have a basic level of under fuelling, a lot of exercise for a long time, and still maintain a period if they're not on birth control pills. That gets into a whole different area that maybe we can chat about in a minute. But once a period goes away, she then often has to gain a bit more weight, eat more, exercise less than she was at the point where she lost her period because the hypothalamus has to do more work to actually get started again.

Andrew: Yeah, yeah. Now, I need to ask the point of stress. I mean, women carry the major burden of stress, let's face it. So, when we're talking about a hormonal trigger or a hormonal player in the game, prolactin. How much do you work on stress and managing stress in women to soothe, if you like, their prolactin levels?

Nicola: So, most women with HA actually tend to have low prolactin levels, so that doesn't seem to be too much of an issue. 

Andrew: Right. Hmm. Okay.

Nicola: Just generally in terms of stress, I think that's actually the hardest part of the equation to really work on because, as you say, we tend to be in a very goal-oriented society and you've got all these things piled on top of you. We do talk about things like maybe doing some yoga or meditating or doing what you can to remove stress from your life. 

But I'm not a psychotherapist or anything like that, so I often will say maybe going to see a therapist is something that's going to be beneficial. Acupuncture can certainly be helpful in terms of reducing stress levels and helpful in that way. But I'm not a great one with the, sort of, stress management. I think there are other people out there that are better at handling that aspect of the problem than I am.

Andrew: Yeah, forgive me, but I'm concerned about my knowledge here. So, I thought that stressors had a great effect on promoting prolactin but these ladies have lower prolactin. Is that because of a misread, or is that because their hypothalamus is just not kicking in, or is this just a totally erroneous concept?

Nicola: I'm actually not aware of any connection between stress and prolactin. 

Andrew: Got you, okay.

Nicola: So, what I've seen is that stress increases cortisol levels, and that can suppress the hypothalamus, pituitary, and the reproductive organs. So, the ovaries. 

So, I'm not aware of a connection there. Like I said, most women that I see where they've had prolactin tested, it does tend to be on the lower side. So, in this case, I don't know that there's necessarily a connection there. There may be in other aetiologies.

Andrew: Got you. What about a set point? I've heard about there being a set point with regards to weight management and trying to lose weight, that it's hard to shift this set point which we tend to gravitate back towards. 

Is there a hypothalamic set point that you have got to, sort of, have this nutrient intake to override and then we have to build upon it as the woman recovers from amenorrhea?

Nicola: So, I do think that there is something to the set point, set range theory. There's been a lot of discussion about it. There was actually a really good review that I read when I was working on the book that sort of looked at four different theories. There's a set point versus, well, that doesn't necessarily make sense because, you know, body sizes have changed quite a bit over the ages. So, you know, having a genetic set point is maybe not necessarily the case. Maybe it's a set range and maybe we can do things to adjust that range.

So, it's actually a really interesting field. But what I do tend to find in women that have HA is that, like we talked about, they've often had a fairly significant weight loss in the past. 

Andrew: Right.

Nicola: What tends to happen is that, if that was typically around their set range and it takes getting back to that point or maybe a little bit more for the period to be restored. Obviously, there's so many nuances in this. There are women that have been far above their set range, and then come down, and maybe come down too far.

And so, I mean, it's very individual, as is so much of this area. But just as a general rule, women have to get back to the weight that they were at when they were just eating freely and not super obsessive about exercise. 

Because that tends to happen, it can be high school or college or maybe post-college. For me, it was the end of graduate school, and I was exercising a lot and decided I needed to change my body size. I decided I wanted to lose some weight, so I cut my calories significantly and then the next month I went off the pill to try and get pregnant and I didn't get a period. So I think it’s, sort of that trying to manipulate our body to match what society thinks, that can really actually get us into a lot of trouble.

Andrew: Now, you were talking about having children and we need to ask the question about birth control pills. Do they help with recovery?

Nicola: So, birth control pills, they can be helpful for a woman who does not want to conceive children. It's certainly a viable option for that. One of the problems with it is that it masks a missing period. So, you get a bleed from being on birth control pills every month if you're doing the three weeks on, one week off, kind of thing. 

Andrew: Yes.

Nicola: And if that goes away, that's a super red flag that something is wrong with your system. But other than that, you can be completely unaware that there's something wrong because you get this bleed every month and you think everything is fine. It's not an ovulatory bleed, so it's not actually a period. It's just a pill-induced bleed. 

Andrew: Yeah.

Nicola: So that's one of the issues with it.I've also seen some doctors prescribe the pill to women who have HA saying, "Oh, it'll fix everything." No, it doesn't actually fix anything. Again, it's just an artificial bleed, and it does nothing whatsoever to alter the underlying hormonal system to then make you get a period when you stop taking them. I mean, you will get that last pill bleed but it does nothing to fix your hypothalamus.

So, it's really not at all useful in this situation, and it's definitely not good to just give somebody pills because their period is missing. I think it's really important to work on the underlying issues rather than just saying, "Here, take the pill, and come back to me when you want to get pregnant," because it can actually be difficult for somebody to get pregnant who has HA because your body needs energy to fuel a pregnancy. You can have trouble with...your lining doesn't get thick enough. It takes you a long time to ovulate if you ovulate at all. It can even cause issues with in vitro fertilisation. 

Andrew: Right.

Nicola: So, I think it's really, really important for somebody who's experiencing HA to actually address the underlying issue of under fuelling and/or stress and/or exercise-induced stress.

Andrew: Got you. Okay, so let's move on to exercise-induced stress because this is a big issue. Are the recovery requirements different for the elite athlete or the professional athlete compared to the weekend warrior? What's happening here?

Nicola: That's a really interesting question. So, for somebody who's a recreational athlete, what my recommendation is, is basically cut out the high-intensity exercise because that induces changes in your cortisol. It increases cortisol levels quite significantly, and that in and of itself can be enough to continue suppressing your hypothalamus. 

So, I've seen a number of women who have started eating theoretically enough to get their periods back and they just don't while they're continuing the high-intensity exercise. They cut out the high-intensity exercise and then get their period back within a couple weeks or a couple months. I mean, the timeframe varies from person to person. But it really does seem like the high-intensity exercise and the cortisol-induced changes based on that can keep your hypothalamus suppressed.

Andrew: Got you.

Nicola: So, I've seen other practitioners say, "Well, it's different for elite athletes," but I've worked with a few elite athletes and they've also found that they've had to follow the same recommendations of basically cutting out the high-intensity exercise. You can certainly try just eating more and really making sure that you're fuelling properly, but I think that the rest itself is important. 

And I don't know of physiological differences between a recreational athlete versus an elite athlete that would mean you would actually need fewer calories, or you would respond differently to stress. So, I think that would actually be an area that would be very interesting to research.

I do often point to a study that was done in Sweden a few years ago where they looked at elite athletes, and these women were all eating about 3,500 calories a day and doing 1,000 calories a day worth of exercise. Some of them had their periods, and some of them didn't. 

And so the researchers were interested in further understanding, well, what's the difference between the two groups? On the surface, it seems that their energy balance is the same, so what's going on? 

So they looked at what they called the “within-day energy balance.” So they computed on an hourly basis how much energy are they taking in, how much are they expending? They actually found that the women without periods were in an energy deficit for 4 hours more per day than those that did have their periods, which I find absolutely fascinating.

It's kind of an indictment of the whole intermittent fasting idea, particularly for athletes, anyway. Basically it's a thing that's fairly common in women with HA. There's a lot of women who get up in the morning, get ready, go and do their exercise, go to work and then maybe they'll eat something at that point. 

Andrew: Maybe, yeah.

Nicola: But they're getting into a huge energy deficit because their body has been using fuel the whole time they were sleeping and then obviously even more with moving around, doing the daily movement and then the exercise on top of it. 

I think that that's an indication that, even elite athletes are experiencing this kind of energy deficit and issues with it, so I'm not convinced that there is a biological difference that's meaningful there.

Andrew: Right. Nicola, what about body composition in this group and indeed, any group of women? You were mentioning earlier on about women who suffered HA having a 5-kilogram weight loss sometime previously. When you're talking about re-gain of weight, what about body composition versus just BMI? I guess I'm concerned about lean muscle mass here versus total body mass.

Nicola: So, that's an interesting question. I know there are some studies and I've seen people say that it can be just a drop in body fat that can cause amenorrhea and therefore, you just need to increase your body fat by a couple percentage points to get it back. 

Andrew: Right.

Nicola: I haven't really noticed that it's that specific. 

Andrew: Okay.

Nicola: It seems to me to be much more about fuelling your body properly and sort of getting back to where your set point is. I do think that our fat is actually a hormone-secreting organ. 

Andrew: Yes.

Nicola: It secretes leptin. It secretes adiponectin. So, our body can use that… our hypothalamus senses that. So, I think often we do need to get back to the level of body fat that we were at previously. So that can mean for somebody that has been body-builders, for example, that have increased their lean body mass quite significantly, they might need to increase their fat mass to get back to that point where their leptin signalling is working properly.

Andrew: The thing is, you know, we concentrate so much on lean muscle mass as being the health indices, if you like. But there's a certain amount of fat that we need for our bodies to work. 

Nicola: Yes.

Andrew: Too often particularly… I mean I'm certainly not including myself in this group, but elite athletes talk about the lean muscle mass and yet it's the fat that will enable them to indeed have a period. So, there's got to be this nurturing period. And as you say, you've basically got to nurture your hypothalamus.

Nicola: Yes, exactly. So, I mean obviously what somebody chooses to do depends on where they are in their life. I worked a bit with a runner, Tina Muir. I don't know if you heard her story at all. It went viral for a while here in the U.S. 

Andrew: Right.

Nicola: She’s a runner from Great Britain who was an elite and decided she wanted to get pregnant and so she actually stopped running for a while in order to do that.

I know there are women who are able to run marathons and get pregnant. It just speaks to how all our bodies are different in so many ways. I mean, people can have amenorrhea at a range of different sizes, body fat levels, athletic levels, everything. It's a very unique… we're each unique individuals and so there's no magic number in any of this. 

There have been other stories that have come out recently. Mary Cain talking about how she was basically continually told to lose weight, and it ended up making her very unhealthy. I think that changing the focus in athletics from body size to function I think would be really valuable.

Andrew: Yes, yes.

Nicola: Because there are absolutely long-term fairly serious consequences of amenorrhea and starvation and all of the other symptoms,  the whole relative energy deficiency and sports, you know, that cluster of symptoms that can come with the under fuelling.

Andrew: There's a few athletes that I've spoken to here in Australia, and indeed they talk about how the recovery recommendations go against what is commonly prescribed as healthy advice. How can this be right? What does life look like after recovery? How do they continue?

Nicola: So, I think that's very true. There's this idea in health and nutrition at the moment that you should only eat x amount. You shouldn't eat foods x, y, and z. You need to exercise every day. 

But the thing is, it is possible to take those healthy behaviours too far, and that's when you end up with relative energy deficiency in sport or hypothalamic amenorrhea. So, one has to, kind of...as we've already talked about, you kind of have to push back a little bit in the opposite direction to get to that middle point of actually really being healthy. 

So, the recovery recommendations in and of themselves, 2,500 calories a day, no high-intensity exercise, that's not necessarily beneficial for the long-term. Certainly, on the exercise front, it's very clear in all the research that exercise is beneficial and healthy for the long-term. But it has to be properly fuelled exercise because when you're exercising in an unfuelled manner, then you have all these other negative health consequences.

And so I think life after recovery is actually kind of amazing because I think one of the things that people tend to learn through the recovery process is you don't actually have to control your eating as much as we are all told that we need to. You can take a day or two off exercise and your body is not going to suddenly fall apart. The world is not going to end. 

It ends up being a place where once you've recovered, you just have to live your life and you exercise as you want to. And if you don't feel like exercising, or you're sick and you don't exercise, and you eat freely, you eat what you want to. Our bodies tend to be stable when we're really listening to our hunger and fullness cues, following the intuitive eating model.

For many people, it ends up being a much more enjoyable place to be than the time when they felt like they had to micro-control every morsel that was going into their mouth and exercise for hours a day every day.

Andrew: Can I drill down a little bit into the types of foods that we need to be nourishing our bodies with? You spoke about intuitive eating and very often, in a lot of the population, that intuitive eating has gone out of the window because of marketing. 

Nicola: Yes.

Andrew: So they're eating the fast foods and the high-caloric, poor nutrient-dense foods. So, how do you change that picture in your patients? And indeed, what sorts of foods, when we're talking about proteins, fats, and carbs, what types of foods should we be favouring versus what types of foods avoiding?

Nicola: For recovery, it's actually interesting because the calorie-dense foods tend to be the best ones for recovery, because you can get a good caloric punch in a small volume. So I think that those foods are actually helpful for recovery. I'm not going to tell somebody, "Go out and eat McDonald's for every single meal." That's not going to be good for everybody. I mean for anybody, right? 

Andrew: Yes.

Nicola: But, you know, eating a slice of pizza or having some ice cream or a cookie, that's a lot of calories in a small volume and that's much easier to do than eating the "healthy foods.” A big salad, you have to eat a lot of salad to make up one cookie.

Andrew: Yes.

Nicola: Again, HA is kind of about having taken healthy behaviours too far. So there tends to be almost an aspect of orthorexia to it in a lot of cases, or anorexia, that kind of thing. And so it's kind of pulling back from that and realising that, yes, you can eat some of these foods and it's actually going to be fine. Obviously, you're going to be unhealthy if you're eating cookies all day every day, but equally, you're going to be unhealthy if you're eating broccoli all day every day. 

So, you know, I think a nice balance between whole foods, fruits and vegetables, and a treat every now and again. I think we've come to a very black and white place in our society where it's like: either you eat healthy or you eat unhealthy. There can be a balance, and I think that that's kind of what's missing in a lot of the discussion about nutrition.

Andrew: I love the saying, "Everything in moderation, especially moderation.” When you're talking about these women that are high...they seem to be highly-driven. They seem to be highly controlled. 

Nicola: Yes.

Andrew: Do you find in your research that there are...and this may be digging a little bit deep, but dare I say the word personality types, the A-type personality, are they more at risk of HA?

Nicola: So, that is not my research but there are studies that have been done that have found out to be the case, that women that have HA tend to be sort of more of the type A controlling perfectionist. 

Andrew: Yes.

Nicola: That’s definitely something that people have found in other studies; not my work.

Andrew: So, how do you tell a woman like that to calm down?

Nicola: You show her lots of evidence of how this works because I think that's one of the things that people tell me they really like about my book, is that I have the data to support the claims that I'm making. 

The survey that I did is 300 women. I asked them all sorts of questions. I mean this is a substantial survey. So, I asked about how long did it take to recover? What kinds of things did you do during your recovery? And I continue to have that data set to go back to. I think supporting my claims with hard evidence is one thing. 

And also, the book includes lots of stories of other women who have gone through this. So, seeing that positive example of somebody just like me was able to do this and come out with their period. I also have a Facebook support group that is much more of the same. I mean, every day now there are people posting about getting their periods back. So I think having that example of somebody else who's doing exactly the same things, and feeling the same things, and then is able to make these changes, and get their periods back. I think that's a big part of why the type A women are able to do this because they have the evidence in front of them.

Andrew: Okay. So, where to now with your research? It's got to continue. I mean this is important stuff. HA is rife and growing throughout the community.

Nicola: So, I've got a couple things in the works. I'm working with a dietician in Australia actually, Fiona Sutherland. We're working on a course for dieticians actually, to help them understand HA and then coach their patients. Because I think it's spreading awareness both in the community of dieticians and hopefully at some point in the medical field, would be really beneficial. 

I'm also thinking about writing a book for teenagers, because I think there's something that's experienced in a lot of younger women. My book is very pregnancy-focused because that was how I came to it and many of the women that I followed for my survey… Often it doesn't even impinge on your consciousness that this is a problem until you want to get pregnant because then obviously you need to be ovulating and getting your period because otherwise, you can't get pregnant. So I think working on a book for teens is definitely something that I'm planning to do in the next year or two as well.

Andrew: Got you. And for further information, where practitioners can get good information where they can learn. You’re obviously working on a course for dieticians. It seems to me by a couple of comments that doctors need to have a course as well. Where's good information where we can glean?

Nicola: The medical community is a hard one to break into because I don't have an MD. I have a PhD, and so there tends to be some thinking that I don't really know that well what I'm talking about. I know there are some medical practitioners who have read my book and recommend it, but I don't really know how to break into that community. That's something that I'd love to work on but I haven't really gotten there yet.

Andrew: Nicola Rinaldi, I can't thank you enough. You've opened my eyes certainly and I need to do some extra learning on prolactin, I know. But thank you so much for taking us through what is an otherwise very confounding and it's not just distressing, but it leaves a lot of women distraught when, you know, it ends up adding to the stressor of infertility and how they can't get pregnant. 

So, thank you so much for taking us through at least some of the ways in which we can help these women nourish their hypothalamuses and nourish their bodies indeed, back to fertility and health. Thanks so much for joining us on FX Medicine today.

Nicola: Thank you so much for having me. It's been a pleasure.

Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook.


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