HPN 5: How To Get Your Period Back and the Vital Role of Energy Availability

March 20, 2019
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We’re back with episode 5 of Holistic Performance Nutrition featuring Tawnee and Julie McCloskey, a certified holistic nutrition coach who runs wildandwell.fit. On this show we take another dive into the topic of amenorrhea and female athletes, with Tawnee and Julie offering new advice that we’ve not yet shared on the show yet.

Amanda asks:

I am a huge fan of your podcast and have listened to nearly every one. I know you’ve addressed this topic before but I am a female triathlete with large goals in the sport. I currently podium in my age group at nearly every 70.3 distance I participate in but have hopes to turn professional in the next few years. A year ago I began working with a nutritionist as I was gaining body fat and weight even though training had increased and my diet hadn’t changed. It was really frustrating but after working with nutritionist I quickly saw results and lost 25lbs over the course of a few months. Just for reference, I am 25 years old, 5’6” and currently sit around 125lbs although was probably closer to 119lbs at the end of the 2018 season. If you haven’t guessed where this question is going here it is, I lost my period in July and it still hasn’t returned (as of March 2019). Along with that, I have noticed a significant dip in my sex-drive. In fact I would say it’s nearly absent. My partner is also a triathlete and we both notice fluctuations in sex drive but mine seems to be steadily low if not none which I know frustrates him sometimes let alone myself. My period has always been fickle even as a youth and before endurance sports were a part of my life. Beginning March last year, I have tracked my calories and macros daily and have been very diligent in making sure I nail the numbers my nutritionist has given me based on hours of exercise per day aligned with consumption. In recent weeks, I have let go of the tracking a little bit and focused on eating more carbs and protein and not restricting even when I feel like maybe I should. I am averaging 12-15 hours of training per week right now but body weight hasn’t fluctuated much in a while. Any tips on boosting sex drive and getting the period back without putting on additional pounds or body fat %? Is this nutrition based? When should I be worried? I would guess my current body fat is around 15%. I had blood work done recently to check a number of things including Sex hormone which was in normal range (globulin- 21 and testosterone-12) and Cortisol 13.2 (blood test was taken at 4:30pm). I’ve listened to the Stacy Sims podcast on here multiple times and I still don’t know what else could be causing me to lose period and have no sex drive. Any help or advice would be SO appreciated.

The coaches say:

  • Hypothalamus signaling (HPA axis, HPO axis, HPT axis)
    • The hypothalamus is the hormone control center located in the brain that senses stress levels in the body and responds accordingly.
    • If the hypothalamus does not “tell” the pituitary to make sex hormones, a domino effect takes place.
    • “Endocrine and neuroendocrine experiments have found that the proximal cause of menstrual and ovarian dysfunction in these women is disruption of the pulsatile secretion of luteinizing hormone (LH) by the pituitary and that this is caused by disruption of the pulsatile secretion of gonadotropin-releasing hormone (GnRH) by the hypothalamus.” https://www.physiology.org/doi/full/10.1152/jappl.1998.84.1.37
    • Bottom line: Your hypothalamus has direct control over hormone production. You have direct control over the signaling of your hypothalamus.
  • Weight loss
    • Significant weight loss can be a huge stress and trigger for hormones to act funky.
    • Weight is one area where women struggle the most—in being told to eat more and actually regain weight that they don’t want to necessarily gain, but it’s crucial.
    • Need to find our unique weight “setpoint”—that point in which biological functions reach an equilibrium.
    • The word “restriction” was introduced to Amanda through this weight loss journey.
    • “Normal” body fat (BF) and body weight are often not enough, periods can go absent if other variables present, even if body fat is 25%.
    • Anecdotally we see that BF under 18% increases your risk of trouble, and this is more than the recommended 14% that you will see in literature and sports texts.
  • Stress
    • Everything may look “perfect” on paper but stress can overrule that (see above).
    • Stress comes in MANY forms. Not just exercise stress.
    • Some good news: The stress of exercise is shown to be ok AS LONG AS energy needs are met, and this definition of energy needs may vary—often more calories than you think!
  • Energy availability (EA)
    • Don’t rely on hunger
    • EA = Energy intake minus energy expenditure
    • Research shows that EA is often the biggest culprit in HA. This is why weight and BMI can be normal but you’re not having a period.
    • Low EA results from dietary restriction or high training levels in which calorie needs aren’t met (high training should be ok if calories in abundance and HPA axis is functioning).
    • Low energy availability, not stress of exercise, alters LH pulsatility in exercising women
      • Low EA suppresses hormones—this could be from not eating enough to support exercise energy expenditure, not just outright dietary restriction.
      • Results show reductions in T3, insulin, and IGF-I and increases in cortisol and growth hormone that would be expected under energy-deprived conditions. All these hormones affect reproductive tissues (low T3 common in eating disorders and amenorrhea).
      • “As in our previous experiments, the exercising women in this experiment reported that they were satisfied with the amount of food they consumed during the low energy availability treatment and that they had to force themselves to consume all the food they were administered in the balanced energy availability treatment. Thus, hunger may be an insensitive indicator of the energy needs of physically active women, just as thirst is an insensitive indicator of water needs during prolonged exercise. Athletes may need to eat by discipline without hunger to prevent reproductive disorders while training, just as they drink by discipline without thirst to prevent dehydration during a long race.”
      • “Our results suggest that prolonged exercise has no disruptive effect on LH pulsatility in women apart from the impact of its energy cost on energy availability or glucose availability, and that LH pulsatility is disturbed less by exercise energy expenditure than by dietary energy restriction.”
  • Is dieting ever ok?
    • Yes! You can actually be ok lowering calories but not if it’s in combo of high exercise energy expenditure, so if you’re training like you are, don’t diet.
  • What is a safe EA for normal hormonal function?
    • Generally, research shows the sweet spot is 45 kcal per kg LBM.
    • Never go below 30 kcal per kg LBM.
  • Energy Availability, Not Body Fatness, Regulates Reproductive Function in Women
    • Amenorrheic athletes were estimated to habitually self-administer an energy availability of 16 kcal·kgLBM−1d−1, whereas regularly menstruating athletes habitually self-administered 30 kcal·kgLBM−1·d−1. Thus, although the precise location of the energy availability threshold between 20 and 30 kcal·kgLBM−1·d−1remains to be determined, 30 kcal·kgLBM−1·d−1 appears to be sufficient energy availability to preserve normal reproductive function and skeletal health.
    • Because the exercise energy expenditure in this experiment was ∼840 kcal, many women may be able to maintain normal LH pulsatility while running up to 8 miles·d−1as long as they do not simultaneously reduce their dietary energy intake below 45 kcal·kgLBM−1d−1. If they do reduce their dietary energy intake, as many exercising women do, then they risk falling below the threshold of energy availability needed to maintain normal LH pulsatility.
  • Diet & timing of eating around exercise
    • Are you going long periods without eating or not eating enough before/during/after exercise? Underfueling is common among all endurance athletes.
    • Carbs: 150-300g /day until things balance out, don’t shy away, and only count to make sure you’re having enough not too few
    • Fat: There is a hug correlation between fat intake in injury risk including SF. Not only fat but healthy fats and not enough Omega 3s and PUFAs.
    • Fat intake and injury in female runners
        • “Injured runners had significantly lower intakes of total fat (63 ± 20 vs. 80 ± 50 g/d) and percentage of kilocalories from fat (27 ± 5 vs. 30 ± 8 %) compared with non-injured runners. A logistic regression analysis found that fat intake was the best dietary predictor, correctly identifying 64% of future injuries.”
    • Also the type: Deficient intake of n-3 PUFA could theoretically contribute to an enhanced inflammatory response and increase injury severity and, in fact, injured runners did consume significantly less PUFA (13.3 ± 4.8 g/d vs. 17.2 ± 9.7 g/d, p = 0.016), although the distinction between n-6 and n-3 was not made.
  • Actionable steps to healing
    • DUTCH test (preferred over blood) to measure current status of sex hormones, adrenal function and downstream effects.
    • Avoid any fasted training (fat adaptation is NOT your goal right now)
    • Measure food for a bit only to make sure you’re meeting needs (see EA section).
  • Supplements
    • Work with a medical professional and/or health coach if you plan to supplement, do not start supplementing without being under supervision.
    •  Use as a last resort and work with a health professional before taking any supplements.
    • Acetyl-L-carnitine (ALC) administration positively affects reproductive axis in hypogonadotropic women with functional hypothalamic amenorrhea.
    • Acetyl-l-carnitine as possible drug in the treatment of hypothalamic amenorrhea.
      • ALC helps counteract the stress-induced abnormalities in hypo-LH patients affected by hypothalamic amenorrhea.
      • Major hormonal changes after ALC administration were observed in the hypogonadotropic subjects. They showed a significant increase in baseline plasma LH levels, a significant increase in LH pulse amplitude with no changes in LH pulse frequency, and a significantly increased response of LH to the latter Gonadotropin-releasing hormone bolus during the GnRH test. Hypogonadotropic patients also showed a significant increase in both estradiol and prolactin.
    • Vitex for hormonal balance (even after you regain period).
      • Vitex supports the pituitary gland to produce progesterone and luteinizing hormone– needed for your body to ovulate, for regular menstrual cycles, and for you to avoid symptoms of hormonal imbalance like PMS. Vitex also keeps prolactin secretion in check and improves both estrogen and progesterone levels.
    • Other:
      • Progesterone, using sublingual (not topical) for more optimal absorption rates.
      • Evening primrose oil
      • Fish oil
      • Zinc
      • Rhodiola
      • Damiana
      • Shatavari
  • Also mentioned on this show: