Episode 063: Welcome to another instalment of Real Health Radio. Today I’m joined by Nicola Rinaldi. Nicola has a PhD in computational biology from MIT.
After graduating she worked for a biotechnology company while pursuing her dreams of a family, which were thwarted by a diagnosis of hypothalamic amenorrhea (no periods). Eighteen months of trying to conceive followed.
She spent hours on research, using the knowledge gained to work on recovery. Concurrently, she tried the medical route to pregnancy, with multiple doctor visits, injections, and ultrasounds resulting only in failure. Ultimately, she was able to achieve a natural pregnancy.
Since that time, Nicola has shared her knowledge of the path to recovery, helping hundreds of others achieve their dreams of womanhood and pregnancy. She has spent the last three years as a stay-at-home mom, with her three boys, while writing a comprehensive guide to recovery, a book called “No Period. Now What?”
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Chris Sandel: Welcome to Episode 63 of Real Health Radio. You can find the links that I talk about as part of this episode at the show notes at www.seven-health.com/063.
Welcome to Real Health Radio: Health advice that’s more than just about how you look. Here’s your host, Chris Sandel.
Hey, everyone, and welcome back to another episode of Real Health Radio. I hope you’ve had a good week. On the show today I have a great guest. It’s Nicola Rinaldi.
Nicola had a PhD in Computational Biology from MIT. After graduating, she worked for a biotechnology company while pursuing her dream of a family, which was thwarted by a diagnosis of hypothalamic amenorrhea – which is basically no period and is what we are going to talk about as part of the show and we go into in a lot of detail. She had 18 months of trying to conceive that then followed. She spent hours on research, using the knowledge gained from work on recovery. Concurrently, she tried the medical route to pregnancy, with multiple doctors’ visits, injections, and ultrasounds, resulting only in failure.
Ultimately, she was able to achieve a natural pregnancy. Since that time, Nicola has shared her knowledge of the path to recovery, helping hundreds of others achieve their dreams of womanhood and pregnancy. She’s spent the last 3 years as a stay-at-home mom with her three boys, Anthony, Timmy, and Cameron, while writing a comprehensive guide to recovery, a book called No Period. Now What?
Nicola reached out to me about a month ago, 6 weeks ago. She knew that I worked with women around fertility and around disordered eating, so she sent over her book, No Period. Now What?, for me to check out. At some point I started reading it; I normally have so many books on the go at once, and I definitely didn’t need to be reading another one, but I thought I would check it out, and I’m really glad that I did. The book is just so well-researched. It’s also really easy to read. It explains things in very simple ways so you can understand it. It weaves in narratives and first-person accounts from people who have followed her advice and have worked with her.
Without wanting to put anyone off, it is a long book. Normally when I get a Kindle book, I’ve been reading it maybe for a couple of hours and I look down and maybe 25% is gone or 50% is gone, depending on how short the book is. Well, I remember reading this for quite a while, or what felt like quite a while, and then looking down and noticing I was at 3% or 4%. But as I said, I don’t want you to be put off by this because, as I’ve also mentioned, it is an easy read and it contains an absolute wealth of information.
I then sent Nicola an email and said that I was loving reading the book and that I wanted her to come on the podcast and to discuss it with me and to share it with you guys. This episode is all about female hormones and specifically about hypothalamic amenorrhea. We cover what this term means and what it means for the body. We talk about fertility and pregnancy and the importance of so-called reproductive hormones and why these are important even outside of reproduction for general health, and we also discuss a plan for what to do if someone is suffering with hypothalamic amenorrhea.
One last thing before I jump into the show: I just want to mention that in the show notes, I’m putting some links for how you can get the first chapter of the book for free, as well as a chapter of the book all about PCOS for free. My suggestion is just go out and buy the book, and I’m going to put a link to that in the show notes. But if you are interested in finding out more before making the purchase, then you can check out those two links to get that.
With all of that out of the way, here is my conversation with Nicola.
Hey, Nicola. Welcome to the show.
Nicola Rinaldi: Hi, thank you so much for having me.
Chris Sandel: It’s a pleasure. Today’s show is going to be female hormones, a lot of information on female hormones. You’ve written a fantastic book called No Period. Now What?, which is really well-researched, a ton of great information. I’m really loving it.
But before we get into that, I’d like you to share a little bit about your story. This book came about I think because of issues you were facing and because you wanted to know more, so I’d love you to just start with your story, your background, and how you came to write this book.
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Nicola Rinaldi: Absolutely. I went to MIT for graduate school, and I didn’t really have any issues with eating or exercise before that. I term myself a “band geek” in high school. I played a lot of music, didn’t really play a lot of sports, didn’t really exercise.
Then I got to college and I started getting more interested in exercising. I started weightlifting and a little bit of running and playing tennis, and just doing stuff that I enjoyed with friends and my boyfriend. Then I went to graduate school. I had gotten married not too long beforehand; my husband was away a lot, so I had a lot of free time on my hands, and I took up extra time with my schoolwork and then also with exercising.
I started playing ice hockey and volleyball, and I would ride my bike and lift weights and play squash. It was all stuff that I did because I enjoyed it and I liked feeling strong and healthy. And for a long time, I was.
Then some of the folks in my lab decided to go on a diet, and I was like, “Oh yeah, I need to lose some weight too. I’ve got these love handles.” I was starting to think about getting pregnant and reading everywhere that to have the best chance of getting pregnant, you should lose weight. I didn’t stop to think that that doesn’t necessarily apply in all situations – not to mention the whole weight loss thing is getting out of hand anyway, but that’s a whole other topic of discussion.
So I started limiting my calories to 1500 a day, and I lost weight like it was going out of style. It was ridiculous how much weight I lost.
Chris Sandel: Where had you picked that number from, 1500 calories?
Nicola Rinaldi: That was what the guys in my lab were doing, and I figured if it was a good number for them, it was a good number for me. That’s on the low end of what you read you “should” be eating to lose weight, 1500-1800 calories a day. So I started tracking. I would record every single morsel that went into my mouth, and if I didn’t know the number of calories, I would tend to overestimate rather than underestimate.
I felt pretty good. I thought I looked good. I was very muscular. My body fat percentage went down to about 16%.
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Then I went off the pill to try and get pregnant, and surprise, surprise, I did not get my period. In hindsight, it’s no surprise at all, but at the time I was like, “I’m doing everything right. I’m fit, I’m eating well.” I thought I was being healthy.
Chris Sandel: What age were you at this stage?
Nicola Rinaldi: I was in my late twenties, or it was around 30. So then I went to my doctor and she said, “Oh, it can take up to 3 months to get your period after you go off the pill, so come back and see me in 3 months.”
I did a little bit more reading and started getting some sense that I was not eating enough to support having a period, so I started eating a little bit more. But my thinking had started to get disordered by this point. I was getting addicted to seeing the number on the scale going down and tracking everything, and it was becoming – I didn’t get as far as an eating disorder, but it was definitely disordered eating. I was having a hard time trying to increase my calories.
So I went to see a nutritionist and she gave me some great ideas, like swapping out skim milk for 2%. Now I drink whole milk; it’s so much tastier and so much better for you. And adding oil to what I was eating. I grew up in the ’80s and ’90s, where everything was low fat, low fat, low fat, so oil was anathema to me. I was like, “Oh, I could add it to things? Yeah, that’s a great idea!” [laughs] And eating more nuts. So she gave me some really good ideas to help me.
But it ended up taking me 18 months to recover and eventually get pregnant. During that time I did a lot more research, and I had a blog that I was writing on and getting much more into the infertility community. Then when I did eventually get pregnant, I was on bed rest for a while, so I really started posting on a forum, then, about recovering from hypothalamic amenorrhea, which is the missing period due to undereating, over-exercise and stress.
From there I continued posting for years and years, just sharing my story and all the information I had gleaned during my research – which was quite thorough because I have a PhD, so that’s my wheelhouse.
Chris Sandel: You said you were at MIT. What had you been studying at that stage?
Nicola Rinaldi: My degree is in computational biology. It’s kind of a combination of computer science, biology, and statistics.
Chris Sandel: So research is probably a big part of that already, so you were pretty okay with reading research, understanding research, etc.
Nicola Rinaldi: Yes. There’s some good papers on the topic and there’s some really bad papers on the topic. [laughs] So it’s good to be able to sift through and realize what’s accurate and what might not be so accurate.
Anyway, after I’d been posting on this online forum for a number of years, people kept saying to me, “You know so much, you should write a book.” I was like, “Yeah, I should.” So that’s when I got started working in No Period. Now What? It took me 3-½ years, but it’s finally published and getting really great reviews, so I’m excited to be able to share some of my knowledge with you.
Chris Sandel: Perfect. A lot of the focus of the book is on hypothalamic amenorrhea, which is abbreviated to HA, and we can just call it HA from this point forward to make it easier for both of us.
Nicola Rinaldi: Yes. [laughs]
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Chris Sandel: Most people probably haven’t come across that term before, and that could be even if they are actually experiencing it. I would love for you to explain what it means – and if you need to give people a little bit of a physiology lesson so that they understand it, then, by all means, go ahead.
Nicola Rinaldi: Absolutely. It’s easiest if we just dissect the term. Hypothalamic amenorrhea. The hypothalamus is a part of your brain that’s one of the major control centers. It controls everything from eating to sleep to reproduction. It’s involved in stress. It takes in inputs from your body from other nerve cells, from hormones that are in your bloodstream, small molecules that are in your bloodstream, and then it sends out a whole host of other hormones. It really drives a lot of what goes on in your body. Then amenorrhea is just a missing period, lack of menstrual flow. So the term really means lack of menstrual flow due to your hypothalamus.
There are a number of different ways that you can lose your period. These range from some genetic conditions that make it impossible for a woman to have periods; there are some physical conditions. You can have Asherman’s syndrome, for example, which is scarring in the uterus that can prevent monthly bleeding. PCOS is another big one that can be associated with amenorrhea. That’s also perhaps a topic for a different conversation.
Chris Sandel: It’s something that I wouldn’t mind chatting with you about later on, but we can just stay on this for now.
Nicola Rinaldi: Yes. The drivers behind hypothalamic amenorrhea is that the hypothalamus gets shut down because it’s either receiving inappropriate inputs or not enough inputs from the body. There are a multitude of different hormones that are in play here.
These can be derived mostly from undereating – there’s a hormone called ghrelin, for example, that makes your body feel hungry that is secreted by your hypothalamus. If you’re not feeding yourself when you get hungry, that ghrelin stays high, and that then signals to your hypothalamus and it’s one of the pathways that can shut your hypothalamus down.
If we talk about exercise – over-exercise particularly, but any exercise can actually have an effect – that can increase hormones like cortisol, which is part of the stress response, which is sensed by the hypothalamus and can shut it down.
Then you have psychological stress, obviously, as you just discussed in your recent podcast. That also can increase the other stress hormones, which can shut the hypothalamus down.
What happens when the hypothalamus gets those inputs is that it says “Okay, I don’t have enough energy or there’s too much stress. I need to prioritize what my body is doing and really take care of the important things.” Those important things are things like sending blood around your body and pumping your heart and your lungs. Other things that are not so important are like keeping you warm and your reproductive system. The reproductive system is really something that is not a need-to-have; it’s a nice-to-have. So that’s one of the first things that the hypothalamus can shut down. When it shuts that down, the manifestation is no ovulation and no period.
Hopefully, that’s a good start.
Chris Sandel: It is. I’ve previously done a podcast called “Issues with Your Menstrual Cycle” that covers some of this stuff or a lot of this stuff, so for anyone who wants to give that a listen, you can find it at www.seven-health.com/025. I’ll also put it in the show notes to this show. It goes through lots of lifestyle and dietary factors that could predispose someone to be having problems with their period.
I know that you’ve had a listen to that podcast, and when we were originally emailing with each other, you said you think we disagree slightly on the importance placed on each of these factors. Your email was incredibly complimentary and went on to say very nice stuff, but I would just love to hear your opinion on what you think are the most important factors that start to shut this down ad what are the things that aren’t maybe so important.
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Nicola Rinaldi: I think when I listened to your podcast, it sounded like you were focusing very much on stress and thinking of undereating and exercise in terms of how that’s a stress on the body.
Where I see that slightly differently is that from my research, the main cause is undereating and the hormonal effects of that. But of course, it’s absolutely not incorrect to think of that as a form of stress on the body. There are so many hormones that come into play in terms of what we eat, how much eat we, when we eat, that I think the way that those impinge on the hypothalamus can shut it down without any exercise or psychological “stress.”
Chris Sandel: Have you come across people with HA who haven’t had disordered eating or issues around food where food was restricted at all, where the other components were enough to really drive that? Or it just doesn’t seem to happen so much from your side of things?
Nicola Rinaldi: I absolutely have seen people like that – although I would say a very large majority are undereating or restricting different food groups. For example, low carb, that can really play havoc on the reproductive system. But there definitely are people who do eat enough, but their psychological stress and/or exercise is enough to completely shut things down.
I think of it like you have multiple inputs to the hypothalamus and you can either shut one down completely – like if you’re doing 4-5 hours of exercise a day, but you’re eating enough to support that, that alone can be enough to shut down the hypothalamus. If you experience extreme stress – death of a very close family member, for example – that can be enough to shut down the menstrual cycles. If you’re undereating significantly, as women with anorexia do, that alone can be enough.
But then less extreme combinations of any of those factors can work together to shut down the hypothalamus. There are women who exercise 3 days a week for half an hour at a time, but they undereat fairly significantly, so they don’t get a period. There are women who exercise moderately, undereat moderately, and have a fair bit of stress in their daily life, and that can be enough to shut it down.
So it’s really unique to each person exactly what the combination is, but those three themes tend to be involved in the shutdown of menstrual cycles for most women.
Chris Sandel: How much do you think is dependent on hereditary factors as well, where someone is just a lot more predisposed to that stuff versus someone being more robust? Or that doesn’t come into it so much?
Nicola Rinaldi: That definitely does play a part. But genetic testing is not that common yet, so we can’t go and get this genetic test and say “I’m predisposed.” In the end it really doesn’t matter. You just have to do what your body needs to recover your cycles.
Chris Sandel: One of the things you talk about in the book is just how hard it is to get a diagnosis for HA and how often it takes quite a long time, or people don’t ever even get that diagnosis despite that being the thing that’s going on, and quite often it being misdiagnosed as PCOS – which most people have obviously heard about, but most people haven’t heard of HA. Do you want to speak to why it is often misdiagnosed and people are just told “we don’t really know what’s going on,” or why it’s misdiagnosed as PCOS?
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Nicola Rinaldi: Yes, I would love to. There are a couple of things at play here. First is that many people think that in order to lose your period, you have to be an Olympic level athlete or extremely, extremely thin. They don’t realize that there is this interplay between the factors that can cause missing periods in women who are not at those extremes.
So a lot of doctors will see women and say, “You’re not thin enough to lose your period.” That’s just not right. There are women who lose their periods at all different levels of weight and all different levels of body size, and it has more to do with what we’ve talked about: the under-fueling, the over-exercise, the stress. It’s not about how big your body is. There was actually a study I saw where women with a BMI of about 45 had bariatric surgery, and many of them lost their periods. So it’s not about being super skinny.
And same thing with the exercise. You can see a woman who’s exercising an hour a day and the doctors will say, “That’s not enough to lose your period.” But in combination with undereating and stress, it absolutely is. So I think there’s this real misunderstanding in the medical field about what causes missing periods. It’s interesting that that seems to be much more the case outside the U.S., although it definitely does happen here. But I’ve spoken to a number of women who are in the UK, for example, who’ve just been told “We don’t know what’s going on,” and their doctors don’t really seem to understand the basis of HA and what this is all about.
Then as far as PCOS goes, one common factor with women with HA is having a lot of follicles in their ovaries when an ultrasound is performed. That is one of the hallmarks of PCOS. Doctors will look at that and see that they’re not getting a period and say “You must have PCOS.” The problem with this is that the lifestyle changes to address PCOS and HA are essentially opposite. There have been studies that have shown that with PCOS, it can be helpful to exercise more and eat a little bit less, and that can help ameliorate some of the symptoms. But if you do that and you have HA, you’re just going to make things worse. So it’s really, really important to get the right diagnosis.
For a woman who is on the smaller side and undereating/over-exercising, I would never, ever diagnose PCOS in the absence of hormonal bloodwork that shows elevated androgens – that’s testosterone or androstenedione or DHEA-S – or physical symptoms of PCOS like excess hairiness. And that’s not just one or two extra hairs on your chin or your breasts or whatever. It’s a lot of extra hair. Acne, not just on your face, but on other body parts that normal treatments don’t work for.
Insulin resistance, that’s something that is very closely associated with PCOS, and it’s hardly ever an issue in a woman with HA. So if somebody’s told “You might have PCOS,” doing a glucose tolerance test, for example, might be helpful. As I said, I would never diagnose PCOS in the absence of any irregularities on some of the bloodwork or the insulin resistance.
Chris Sandel: I think that is one of the bits of the book that I really liked, and you go into a lot of detail around that – and I find that PCOS is very common as a diagnosis when things aren’t going well from a cycle perspective. As you describe, and I’ve looked into this before, having follicles on the ovary isn’t actually that uncommon, and especially if someone’s not getting their cycle. So just that alone shouldn’t be the thing that makes the PCOS diagnosis.
Nicola Rinaldi: Yes, absolutely.
Chris Sandel: One thing I just want to ask about with this – while the book isn’t so much about PCOS, this is something you touch on, and you just talked about it there in terms of weight loss can possibly help, or restricting can possibly help.
I know that for a lot of the communities that I live in, and maybe that you live in, in terms of the whole anti-diet approach, it seems like anything to do with suggesting weight loss is heresy. I also know that hearing other interviews with you, you can be quite anti-diet and the problems that they can cause. So I just wanted to find out from you about how was it writing these suggestions about weight loss, and have you had any backlash from people at odds with these ideas?
Nicola Rinaldi: I am very clear in the book that I’m not an expert on PCOS, so when I said that, that’s what’s out there in the literature. I haven’t even really looked that closely, so it’s not something that I personally would recommend. But that’s “what you are told to do.” A lot of doctors, when they diagnose women with PCOS, will say “lose weight and exercise more.” I have not looked into whether that actually is an effective treatment for PCOS, so please don’t anybody take my word. I’m simply repeating what I have read generally. I haven’t even looked into the research papers on that.
Chris Sandel: One of the other things that I really like in the book which you talk about, and something I’ve been talking about for a long time, is that a woman’s cycle is not just about reproduction. These hormones as part of that cycle have lots of beneficial health functions within the body, and when a cycle is not happening, there can be lots of negatives to health, especially over the long term. Is this something you can talk a little about?
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Nicola Rinaldi: Absolutely. It’s one of the reasons that I encourage women of any age to work on recovering cycles. Obviously you can’t do so after menopause, but if you’re missing a cycle because you might be undereating or over-exercising, there are so many health benefits to that monthly increase in estrogen.
In a normal menstrual cycle, your estrogen is fairly low at the beginning of the cycle, but as you get close to ovulation, it increases by ten- to twentyfold in the middle of the cycle, and that is what we really get the benefit from. These benefits have been illustrated in studies of women who have gone through menopause and those who’ve had surgical menopause, which is when you have to have a hysterectomy or ovariectomy for medical reasons.
The number one problem that most people do know about is brittle bones. That can be both a short-term and a long-term problem. In the long-term, obviously, osteoporosis can really wreak havoc on somebody’s life because it means that you can fracture your bones from just daily activities. You don’t even need to fall; you can just step off the curb in the wrong way and something can break. So that’s obviously something that you would want to avoid.
But even in the more near term, stress fractures seem to be fairly strongly associated with lower bone density. That’s something that can prevent you from exercising for a long time, or should because if you try and come back from a stress fracture too soon, you can just do more damage.
A lot of doctors will say, “Oh, you’re not getting a period? That’s fine, we’ll just put you on birth control.” The more I read about it, the more horrifying that is to me because there’s more and more evidence that birth control pills do not allow you to build bone density as you’re supposed to in your teens and your twenties and your thirties. It can maintain you where you’re at, but that’s not what you need for the long term. So I really hate throwing that Band-Aid at people. It’s much, much better to work on recovering your natural cycles.
Then there are other effects that have been demonstrated in those studies that I talked about where women have surgical menopause, and that is there can be cardiac effects, so a higher risk of cardiovascular disease. There have been other studies that show in women who have HA, essentially, that there are negative changes to the heart and the blood flow that can eventually lead to cardiovascular disease. That one I’m fairly confident in.
Then the last major effect is that there are some suggestions that not having that monthly exposure to estrogen can lead to worse neurological outcomes, so earlier onset of neurodegeneration like Parkinson’s or dementia. Obviously that’s something else that we’d like to avoid for as long as possible.
I just think that pushing past this idea that you have to be thin and super muscular in order to be healthy or to be attractive – it’s just not right. The health aspects are clear. I think you’re much healthier if you’re menstruating, and if that means an extra 20 pounds, as it did for me, that’s good. That’s what your body needs.
The appearance aspect – I think our society has really pushed this idea that thin is attractive and anything that’s not thin isn’t. But when you look around at the people who are actually around you, we don’t look like the models in newspapers or anything like that. It’s really become a passion of mine, along with many other people, to push back against those ideas, especially the negative health consequences.
Chris Sandel: Totally. I think what is thought of as appropriate and thin is just getting thinner and thinner, and the ideals that people are having to live up to are getting more and more difficult, so that fewer and fewer people can actually live at that level, and fewer and fewer people who can live at that level will actually be healthy. I think that’s a whole massive issue that is in a lot of ways at the root of why this is going on, because people are over-exercising or they are undereating or doing a combination of both that makes this much more likely that it’s going to be outcome.
Nicola Rinaldi: Yes.
Chris Sandel: With some of the comments you made there in terms of long-term health and why it’s important to get a regular cycle – and it’s one of the things I did notice when reading through the book; a lot of the focus is on the importance of estrogen. From a lot of the reading I’ve done previously, it’s also looking at the importance of progesterone. I know people like Dr. John Lee focus a lot on the benefits of progesterone and why that can be so important for a woman’s monthly cycle. Is that something you’ve read in research as well?
Nicola Rinaldi: Yes, absolutely. I tend to talk about estrogen because in a way, the estrogen drives the progesterone. When I spoke earlier about your monthly cycle and how in the middle, the estrogen really bumps up by ten- to twentyfold, what comes after that is you ovulate, and then your progesterone increases significantly. So yes, it’s absolutely not just estrogen. It’s progesterone as well. But when you’re having a normal cycle, the two go hand-in-hand.
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But there is an interesting phenomenon that I myself have experienced even after I’ve been cycling normally, and that is that exercise, undereating, and stress don’t have to shut your cycles all the way down. They can just have not-so-severe effects, one of which is called a luteal phase defect.
The luteal phase is the time in your cycle between when you ovulate and when you get your period, and that’s when the progesterone has increased. For me personally, I’ve been tracking my cycles for years now, and I’ve definitely noticed a correlation between increasing exercise and a much shorter luteal phase. I recently started going to the gym because I hadn’t lifted weights for quite a long time and I was feeling weak, so I was like “I’m going to start going to the gym and try to get a little bit stronger.”
My cycle that month was 21 days. So I went from having a perfectly normal cycle to having it shortened by a week, just from lifting weights 3 days a week. It’s remarkable how sensitive my body is, and I think the same is true for many other women.
Then there was another case where I experienced a lot of stress because my two-year-old had broken his leg, and even after he got the cast off, he wasn’t walking. I had two older children and essentially a newborn in a two-year-old body, and it was incredibly stressful. And again, I experienced this much, much shorter luteal phase.
So it really goes to show that even if you are “cycling normally,” you still have to be a little bit careful about what you’re doing in terms of exercise and stress. I do advocate for people to track their cycles just to keep a handle on that and make sure that they are doing things that will be long-term healthy.
Chris Sandel: Do you find that people who’ve previously had HA, after they get over it, there is a tendency to just be a little more sensitive when they’re doing exercise or with psychological stress? Or people can get back to being super robust where they just aren’t affected with that kind of stuff?
Nicola Rinaldi: It really seems to be very, very individual. I just described my issues, but I know a couple of women who’ve recovered from HA and are running marathons while continuing to cycle normally. My co-author Stephanie got pregnant two weeks before she ran a marathon. So it’s very, very individual. I think that’s why it’s important for women to track their own cycles and know what their own triggers are.
Chris Sandel: Yeah. If I’m thinking out loud here, there’s probably genetic factors or hereditary factors that are like that, or depending on how much someone had to put their body through before HA showed up. For someone, it’s doing a little thing or a couple of things, and then within 3 or 4 months it’s gone; for others, they’ve really had to push the boundaries for 2 or 3 years before that started to happen. So when they get over it, they’re back to being a little bit more robust.
Nicola Rinaldi: Yeah.
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Chris Sandel: As part of the book, you then outline a bit of a recovery plan as part of this, and there’s tons of research backing this up, and there’s a lot of detail in terms of your explanation around all this stuff. But for those who are listening now, can you give a bit of a CliffsNotes version of that stuff, like what people should be doing? I know we’ve maybe touched on some of this stuff already, but just summarizing it in this one place.
Nicola Rinaldi: The recovery plan really is pretty simple. We encourage women to eat more. We give a calorie target of 2500 calories a day, but I really don’t like people to focus on calories because that can just continue to perpetuate the mindset of tracking and being meticulous about everything, and that’s really not the end goal. But sometimes if somebody has been tracking for a long time, it can be helpful for them to have a target to start with. But I just encourage people to aim for that target and work as much as you can to get away from really focusing on those numbers.
The other aspect of eating more is to include all different food groups in what you’re eating. As we spoke about earlier, there are these nutritional trends. When I was growing up it was low fat. These days it’s low sugar, low carb. But the thing is that every nutrient, every macronutrient, has properties that help to keep the hypothalamus going.
There are hormones that are secreted when we eat by our stomach and the large intestines and small intestines that signify that we have eaten, so that’s one input that the hypothalamus gets. Then there are also individual hormones that respond to protein or fat or simple carbohydrates, and those also can either shut down or turn on the hypothalamus.
There was an interesting study that I saw long ago on people with uncontrolled Type I diabetes that had very low insulin chronically, and many of those women – or in the animal studies that went along with it – were not cycling. That’s just because of low insulin. So for people to say you need to eat low carb because you don’t want glucose and insulin around – our bodies need those hormones. Glucose is fuel for so much of what we do.
So I really encourage people to eat some of everything. If there’s somebody that’s close to you who is a “normal eater,” as much as anyone can be, look at what they’re eating and eat with them instead of preparing your own meals. I think that can be really huge not only for your personal food intake but also for maintaining relationships. If you’re cooking yourself separate meals all the time, that can be very isolating. So that’s the food side.
00:40:55
Then on the exercise side, I encourage people to cut out high-intensity exercise. That is running, high-intensity cycling, ellipticals, spin classes, high-intensity training, all that kind of stuff, because there’s absolutely a correlation between that high-intensity exercise and cortisol and other stress response hormones. As we’ve discussed, those shut down the hypothalamus.
Lower intensity exercise like walking or gentle yoga – I’m not talking hot yoga, just something gentle, three or four times a week, half an hour at a time, something like that – those types of exercise seem to be fine. So those are the exercise recommendations.
Then as far as stress goes, that’s something that’s also super individualized. But if you’re somebody who’s anxious or gets stressed easily, I encourage you to go and see a therapist or look at meditations or other ways of calming your mind and your body. Taking up new hobbies to keep yourself occupied, especially if you’re somebody who exercised a lot, having something else to fill that time so you’re not just sitting around twiddling your thumbs can be really, really helpful.
Purging your social media feed can also help a lot. [laughs] Those are the main recommendations of the recovery plan. As I said, it’s pretty simple. Eat more, exercise less, try and “relax.” But so very hard to put into practice because of everything that we’ve been told is healthy over the years, and when you’re trying to recover, it feels like you’re doing the opposite of what you should be and what you’ve been told for such a long time. So it’s really hard to do.
Chris Sandel: It is so easy for someone to understand what you’re saying intellectually; very difficult to then put it into place when they’re thinking, “but I’m now having to not exercise,” or “I’m eating these different foods,” or “I’m eating these foods that I used to fear,” or “I’m having to put on weight as part of this process.”
00:43:20
Nicola Rinaldi: That’s why we included a lot of supportive chapters in the book in terms of we have stories from hundreds of other women who have gone through this, as well as chapters where we talk about some ideas to help with getting over the mental aspect of recovering.
Chris Sandel: I would love for you to share some of the mental stuff. I know you mentioned just there meditation and taking up new hobbies, but if there’s any other ones that really stand out that are really helpful for people, tell us those ideas.
Nicola Rinaldi: Absolutely. A huge one is getting rid of the scale. Weighing yourself can be so hard when you see the numbers on the scale going up when you’re used to having a fixed number in your mind. So we encourage women to – if you can’t just get rid of it cold turkey, you can decide “I’m only going to weigh once a week” or ask a partner or a friend to take the scale away. Or I’ve seen a couple of videos on YouTube of people smashing the scale, and that actually looks really empowering, and I think it would be really fun to do. [laughs]
In terms of clothing, that can be a huge one. If you’re trying to squeeze yourself into clothes that are too small for you every day, that’s such a huge reminder of the changes in your body. I’ve gone to wearing yoga pants full-time because they’re so comfortable. I put on jeans these days and I’m like, why did I ever like these things? They’re just so constraining. [laughs] Not having that tight waistband on you throughout the day can make a huge difference to how you feel mentally about the changes in your body.
We love the idea of affirmations, so finding positive statements on the internet. If you google “affirmations,” or if there’s something that’s bugging you on a particular day, just google “positive thinking,” and there’s so many great little statements that come up that you can print out and stick in your pocket or on your mirror or any place. When you find yourself feeling uncomfortable and feeling like “I’m not doing the right thing” or “what am I doing?”, if you focus on what those trigger points are, then you can have a little printed-out affirmation that you can pull out and look at. It just gives you a calm feeling and like you’re doing the right thing for your body and your health.
Chris Sandel: One comment I just want to make with that is I am often put off by a lot of books around this topic about reproduction and women’s health. I know I’m not the target audience for reading those books, but so much of it is often talking about chakras, or it just feels really New Age-y. I didn’t get that feeling with this book at all. It’s so well-researched, very empathetic, and really speaks to people at the level they’re at, but without going in that direction. So I really want to thank you for providing that kind of a resource where I was able to enjoy reading it and making it through without all of that other stuff.
Nicola Rinaldi: Oh, I’m really glad to hear that. [laughs] Yeah, I’m not a New Age-y type person. I’m a scientist, so what speaks to me is facts and figures and information, so that’s how I wrote the book. I’ve had many women talk to me about how helpful it’s been for them to understand what’s been going on and why they need to make these changes rather than just being told “you need to eat more.” Well, why do I need to eat more? I work very hard to try and explain that for people.
Chris Sandel: Definitely. Just going back to one of the things you said in terms of people wearing clothes that actually fit them and aren’t tight, sometimes when I’m working with clients around this stuff, there’s that resistance around “if I’m getting new clothes, it means that I’ve somehow failed or I’ve somehow let myself go.”
The other one that I commonly get is “but what if I buy these new clothes and then, later on, I lose the weight?” I’m like, if you buy new clothes and you fit into them and later on you lose the weight, the fact that you have some slightly big clothes is going to be the least of your worries. You are not going to be lamenting that. You’re going to be like, “wow, I’m back into my smaller clothes.”
I honestly think people should wear stuff that makes them comfortable during the day, and it makes a massive difference. I’ve seen this happen so often, when people go and get some new things that actually fit them, how much better they feel within themselves, and then how much better they talk to themselves, how much more likely they are to show themselves compassion and to actually eat well, support themselves, go to sleep properly – it has this real knock-on effect, even though it feels like it should be something very innocuous.
Nicola Rinaldi: Yep. And for women who are trying to get pregnant, I encourage them to think of them as first trimester clothes, because in the first trimester you’re getting bigger, but not really big enough to wear pregnancy clothes. So it can be a nice reminder of your goal, too, if you’re trying to recover your periods to get pregnant. “This is what I’m going to fit into when I’m pregnant.”
Chris Sandel: I guess that then brings us on to something I wanted to chat with you about. Obviously getting the cycle back for a lot of people is the start of it, but for a lot, or maybe even most, it’s to actually get pregnant and for pregnancy and to have children. This is something that you cover a bit in the book, but what are people’s outcomes like in terms of pregnancy if they’ve had HA, and how does this all play out in terms of recovery?
00:49:30
Nicola Rinaldi: The pregnancy outcomes are actually quite astonishing. Among the women that I have helped recover from HA, every single one of them has gotten pregnant over the longer term. It’s not always immediately. A lot of women do get pregnant on their first few ovulations; for some, it does take longer. But every single woman that I have worked with who has desired pregnancy has eventually gotten pregnant.
It’s about 50% who recover natural cycles prior to pregnancy, and part of that is wrapped up in once you decide you want to be pregnant, you kind of want to be pregnant right now. So there’s this lack of willingness to wait – which is perfectly understandable. I talk about the various treatments that one can use to get pregnant in terms of oral medications or injectables or in vitro fertilization, and I offer a lot of recommendations around those areas that many doctors are not necessarily aware of because they don’t treat a lot of patients with HA.
Let’s see, where was I going with that? I’m sorry, I lost my train of thought. [laughs]
Chris Sandel: That’s cool. It was just in regards to the outcomes in terms of HA with pregnancy, if that jogs your memory at all.
Nicola Rinaldi: Yeah, so it’s not necessarily a one-size-fits-all kind of “you do this and you will get pregnant,” but there are a lot of different options to help women with getting pregnant.
What’s really interesting is that for those women who don’t recover natural cycles prior to pregnancy, about 85% of them have recovered cycles after pregnancy and were able to go on and get pregnant a second time naturally. And of those who didn’t recover between pregnancies, when they had a little more time after their final pregnancy, almost all of them recovered natural cycles. There are very few women that haven’t been able to recover a natural cycle at some point in time.
I think that pregnancy helps reset the hormones because there are such huge hormonal changes that happen during pregnancy that when everything settles back down afterwards, you’ve reset to a baseline. So if you’ve had HA and you get pregnant, after pregnancy, as long as you make sure that you are not dropping to too low a weight, certainly not trying to lose weight, it often just happens naturally. If you don’t exercise too much, you take rest days, you have a very, very high likelihood of recovering your cycles.
Chris Sandel: That’s quite interesting because I often hear women talking about the fact that getting pregnant the first time was really easy; second time was either much more difficult to conceive or it was just a much more difficult time because basically they just never recovered after having that first child. So it’s interesting you’re saying that from a cycles perspective, with HA it seems to get better after a pregnancy.
Nicola Rinaldi: Yeah. There are some women who did not have HA prior to their first pregnancy, and then after their pregnancy, they decided they needed to lose all the baby weight and they started getting into exercise and they gave themselves HA at that point. And obviously there is secondary infertility that is completely not related to HA, but that’s a different ball of wax.
00:53:20
Chris Sandel: One of the other things that you talk about as part of the book, which I really want people to start to understand around this, is proper recovery versus pseudo recovery because I think it is really important and it is something I chat about with clients. I’ll let you explain it and then I’ll give my input on this.
Nicola Rinaldi: Sure. I think of full recovery as getting to a body size that your body is happy at and letting go of the idea that you need to control what you eat and letting go of the compulsions to exercise. For some people that can seem like a unicorn, but it does happen. That’s what I consider full recovery. It’s not just about recovering your menstrual cycles, but also recovering mentally and getting to a place where you can just eat and exercise because you like moving your body, not because you have to.
Then pseudo recovery is when women say “I’m not going to get past this weight” and they have this idea in their mind that “this weight is okay and going beyond that is not okay.” So they’ll gain up to that, but with that mindset, there’s no freedom from the restriction because you still have to watch what you’re eating and probably continue to exercise because you feel you need to, to maintain that body size, as opposed to because you enjoy it.
So there’s still this long-term focus on diet and exercise that consumes so much mental energy. It’s not a great way to live. It doesn’t allow you to fully enjoy your family and your friends because instead of just feeding yourself and your kids, you’re worried about “Have I eaten too much? Oh, I can’t eat this, I can’t have my child’s birthday cake because I might get fat” or what have you.
That’s one of the things we see with women who don’t really work on recovery and get pregnant through injectables, which doctors often throw out as this panacea because they haven’t gone through that mental work to recover fully, so they end up in the same place they started. I have a Facebook group; I love to see women posting in there about how free they feel when they’re not counting their calories anymore or when they’re not having to get up at 5 a.m. every day to go and exercise. It’s about having a life that’s not focused on your body size and what you’re eating and what your exercise is.
Chris Sandel: This is the thing, when I’m chatting with clients, especially with clients who are wanting to get their cycle back, who have been in that disordered eating/over-exercising place – there’s almost this “I will do the bare bones minimum just to get my cycle back. I want to keep the clean eating up. Okay, I’ll eat a little bit more, but it’s still very much within this narrow band.”
It just genuinely doesn’t work, because you’re not dealing with a lot of the psychological stressors driving it. You’re typically not getting up in terms of the calories for what you need. I may be able to convince them to stop the exercise, and that’s normally one that we can get fairly good on, but the food often seems to be more difficult. What I always find is we go around this topic for a while, and for some people, it takes them a month, for some people it takes them 3 or 4 months. But at some point, they’re like, “Okay, I get it. I’m going to do what you say. I’m going to go full-in on this.” But I really don’t think it repairs until people do really go for it and get out of that mindset of “I will do the bare-bones minimum.”
Nicola Rinaldi: Yeah, I completely agree. And it’s different for everyone when they can get there. Some people can, as you say, just turn the switch immediately and be like, “Oh, okay, I get it,” and immediately make changes. For others, they have to see, “I’ve done this and it’s not working, and I’ve gone a little further and done this and it’s not working.” Then it’s like, “Screw it, I’m just going to go all-in.” That’s one of my favorite terms, going all-in. It’s when you really have made that decision to let go and just trust your body.
Chris Sandel: I can’t do that for anyone, so often I see my role as I’m trying to convince you or explain why I think this is useful. I will try it from all different angles, and at some point hopefully, you get on board with it. But whether that takes a month or whether that takes 5 months, that’s not down to me.
Nicola Rinaldi: Yep.
Chris Sandel: One of the things you talk about a lot in the book, and you have interviews from people from, is “the board.” I assume that was an old message board. Is that still around? Has it now moved over to Facebook? That was just one of the bits that always interested me as part of it.
Nicola Rinaldi: That board is still active. It’s at https://fertilethoughts.com. If you google “fertile thoughts hypothalamic amenorrhea,” you’ll find it. That’s where I got my start. I haven’t been posting on there much recently at all because it is quite time-consuming, because the way that it works is everybody responds to everybody. It can take a lot of time. [laughs] But it’s so helpful when you’re actually in it to have that ongoing support, really great support from a lot of other women.
Then I do also have a Facebook group that people can find if they just search “No Period Now What.” The Facebook group is also great because you can ask pointed questions and get responses from other women who’ve been through it. But I think the Fertile Thoughts forum does have more – there’s a little bit more hand-holding that goes on because people get to know each other much better, and they’ll ask after you if you’re not posting for a few days and that kind of thing.
Chris Sandel: That sounds really supportive. I’m always slightly wary with message boards in terms of the quality of information that people get back and is it going to be helpful, is it just breaking down into diet talk and all of that. But I got the impression that it is a really good place for people to be hanging out and finding out about this information.
Nicola Rinaldi: Yeah, there’s a board moderator who’s actually one of the women that I helped recover, and she actually helped edit the books. Whenever I go on there and she’s giving advice to people, I’m like, “yeah, exactly what she said.” So I think it helps having a moderator because you’re getting information from a solid source as opposed to just random people on the internet who may or may not know what they’re talking about.
Chris Sandel: Definitely. That’s always the thing that I’m worried about. Sometimes it’s the bad information, but it’s also people making triggering comments or giving people advice that is the total opposite of what they should be doing.
Nicola Rinaldi: Yes.
Chris Sandel: We’re coming up on an hour and I need to wrap this up, but before we go, where can people go to connect with you or find out more information? I’m going to put all of the links in the show notes, but please tell people where to go, where they can get the book – and if you’ve got anything else to promote as well, feel free to do so.
Nicola Rinaldi: My website is www.noperiodnowwhat.com. I have a blog section on there, I have links to where you can purchase the book. The book is also available on Amazon. The eBook is only available on my website, though, because the Amazon prices are ridiculous. Yeah, that’s about it. There’s my website, there’s my Facebook group, there’s the Fertile Thoughts forum, and that’s about it.
Chris Sandel: Perfect. Thank you so much for coming on the show. I can’t recommend your book highly enough; I think it’s a really wonderful resource, and it’s been great chatting with you today.
Nicola Rinaldi: I’ve really enjoyed our conversation. Thank you so much.
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