I am excited to connect with Dr. Nicola Sykes today.
Dr. Sykes received her Ph.D. in Computational Biology from MIT. After experiencing hypothalamic amenorrhea and discovering a shortage of information about the condition in the public domain, she wrote a comprehensive guide to help people understand it and recover.
In our discussion today, we dive into the nature of hypothalamic amenorrhea and explore its physiology. We address the effects of amenorrhea on eating habits, discuss caloric restrictions, fasting, exercise, and chronic stress, clarify the distinctions between eating disorders and disordered eating, and examine the role of genetics.
Dr. Sykes also explains why she does not believe in post-pill amenorrhea, and our conversation touches on differentiators with polycystic ovarian syndrome, symptoms, and lab evaluations.
Given the frequent concerns from listeners about losing their menstrual cycles, this conversation with Dr. Sykes promises to be particularly valuable for those affected by prolonged fasting and similar issues.
IN THIS EPISODE YOU WILL LEARN:
Dr. Sykes explains what hypothalamic amenorrhea is and why it is essential for women to understand it
How a lack of exercise and energy deficits can impact menstruation
Why we must support our bodies with exercise and proper nutrition rather than focusing on weight loss
How stress impacts the body, particularly during perimenopause and menopause
Why rest and recovery are essential when doing high-intensity workouts
How we need to eat enjoyable foods and focus on moderation instead of striving for an ideal standard
How disordered eating differs from eating disorders
The difference between hypothalamic amenorrhea and PCOS
Some common symptoms of hormone imbalance
The benefits of tracking menstrual and ovulation cycles
Bio:
Dr Sykes (formerly Rinaldi) has a PhD in computational biology from MIT. After experiencing hypothalamic amenorrhea herself and finding a lack of information about the condition in the public sphere, she set out to write a comprehensive guide to understanding the condition and how to recover. Her book, "No Period. Now What?" has helped thousands of people recover from missing periods and better understand their bodies and hormonal systems. The book has been translated into multiple languages and serves as a guide for numerous dietitians and medical professionals helping those experiencing missing periods.
“You cannot expect to be the same size in your late 30s as you were in your teens because your physiology is different.”
-Dr. Nicola Sykes
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Connect with Dr. Nicola Sykes
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Buy ebook: No Period. Now what?
Schedule a one-on-one session with Dr. Sykes
Transcript:
Cynthia Thurlow: [00:00:02] Welcome to Everyday Wellness podcast. I'm your host Nurse Practitioner Cynthia Thurlow. This podcast is designed to educate, empower, and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives.
[00:00:29] Today, I had the honor of connecting with Dr. Sykes. She has a PhD in computational biology from MIT, and after experiencing hypothalamic amenorrhea herself and finding a lack of information about the condition in the public sphere, she set out to write a comprehensive guide to understanding the condition and how to recover. Today, we spoke at length about what is hypothalamic amenorrhea the physiology, and why it is so important. The impact on our eating habits, caloric food restriction and fasting, as well as exercise and chronic stress, the differentiators between eating disorders versus disordered eating, the impact of genetics, why she does not believe in the existence of post-pill amenorrhea, differentiators with polycystic ovarian syndrome, symptoms and labs.
[00:01:23] I know you will find this conversation invaluable, largely because so many of my listeners have reached out with concerns over losing their menstrual cycle at certain periods during their lifetime. People that have been over fasting for a long period of time and have lost their menstrual cycles. I know you will find this conversation truly invaluable.
[00:01:45] Welcome, Dr. Sykes. It's so nice to connect with you. I've been admirer of your work, and I know that your area of expertise will definitely be of interest to many women in my community.
Dr. Nicola Sykes: [00:01:56] Thank you so much for having me. I really appreciate you having me on and inviting me to chat with all the people that you work with.
Cynthia Thurlow: [00:02:02] Yeah. So, let's help define some of these terms that are a huge focus and component in the work that you do. What is this hypothalamic amenorrhea? That's a big mouthful.
Dr. Nicola Sykes: [00:02:16] Yeah. It is.
Cynthia Thurlow: [00:02:17] And why is it so important for women? Now, obviously, my community are women north of 35, so perimenopause and menopause.
Dr. Nicola Sykes: [00:02:24] Yes.
Cynthia Thurlow: [00:02:25] But this is something that I see even in this community, women that are still menstruating or have gone through periods of no longer menstruating before they get to menopause. Why is our menstrual cycle a vital sign?
Dr. Nicola Sykes: [00:02:37] So, two components to that question. So, I'll start with just what is hypothalamic amenorrhea. So, basically amenorrhea is a period that's missing the technical definition is for three or more months. And the hypothalamus is a little part of your brain. It's a control center, so it takes inputs from all over your body, including hormonal inputs, small molecule inputs, neuronal inputs, and then it sends out signals. So, it controls your pituitary gland, it controls your thyroid, it controls your adrenal glands. So, it's like basically a master regulator. So, it's like synthesizing all this information and then sending out information. It controls your reproductive system through your pituitary gland, because your pituitary gland makes a hormone called follicle stimulating hormone, FSH, which increases a little bit at the beginning of each menstrual cycle to cause the eggs inside your ovary to grow, mature, and eventually ovulate.
[00:03:32] So hypothalamic amenorrhea is amenorrhea, basically, because your hypothalamus is sensing a negative environment, and so it's shutting down your menstrual system, as well as other things. So, there's a lot of components, usually that suppression comes from under fueling in the most part. Sometimes there's a component of over exercise. Sometimes there's a component of stress. But I really do find that the biggest culprit for this form of amenorrhea is under fueling.
[00:04:00] So, in terms of why it's important to have your period, the bleed itself is not that important. It's actually the hormonal changes that happen throughout the cycle, particularly around and after ovulation. So just before ovulation, there's an enormous spike in estradiol, estrogen. Estrogen is fabulous for our bodies. So, it's helpful for bone density, it's helpful for heart health, it's likely helpful for our brains, so that's all a big plus. So, you get this big spike that actually leads to a surge of luteinizing hormone from your pituitary again, that causes ovulation. And then after ovulation, progesterone increases and estrogen increases to maintain your uterine lining in your body's hopes of being pregnant. So that two weeks between when you ovulate and when you get your period, both progesterone and estrogen are on the higher side. And so that's a time, again for good bone density building. It's good for your heart health. There was actually a study that found that women were more likely to have a heart attack in the first half of their cycle than the second half of their cycle. So, there's lots of evidence that points to estrogen and progesterone as being quite important hormones for us.
[00:05:08] So, the bleed itself, it's just shedding your uterine lining doesn't really matter, but it's the ovulation that's important. And so that's why, if you're missing your period, it's good to investigate and figure out why and what's going on. And is it something that you could recover? Is it something like premature ovarian insufficiency or something else that's going on, and then the path is different depending on what the underlying cause of the missing period is. Yeah. I think that answered your questions. [laughs]
Cynthia Thurlow: [00:05:38] No, no. That was done so eloquently and beautifully. And I think it's important for women to understand these complexities to be able to appreciate why suppression of our menstrual cycle is not a benign thing. Certainly, my generation, many of us were started on oral contraceptives as teenagers because we had irregular cycles, heavy cycles. And for anyone that's listening, if you are on the pill, there's no judgment. I certainly was on the pill for a long period of time. But what I've come to find is that the more I now understand, the more I actually will say, let's make sure we've explored all of the available options. If you need good quality contraception, a woman's right to choose for her body is very important.
[00:06:23] And so you touched on some possible reasons why we can have these skipped cycles. And you mentioned the eating habits, caloric and food restriction. And I would loop into their intermittent fasting.
Dr. Nicola Sykes: [00:06:37] Oh, absolutely.
Cynthia Thurlow: [00:06:37] And this is why I think many women need to be careful and conscientious about how they are choosing to nourish their bodies and always lay the caution on women, in particular, under the age of 35. It's not to suggest if someone is insulin resistant or has PCOS as an example. There might be a degree of utility for this type of strategy. But what I typically will find is we are in a rampant diet culture. Many women have been influenced just not only by social media now, but maybe by family, friends, to a point where they're not eating a lot of food. And so, when you are interacting with women that are coming to you with these concerns, what are some of the ways that you explore caloric or food restriction in a way that is not triggering? Because I find for many individuals, even though I'm known for intermittent fasting, if I encourage women to stop, it can be really triggering, and so food is one of these-- It's essential for living,-
Dr. Nicola Sykes: [00:07:35] Yes.
Cynthia Thurlow: [00:07:36] -but also, we're in a culture where there's exposure to, as an example, ultra-processed foods 24/7, we could eat all day long and all night long, but helping people understand the differences between nourishing versus over restriction and undernourishment, I think that's a really important distinction for listeners and just for women in general.
Dr. Nicola Sykes: [00:07:56] Yeah, absolutely. So, if you don't mind, first, I am actually just about to publish a new chapter that goes along with my book on contraception and particularly the different ways and the different forms of contraception affect or don't affect your ovulation. So, women that I've worked with in recovery from HA often are like, "Well, what can I do for contraception?" So, I sort of wrote it with that focus. But I've recently been chatting with quite a number of people who've said, like, "My friend is asking me about contraception, what do I do?" So, I just wanted to make that widely known. It should be coming out in the next couple of weeks. So just a chapter that focuses on contraception with the idea of what are the available choices that allow you to continue to ovulate or not ovulate. And what the positives and negatives are of all the different options.
[00:08:41] So, in terms of your question about eating. Generally, when I'm exploring eating with my clients, I just have them walk me through what a typical day looks like for them. So, what time are they getting up in the morning? When are they eating? What kinds of things are they eating? And particularly for those with HA, there tends to be often an overall caloric restriction, sometimes restriction of certain macros. Each of these can play a role in suppressing your hypothalamus enough to cause amenorrhea and other negative consequences and intermittent fasting. So, there was actually a really interesting study that was done in Sweden a few years ago. The authors looked at a group of elite athletes. So, these women were all eating about-- Are calorie numbers, okay?
Cynthia Thurlow: [00:09:24] Sure?
Dr. Nicola Sykes: [00:09:26] So they're all eating about 3500 calories a day and burning about 1000 in exercise. So, net of 2500 calories. I mean, you compare that to like we're supposed to eat 2000, so they're eating well north of that, even after taking out exercise. Some of them had their periods and some of them didn't. And so, the researchers were like, "Well, what's going on? This doesn't make any sense." So, they looked at what they called "within day energy balance." So that's basically on an hourly basis, figuring out how much they were taking in, how much they were burning for basal metabolism, daily movement, digestion. That's something nobody ever talks about. The digestion actually takes energy, exercise, and exercise post oxygen consumption. And they found that the women that did not have periods were in an energy deficit for 4 hours more per day than those who did.
[00:10:11] So, eating the same amount overall, but just the way that they were spreading their food and food burning, energy burning out through the day was enough to-- Don't know if it's causing the amenorrhea or preventing periods from coming back. That's sort of a chicken and egg kind of question in some ways. So often women that have HA are doing this kind of thing where they wake up in the morning and they go and exercise. Maybe they're going for a run, maybe they're going to the gym, and then typically not that hungry after you exercise. You wait a couple more hours before you eat, and next thing your body is sensing this enormous energy deficit every single day. And so that in and of itself can be enough to either cause missing periods or prevent missing periods from returning.
[00:10:54] My general theme is that nourishing your body is really important, letting go of the idea of there being a particular size that's appropriate for you, kind of letting your body decide what that size is, and that size is going to change throughout your lifespan. You cannot expect to be the same size in your late 30s as you were in your teens. Our physiology is different, there's so many things that are different, so letting go of that, making sure that you're nourishing your body throughout the day. The time-restricted window, as you say, there might be times when it's appropriate, but I think that particularly for somebody who is burning a lot of calories through exercise, you have to be really careful to support your body by nourishing that exercise and giving your body the energy that it needs, rather than what we're often told in our society is exercise and cut food at the same time because you want to be thin, that's the overall goal, and I'm like, "Oh, my God," Thin is just, it's like, there's the fact that's a goal for anybody. I support people's right to choose but thin is not necessarily healthy. In fact, oftentimes thin is unhealthy. And so, if you're exercising, fantastic. Exercise is a beautiful thing to do. It's great for our bodies, it's great for our minds. But if it's under-fueled exercise, then it can become really problematic.
Cynthia Thurlow: [00:12:16] It's such a good point. You know, using that Swedish research that you referenced at the very beginning of this conversation. For me, one thing I have learned, and I always say, "know better, do better," but on days when I do strength training, I will eat earlier than I do maybe on other days, and so encouraging people to be open to the possibility that if you get hungry, maybe you actually need to eat, it doesn't mean that you're supposed to suppress all of your hunger cues. I think, unfortunately, like most things, good ideas sometimes get magnified, and all of a sudden this almost monk-like philosophy about, you know, "We only need to eat once a day or I'm going to do a five-day water fast, or I think that once a month I need to fast for four days." And I'm like, "If you are already a thin person, you're already at a goal weight at the expense of losing muscle mass, you are going to potentiate this long fast." And so, I think that in many ways, we have to reexamine some of our personal philosophies and beliefs around this. And nourishing our bodies needs to be the number one message. And I would probably add into the role of exercise. I'm all for walking, and I love weighted vests, I love Zone 2, I love to do strength training, but how many women I meet that will tell me they're doing--
[00:13:42] And I hate, I'm sorry, I don't mean to pick on two things, but I'm going to pick on more intense exercise, like CrossFit, Orangetheory Fitness, very intense. And I'll meet women that are doing that six days a week, and they're exhausted. And so, I think the intensity of exercise is significant. And I know at my age, I'm obviously 52, but what I did at 40 wouldn't serve me well now either. And it doesn't mean that I don't honor my body, but it's also acknowledging that at different stages, we need different things. And so, I think, as I was preparing for our conversation today, one thing that really was very impactful for me was the intensity of exercise. The caloric restriction is very important. And then layering on like another layer is acute versus chronic stress. So, I always think about the type A perfectionistic women that I know and--
Dr. Nicola Sykes: [00:14:37] Right here. [laughs]
Cynthia Thurlow: [00:14:38] Exactly. I've been there myself and how hard we can be on ourselves about whatever it is that we're working towards. But in particular, this physicality piece, whether it's being thin, achieving that. Can we speak a little bit to the piece about stress? Because stress, like hormetic stress, beneficial stress in the right amount is a good thing. It's what allows us to grow as an organism. In many instances, it can make us more resilient. But I think many of us don't realize cumulatively over time. And then you add in perimenopause and menopause, and we become a little less stress resilient. So, understanding there's a time and a place for stress, but chronic stress is going to break us down. Cortisol is a beneficial hormone, but unfortunately, cortisol when it's unwieldy and chronically it ends up initially being high and then it can go low, can deplete our bodies quite significantly.
Dr. Nicola Sykes: [00:15:31] Yeah. Yeah. So, I think that a couple of things that tweak me about what you just said. So high intensity exercise, my exercise of choice is ice hockey, which is super high intensity, I love it, I've played for 25 years. It keeps me sane, honestly. But now I'm only doing it two to three times a week, so I have a rest day almost every time so that my body can recuperate. I've recently gone from playing twice a week to playing three times a week, and I'm noticing that my muscles feel more tired. I'm not bouncing back quite as well. So, I think you have a good point.
[00:16:05] But also, like, high intensity exercise, I think is really good for, it's really beneficial for our heart. So, I think always figuring out this balance, but really focusing on rest and recovery is just as important as the exercise. So, I think some of that gets lost in the fitness circles. It's like "no pain, no gain," All that kind of stuff, all that messaging is just, it’s a little problematic. It's like, some pain is okay, but if you're in pain every single day, then no, that's probably not a good thing for the long term, so, yeah.
[00:16:39] And then in terms of stress. So, stress really-- Term we use in biology is synergy. So, there's a synergy between stress and under fueling or stress and exercise. And it basically means multiplication. So, there was a really elegant study where the researchers looked at monkeys, and they either put them in a stressful situation so that was moving their cage, or they had them eat and under fuel and do some exercise or both. So, in the groups of monkeys that were exposed to either the move or the under fueling and exercise, only a couple of them lost their menstrual cycles. In the group that was exposed to both, almost all of them lost their menstrual cycles. So, it's just like your body can handle a certain amount of stuff, but once you challenge it too much, then it's like, "I can't do it." [laughs]
[00:17:27] So, I think that's how amenorrhea starts. And then in order to recover from hypothalamic amenorrhea, I really find that you need to baby your body. I've had lots of people try be like, "I'm fine with adding more food, but I really can't stop exercising." And they do that for a few months and nothing happens, and it's like, "Okay, how about if we try a little bit of time without the high-intensity exercise, and then their period comes back.” So, if you're missing a period and you want to recover, you really have to do as many of these things at the same time as you can to really make your body feel like it's safe and nourished and everything's going to be okay.
[00:18:09] So, I'll often tell people, you can do a lot of high intensity exercise when your hypothalamus is working nicely and a little bit of under fueling. But when you under fuel too much, your hypothalamus shuts down, and then you've got to do all this, like really cut down your exercise, eat more than you're used to, gain some weight, all of these things. And there's nothing bad about that, a lot of people find that going through this process of recovery really helps them reset their priorities, figure out, there are things in life that are more fun than dieting and exercise. Hanging out with friends and family, enjoying a beautiful day for what it is instead of pushing yourself to run x number of miles every single day. There's a lot of value and joy to be found in slowing down. Food is amazing. Like, food is so tasty. I feel like so much of the food restriction is low fat, low carb, they just don't taste very good. [laughs]
[00:19:06] So, I'm certainly in favor of eating foods that you enjoy, especially when you're working on recovery. I mean you need to eat more, so you might as well eat the good stuff and really just focusing on nourishing your body in moderation and rather than trying to meet this particular ideal that is photoshopped and personal trainered and personal chefed and all of those things that us normal people don't necessarily have access to.
Cynthia Thurlow: [00:19:36] Yeah, that's such a good point. And I love that you play ice hockey. I think that's fantastic, it's interesting. Just from a clinical perspective, when you're working with women, how do you make the differentiation between someone that is perhaps just gotten into a bad cycle? Maybe they've just overexercised to a point where between that and a little bit of caloric restriction and maybe a little bit of stress has made them amenorrheic versus someone who truly has an eating disorder, so that fine line of that differentiation, where do you make that determination, or what are some of the signs that for you will stand out? Is it someone that has lost far too much weight at some point?
[00:20:20] I know that when I was preparing for our discussion today, there were certain prognostic indicators for individuals that were at greater risk for going on to develop kind of like a latent eating disorder, where does that all fall? Because I do think it's on a continuum. It's not like there's one thing that's a tipping point, but just clinically, when I've worked with thousands and thousands of patients over the years, there were just certain things that would stand out to me, but I'm curious if they're similar to the things that will stand out for you as well in your work.
Dr. Nicola Sykes: [00:20:50] Yeah, I think the biggest difference that I noticed between somebody that I consider to have an eating disorder versus disordered eating is, people with disordered eating, once they're educated and they understand the damage that this is doing to their bodies, they're able to pull themselves back and make changes and step into this new understanding of their body and the world and how they should be nourishing themselves. Somebody that has an eating disorder often wants to do that. They desperately want to do that, but they'll manage for a day or two, and then they'll slip back into old habits. So, I think that with an eating disorder, there's an extra barrier that seems to be mental, emotional. It's pushed through that. And I think that's where people really need the help and support of professionals who do this on a regular basis, who are trained to do this.
[00:21:55] I think it's also really challenging because I think that there's been some eating disorder treatment is still very weight focused. It's like, "Oh, you get to BMI x and you're fine, you can go." And to me that's not a great marker. Even in terms of period recovery, people will recover their periods at a range of different sizes, and it's really about what is healthy for your body. So, eating disorder treatment that focuses on a particular number, I stay away from that. It really needs to be focusing on, "Are these markers of health improving?" Your liver enzymes, your blood work, your reproductive system, that I think is a much better marker for recovery.
[00:22:43] Your mental recovery, are you able to eat food without thinking about the macros and the calories and all of that, stepping away from that weighing and measuring both of your own body and of the food you're eating. Stepping away from the step trackers, and the heart rate monitors and all of that stuff. The eating disorder recovery for a long time has-- I think there are places where they're like, "Don't get too big. It's okay to get to this size, but you don't want to go in the other direction." And I think that that is really actually quite harmful because it's not allowing your body to get to the place that it naturally wants to be. It keeps you focused on the weight and your body size. And so, I think that the more we can encourage people to find treatment places that are not weight and body focused, but rather health and nutrition and overall well-being focused. I think that's really the way to go.
Cynthia Thurlow: [00:23:44] Yeah. And I think on so many levels, initially when I reached out to you, this is really the heart of the conversation that I was hoping to have because there are hundreds and hundreds of women that reach out to us on social media versus DMs and emails that are really struggling in this area in particular. And, while I was a baby nurse and baby nurse practitioner, one of the hospitals that I trained at is an eating disorder center for the east coast. And I very humbly say that-- I think you are touching on a big crux of what is not focused enough on is that mental personal recovery and not just, "Oh, by the way, you've gained 10 pounds because we've had a feeding tube down into your stomach or your small intestine, or we've been requiring you to not over exercise." All these parameters that I know patients really struggled with, and it was very, very hard for them. They would sometimes say, "I can't wait to go home, but I have to gain x number of pounds just to leave treatment." And you're right that it's not just about the weight, there's so much more to it.
[00:24:54] Now, I know there can be some genetic contributions to HA, and I'm curious-- if someone's listening, I know we can talk a little bit about how genetic mutations can contribute us to being more sensitive, like our endocrine organs being more sensitive to information that our body is taking in. But are there specific genetic mutations that you-- Or are you doing genetic testing with your patients? Are you looking for these things that may be a harbinger of concerns that could be forthcoming? Or is it just an overall, you've noticed that there are people that are just exquisitely more sensitive to these intakes?
Dr. Nicola Sykes: [00:25:34] Yeah. So, I'm definitely not doing any genetic testing. I'm not sure that there's value to it for this purpose. There was a research study that found that some of the women that had HA had various mutations in proteins or receptors involved in the hypothalamic signaling pathways. So, I do think that there are some mutations. We all have mutations in all of our genes. There are some clusters of mutations or particularly individual mutations that might make us more sensitive to losing our period than somebody else. So often people will say, "But my best friend does exactly the same thing, she's the same size, she has her period, and I don't." And I'm like, "Well, that's the luck of the draw." Sometimes I think that people that do get HA are lucky in some ways.
[00:26:22] Like, yeah, it sucks. And it's hard, particularly if you're wanting to get pregnant. And that's how you find out that you're missing a period because you go off the pill and you don't have a period. And you're like, "I wanted to be pregnant yesterday." But I think that really the value is in learning to let go of control a little bit. I think it's pushed on us, this idea that, "If you eat a cookie, you're going to triple in size. If you take a day off your exercise, you're going to turn into a blob of jelly." And it's like, "No, that's not how our bodies work." And so, I think just really learning that in ourselves and for ourselves. Like, learning that we can be healthy without having to punish ourselves on a daily basis and without having to starve ourselves. We can be healthy if we're nourishing ourselves and we're doing movement that we enjoy. And so, I think that's a way in which people that experience this, I think are luckier than those who don't, and just stay on that same hamster wheel for years on end.
[00:27:17] I've had clients in their mid-50s who are like, "I'm just tired of this diet and exercise thing. Can I just stop?" I think that that's a real benefit to going through this. And for people that aren't going through it, take a week off exercise, see what happens. I took a month completely off exercise last summer because I broke my hand. And so, I couldn't play ice hockey, I couldn't go biking, and I was fine, like, nothing happened to me. So, obviously, I think exercise is healthy and I enjoy it, so I got back into it, but nothing changed, a whole month of not doing any of my normal exercise. So, I think that we're just pushed into this idea of, "You must do this every single day or else." And I'm like, "I really hate that ethos."
[laughs]
Cynthia Thurlow: [00:28:04] Well, and I love that you are really encouraging women in particular to find that reframe and give themselves grace. I think that, as an example, every time I go on vacation, I don't necessarily take exercise stuff with me. We've done a bit of travel this spring, and someone said to me, "Well, do you work out in the gym, at your hotels?" And I said, "No," because we're walking and I'm enjoying, and I just want to be able to enjoy the experience. And much to your point, you had to take time off last summer and you did absolutely fine. I think we're entirely too hard on ourselves.
Dr. Nicola Sykes: [00:28:35] Yeah
Cynthia Thurlow: [00:28:36] Now, I just want touch on this post-pill amenorrhea, which is interesting because a lot of women, including myself, actually experience it. So, if you're put on oral contraceptives to fix “in a regular cycle, PCOS, etc. It's not as if that goes away. It's really just masking. And again, no judgment, I was on the pill for a long time, which masked my mild PCOS, which I'm sure we'll probably talk about what differentiates PCOS from HA, but let's talk a little bit about post pill. So, post oral contraceptive use, people that lose their menstrual cycle and what that can represent and how that is a little bit different than what we're talking about with this constellation of other symptoms.
Dr. Nicola Sykes: [00:29:23] So, I don't really subscribe to the idea of post-pill amenorrhea.
Cynthia Thurlow: [00:29:27] Okay.
Dr. Nicola Sykes: [00:29:28] So, there are a couple of studies that have looked at the return of ovulation in menses after people have come off the pill. I think it's something like 90% ovulate within the first month and 95% within the first six weeks. So that means a period within six to eight weeks after coming off the pill. So, I think if it's anything longer than that, then it's probably not related to the pill. It's more likely that there's some underlying cause. So often recommend people, if you haven't had a period by six weeks after coming off the pill, start making appointments for an investigation. If you get your period, great, you just cancel the appointment. If you don't, then you have the appointment coming up.
[00:30:10] Within two weeks after you come off the pill, your hormones are fairly well normalized, so you can have a hormonal assessment done, look at your FSH, LH, prolactin, testosterone, androstenedione, free testosterone, what am I missing? Thyroid hormones. All of those can be markers of other issues that can cause missing periods. So, I think the one study that looked at it found that 5% that hadn't ovulated there was an underlying issue. So rather than being put off for three months or six months or a year, which I've heard. No, start your investigation sooner than that. It's not post-pill amenorrhea if you're more than three months out from your pills, for sure, there's something else going on.
Cynthia Thurlow: [00:30:57] Well, thank you for that, because on many levels, I think that you're absolutely correct. A lot of women are just told, "Oh, it'll eventually come back, don't worry about it." I know when I went off oral contraceptives, when I got married and we wanted to start a family, I went months and months and months. And you're correct, it was not post-pill amenorrhea for me, it was latent PCOS. I was anovulatory. And I think this is probably a good time to segue into talking about how HA differs from PCOS, because I think a lot of people, there is a little scooch of overlap, but they are different, and how people can help determine what could potentially be going on for them. And let me just interject this. I think one of many reasons why I was not appropriately diagnosed at a younger age was because I was thin. 25% of women with PCOS are thin. And that thin phenotype, they just assume that you just have a wonky, weird period. I was told that by so many well-meaning GYNs.
Dr. Nicola Sykes: [00:32:00] Yeah.
Cynthia Thurlow: [00:32:01] I'm not being critical, but I think a lot of people just miss opportunities to really investigate why young women are either not getting regular cycles or why their cycles are anovulatory. But how does HA differentiate from PCOS?
Dr. Nicola Sykes: [00:32:15] So, in a couple of different ways. So, it is a little bit of a challenge because there are a lot of things that do overlap. So, A, the amenorrhea, that's not going to distinguish between HA and PCOS. B, people with HA can often have a lot of follicles on their ovaries. So, if an ultrasound is done and the doctors aren't specific about what they're looking at, they can look at your ovaries and be like, "Oh, you've got lots of follicles, you have PCOS." Hate that. It's a symptom of PCOS. You can also have lots of follicles with HA. There are some recent studies that many doctors seem to be unaware of is that the line to distinguish between polycystic and multicystic ovaries is about 25 follicles on one ovary. So back in the day, it was 12, 12 is not a good cutoff to use. So, 25 or more is really the cutoff that they should be using. I still see ultrasound reports that are like 13 follicles, it's PCOS, I'm like "Could maybe say PCO, but not PCOS based just on the ultrasound."
[00:33:12] I actually find that the factor that is easier to diagnose with is the ovarian volume. So, the cutoff for PCOS with ovarian volume is 10 cc, also sometimes called 10 mm or greater. That's a little bit less subjective than trying to count follicles, so I think that that's a better criterion to use. So, if your ovaries are more than 10 cc's, it's more likely tipping the scales a little bit more towards PCOS. Blood work is really the place where you see the difference. So, there is supposedly a phenotype of PCOS where you don't have elevations in your androgens. But I think that's a really sketchy place to be diagnosing PCOS, because if you're not having the biochemical effects, then what is it that you're really concerned about? And often that's the place where doctors are not looking appropriately and not diagnosing HA or sometimes, they'll miss a thyroid issue, but usually it's a misdiagnosis of HA as PCOS.
[00:34:14] So, I will typically see in people that have HA, a low LH level, luteinizing hormone. So that is actually the best marker that we have of hypothalamic function, because the hypothalamus releases a hormone called gonadotropin releasing hormone, and that's what gets sent to the pituitary to then encourage FSH and LH secretion by the pituitary. We can't measure gonadotropin releasing hormone because it has a very short half-life, so it's degraded quite quickly and it's released in pulses throughout the day, so, like, every few hours, so you can't measure it. But the LH is also released in pulses, but it has a much longer half-life, so you can get a good sense of how well the hypothalamus is working by looking at the LH levels.
[00:34:57] So, in somebody with HA, LH is often 2'ish. I think of normal as being in the 6 to 8 range. Someone with PCOS is more likely to have an elevated LH because their hypothalamus is actually working in overdrive. So, it's speeding up and so you actually have a higher level of LH. Not diagnostic for PCOS, but it goes in concert with PCOS, so that's something that you will often see. In terms of the androgens. It's good to measure both testosterone and free testosterone. Testosterone levels with somebody with PCOS will probably be on the high end of the normal range, if not above the normal range. Free testosterone is almost always above the normal range for someone with PCOS, but well within the normal range for somebody that has HA or something else going on.
[00:35:44] So, one of the reasons for that is that one of the things that happens when you have PCOS is that you have a low level of sex hormone binding globulin. So, you actually have much more of your hormones that are just running around in your body doing things that you don't necessarily want them to do. So low SHBG means then high free testosterone. So, you can also measure SHBG, but the free testosterone is more diagnostic because it's been just looked at in more studies. So those are really the key things that I look for, is what is the LH level? What is the testosterone and free testosterone level?
[00:36:19] AMH, anti-mullerian hormone, is another one that's commonly measured. It's thought that high AMH equals PCOS, but I don't find that to be true either. I often see high AMH in people that actually have HA based on their history and their LH levels and their testosterone levels. And looking at the holistic picture, the high AMH goes along with having lots of follicles on your ovaries, but that doesn't necessarily mean PCOS. So that's another place where some doctors will see, "Oh, you have high AMH, you have PCOS." I'm like, "Oh, let's take a little step back here. It's not part of the diagnostic criteria and it's also high in this other condition." And, a lot of what you're told if you have PCOS is limit carbs, limit your time of eating, exercise more, and that's the antithesis of what you want to do when you have HA. So, it's important to get the right diagnosis.
[00:37:18] I do think that some of the limitations that people are told with PCOS are not necessarily helpful. Exercise more, sure, but all this dieting stuff. I'm not a PCOS expert, but certainly there are people who are like-- The idea that when you have PCOS, you should be undernourishing yourself, isn't appropriate, like you should be nourishing yourself well, maybe eating different foods, maybe spreading you're eating out differently, but you should still be nourishing your body, because starving yourself just means that your body has less energy to work with and then it has to shut other things down, and so it just seems to cause more complications than it helps with.
Cynthia Thurlow: [00:37:55] I think that's such an important message. And you're absolutely correct that even if you have PCOS, and that the basis of PCOS typically is insulin resistance, inflammation, oxidative stress, the ways around that, in terms of nutrition, it's not to undernourish, it's probably to have a bit more protein, have non-starchy carbohydrates, some healthy fats, eat less processed food. It is not the message of undernourish, undernourish, undernourish, which is what, in many ways, people will tell their patients, exercise more, eat less.
Dr. Nicola Sykes: [00:38:27] Yeah.
Cynthia Thurlow: [00:38:28] I might have been guilty of that as a new nurse practitioner many years ago. Now I know better. I always say, "know better, do better."
Dr. Nicola Sykes: [00:38:33] Absolutely.
Cynthia Thurlow: [00:38:35] To round out the conversation, if someone is listening and they're concerned about symptoms that they may be experiencing that are relevant to HA. I think this is really important because many of these symptoms can mimic what women experience in late perimenopause and menopause. Someone tagged me, I think, on it was Instagram or TikTok, about a young woman who was 27 who has in premature ovarian insufficiency. It used to be called premature ovarian failure, now we call it insufficiency, but it is hearkening the same thing.
Dr. Nicola Sykes: [00:39:09] Yeah.
Cynthia Thurlow: [00:39:10] Very different for a 27-year-old to be diagnosed with that than a 47-year-old, because it's many years of the potentiality of the net impact of those loss of hormone. So, when you're working with women, what are some of the common complaints, concerns that they will express to you relevant to this loss of their menstrual cycle?
Dr. Nicola Sykes: [00:39:31] I think it very much does mimic what happens in menopause because your hormones look quite similar to somebody who's in menopause in terms of your estrogen and progesterone being consistently low all the time. Your FSH and LH are different. When you go through menopause, your FSH and LH are quite high, but those don't seem to be related to the symptoms that people feel. The symptoms seem to be related to low estrogen, low progesterone. So, things like let's see, having to urinate quite frequently is a big one that people don't know is related to amenorrhea. And it's actually really interesting how that happens, because when your estrogen is low, the lining of your bladder gets thin and so the urine actually penetrates the bladder lining more quickly and so you have an increase need to urinate.
[00:40:20] So, when you start cycling again, that goes away because the estrogen then makes your bladder lining thicker. And I mean, it's fascinating. There was actually a study where they found that the urge to urinate was happening at like 25% lower capacity in somebody with HA versus somebody without HA. Often brittle hair and nails are something that people notice. No libido, no vaginal lubrication, those are other common complaints. I'm just trying to think. I have a whole list of symptoms in my book. It's just one of the things that people like, "Oh, that can be related," Like a lot of mood issues, anxiety, feeling anxious, anxiety, that's what that means. [laughs] Feeling hungry all the time, feeling cold all the time is another big one, and that really does come from the under fueling, because one of the ways your body can save energy is by not warming you up because it takes energy to keep you warm. So that's actually something people notice is a very early recovery sign, is feeling warmer.
[00:41:13] Another thing is low heart rate. So, a resting heart rate that's in the 30s or 40s, you think, "Oh, I'm athletic." No, your heart is not supposed to beating that slowly, so that is a sign of under fueling. That's another one that tends to improve quite quickly. So, I've had people say that even within a few days of starting to eat more, their resting heart rate will go up from the 40s to the 50s. So in the 50 plus is really ideal for that. So, I mean, there's just lots of little things that people notice that improve once you start eating more.
[00:41:47] In terms of diagnosis, I have seen quite a few people that have HA, that have been diagnosed with POI because they're not looking at the hormones appropriately. So really POI, you're going to have high FSH and LH. If your LH is low, it's probably not that, and it's worth exploring more. So, I find that the cutoff for that is FSH above 20 is most likely going to be POI. I've seen a few people with FSH in the 12 to 20 range where it's like not quite sure what's going on here, but then they work on HA recovery and their FSH comes back down again, and so that can be a gray area.
Cynthia Thurlow: [00:42:26] I think that's really important information. And you mentioned polyuria, which is this frequency of urination. And I find for a lot of my menopausal, late perimenopausal women, when they start using things like vaginal estrogen all of a sudden, because you get changes and alterations in the pH of the vagina, the urethra. And one of the things that I use to use as a marker of improvement of the vaginal flora is they're not waking up at night to urinate anymore, because I think many women will say, "Oh, I must have drank too much." And I'm like, If it's happening every night, too much water or beverages in the evening, I'm like, "it's probably not the fact that you were overhydrating. It's very likely this loss of estrogen." So interesting that can oftentimes be a symptom of HA.
[00:43:13] Is there anything else that we haven't touched on that you feel like would be valuable? Obviously, we will link information to your website, which is a wonderful resource, your book, the work that you do. Anything else that we haven't touched on that you think would be valuable for listeners in terms of determining how best to proceed? I'm sure there are many women in my community, unknowingly that have been part of this kind of rigid diet culture. Maybe they've been intermittent fasting for a long time. They're younger and they're losing their menstrual cycles. And I remind them all the time that average age of menopause is 51, but if you're like 45, 42, late 30s, we don't want you to lose your menstrual cycle before your time.
Dr. Nicola Sykes: [00:43:56] Yeah, I think that is an important point, is that in your early 40s, it's much more likely that it's something like HA than menopause, I mean, honestly. Obviously, it happens, but I think among the women that come to me, it's probably 500 to 1 in terms of HA versus actual menopause. So, I really think it's worth doing more exploring and really making sure that your doctor is checking all of the necessary hormones. It's easy for them to just say, "Oh, you're in your 40s, is probably a menopause." Let's actually do some investigation and figure out whether it is actually menopause in which case you may want to consider hormone replacement therapy, but that's a conversation that you should be having with your doctor as opposed to just like, "Oh, probably menopause. Don't worry about it. It happens to all of us." No, let's have some conversation. Let's figure out what's really going on.
[00:44:50] The other thing that I wanted to point out is that some of the other things that can be negative impacts of amenorrhea is a tendency to soft tissue injury, stress fracture, decreased exercise performance. And all of that goes along with under fueling. People may have heard of either Female Athlete Triad, which has now been renamed to Female and Male Athlete Triad, or relative energy deficiency in sport. It's all the same thing. It's just different names. I focus on the amenorrhea part, but that is a component of the relative energy deficiency in sport. It's a component of the triad. Everything that you read about for any of those conditions, it's really all the same thing. So, I think understanding that those are-- It's one big umbrella term that captures all of that, and we're just coming at it from different angles.
[00:45:41] Some people are also diagnosed with hypogonadotropic hypogonadism. So just another word for HA. I was trying for a long time to figure out, like, "What is going on here? Is it different?" And I can't find any actual differences. So, it's just a difference in terminology. So, I really think that any time that something is awry with your menstrual cycle, it's worth doing a little bit of investigation. Sure, there are things that will cause a minor blip. I had COVID and my cycle was late by two weeks. Every now and again something will happen. I had a time period when my youngest was like 1.5 and he broke his leg and he was like an infant again, and I was under so much stress. And, my luteal phase was super short that month. There have been other random times where I've skipped a cycle, that's no big deal. I mean, if you skip a cycle here or there, whatever it happens, there can be-- Especially if you can look back and point to, "Oh, I was sick right around the time I was supposed to ovulate" or, "Oh, I've been really stressed this month and I haven't been eating well." It's just kind of observing what's going on and like, "Okay, if you can figure out something that's happened, fine." But any kind of ongoing cycle issues I think is really worth investigating.
[00:46:52] The other thing I think is really important is understanding our ovulation. I still track my ovulation. I like to know when am I ovulating? How long is my luteal phase, which is the time between ovulation and your period. And I think that's a really good marker for us of how our cycles are doing until we hit menopause, like, our overall health. So, particularly for your younger listeners in 20s, 30s, it can be really nice to know when you're ovulating. If you want to get pregnant, obviously, it's super helpful. We do not all ovulate on cycle day 14. We do not all have a 14-day luteal phase, that's just garbage. I often ovulate on cycle day 17 and have a 10-day luteal phase.
[00:47:32] So, if I'm trying to time intercourse for pregnancy, it's really helpful to know when you're ovulating. So, I think that that's worth figuring out well before you're trying to get pregnant. And then, like I said, also just using it as a marker of your menstrual health. Yeah, if you're getting a period, that's fine, but you can have anovulatory cycles. You can have a very short luteal phase. That's sort of a pre-- Like, you're going to lose your cycles kind of thing, a marker. So, I think just really understanding your ovulation is super important. I don't know if you've ever had Lisa Hendrickson-Jack from Fertility Friday on your podcast.
Cynthia Thurlow: [00:48:06] I have not.
Dr. Nicola Sykes: [00:48:07] So, she's all about tracking ovulation. And so, I think if you haven't, she'd be a great guest to have to help your listener understand more about doing that, but I think it's super important to do that for all of us, and teaching our daughters as well. I mean, so many of my clients come to me and they're like, "I have no idea what my cycle is like when I was young because nobody told me that it was important." Like, you don't have to track every month, but just understanding what's happening, I think is really valuable. And, maybe if you're in college, maybe take a few months off the pill or whatever contraception you're using if it's preventing ovulation to understand, "Okay, this is what's normal for me. This is how long it takes me to ovulate after I come off the pill." Just so you know your body, I mean, I think that's really important. And our bodies are so fascinating. Like, the changes in cervical mucous that happen around ovulation that allow for sperm to survive in order for us to get pregnant. It's, like, so cool. [Cynthia laughs] It's like our bodies are just amazing.
Cynthia Thurlow: [00:48:59] No, they really are. And it's interesting because I think that when I got married at 32 and when we started trying to get pregnant, had I not been tracking my cycles, I would not have known that I was anovulatory because I had normal length of cycle, but very clearly didn't have enough progesterone. Again, this is what sent me down the rabbit hole about PCOS, and I ended up seeing a reproductive endocrinologist. And I remember my GYN at that time saying, "I'm so glad you actually were tracking, because if you hadn't, we would have had you wait 6, 12 months of trying to conceive and wondering why you weren't conceiving." So, knowledge is power, and now there's all these amazing apps and ways that you can track on your phone, makes things much easier. I think I was like pencil and paper back 20 years ago, it was very different.
[00:49:48] Thank you so much for the conversation today. Please let my listeners know how to connect with you, how to purchase your book, how to find you on social media.
Dr. Nicola Sykes: [00:49:56] Sure. So, my website is noperiodnowwhat.com. I'm @noperiodnowwhat on Instagram. I have a support group that's noperiod.info/support. My book is at noperiod.info/book. I'm not super active on social media at the moment. I've had a tough couple years personally, and I'm feeling a little bit burned out. So, if you want to connect with me, probably the support group is the best way to do that. I do also work with people one-on-one, so if anyone is interested in that, it's noperiod.info/appointments, and that's that.
[00:50:27] So, I'm actually working at the moment. I published a French translation of my book last year, and the German version is coming out shortly, and then I'm going to be working on Spanish next because-
Cynthia Thurlow: [00:50:35] Amazing.
Dr. Nicola Sykes: [00:50:36] I really think it's important to get this information out across the world. And I've been told that people who speak other languages as a native language, like, there's just not the same anti-diet messaging in many of those cultures. And so, I feel the message of understanding your body, understanding your cycles, all of that, I think is important to get out to as many people as possible. So, yeah.
Cynthia Thurlow: [00:50:58] I absolutely agree. Thank you again for your time today.
Dr. Nicola Sykes: [00:51:01] Thank you so much for having me. This is wonderful.
Cynthia Thurlow: [00:51:03] If you love this podcast episode, please leave a rating and review, subscribe and tell a friend.
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