Did you know that one in six individuals struggle with fertility challenges? This causes couples significant distress, stigma, and financial hardships affecting their mental and psychosocial well being. The medical causes of infertility can be vast, but today we're going to clear up some confusion regarding PCOS and HA. Wait a minute, did I say H A? Welcome back to the exam room nutrition podcast, I'm your host, Colleen Sloan. I'm a registered dietitian and pediatric PA. each week I'm giving you answers to common nutrition questions to help you become a more compassionate, Confident clinician.
If you're anything like me and you hear the medical abbreviation H A, you probably think of headache. Today, we're going to uncover exactly what H A means. H A stands for hypothalamic amenorrhea, and it is an easy to miss diagnosis, yet it can profoundly impact the lives of our patients. So today, you're going to learn how [00:01:00] nutrition can promote fertility while ensuring you're diagnosing your patients properly.
I'm super excited to introduce my guest today, Chelsea Deshaun. Chelsea has been a registered dietitian for 10 years. One of Chelsea's biggest passions is to help women overcome their struggles with infertility through nutrition and lifestyle changes.
She has an incredible story of infertility herself, miscarriages, and a misdiagnosis, which all led her to bring awareness to hypothalamic amenorrhea and give hope to those who are also struggling. You can find her on Instagram at fertility period recovery.
And also on her website at nutritioninrhythm. com and all of those will be linked down below in the show notes. Chelsea, thank you so much for being here with me today. Welcome to the show.
Thank you so much for having me. This is an honor.
let's get some groundwork going with regards to fertility. And I wanted to start by asking you, why is it important to actually have a period? And maybe what are the consequences for women to not have [00:02:00] their period?
Yeah. So one of the most obvious reasons to have a period in the first place is, fertility, right?
So if you don't have a period and you're not ovulating, then you can't get pregnant. Most obvious thing. Other consequences that are related to not having a period are bone health, heart health, and also brain health. So it's actually been found in research studies that the effects of having a low estrogen level from missing a period as in having H.
A. It includes, lower bone density, higher risk of heart disease and higher risk of dementia, Parkinson's and Alzheimer's. So as far as bone density, it's connected to amenorrhea because bone cells contain estrogen receptors, and when estrogen is high, this results in bone formation, and when estrogen is low, this causes bones to break down.
So with heart health in women with amenorrhea, there is a change in their heart flow mediated dilation. So this [00:03:00] affects how hard the heart has to work to pump the blood. So when estrogen is low, vasodilators are low and vasoconstrictors are higher. So this shift along with higher cholesterol that's often seen in HA, it increases the risk of heart disease. So the other thing is brain health with amenorrhea. So since estrogen helps with the heart to pump the blood, it helps apply blood to the brain. So there's even evidence that estrogen can help build. new nerve connections and prevent nerve cell death because there is a connection to low estrogen and neurodegenerative disease, the risk for things like dementia, Parkinson's and Alzheimer's, it increases with having a menorrhea. the good news is with menorrhea is that, when you have a recovery with having weight gain and. Recovering your period bone density is shown to increase the risk of heart disease is lowered and the risk of neurodegenerative diseases Decreases which is super awesome [00:04:00] and super important to know when we're trying to recover our periods with ha.
So for my listeners and honestly for me, you know, I'm in pediatric, so it doesn't come up that much. I use the abbreviation HA for headache, . what exactly is hypothalamic amenorrhea?
Yeah, so hypothalamic amenorrhea it's basically having a missing period, from the causes of under eating over exercising and stress. It's also known as female athlete triad in the past.
A lot of times it can be really easily overseen in a lot of women. So, many clients that have H a don't. fit the typical mold that is usually taught in school, such as having an eating disorder, having a BMI that's underweight, less than 18.
5, or being severely malnourished, or participating in sports and being a professional athlete. So it can get easily misdiagnosed. it's also really common for women with H. A. to have low to [00:05:00] normal hormone levels. So many women actually don't ever get diagnosed with, H. A. And they're left questioning why their period went missing in the first place.
and if women are trying for a baby, they're usually referred to starting fertility treatments, including IVF.
Is this sometimes confused with PCOS?
Actually, yeah, it, it definitely is confused with PCOS. quite often. and that was actually my story too. I was misdiagnosed with PCOS and when I actually had AHA and AHA can have a lot of similarities to PCOS. and it is more of a diagnosis of exclusion. So it's also more commonly seen in, intense, athletes and women who are underweight.
So if you don't fit into those categories like I didn't, then it's usually overlooked. So when hormone labs are taken in women with HA, it's characteristic to see like the low to normal, FSH, LH, estrogen, free and [00:06:00] total testosterone, free androgens, DH, EAS, and endosterone. And. it's also normal
to see levels that are normal in TSH, prolactin and androgens. what's interesting is that PCOS has a diagnosis criteria. So you have to meet two out of the three of the Rotterdam criteria. So. That, Rotterdam criteria consists of absent or irregular menstrual cycle related to the absence of ovulation, high levels of androgens, and then presence of small cysts and follicles that are being, stopped and stuck in the development phase.
what's common with HA is to have absent or irregular cycles, and then have some small cysts and follicles. but the difference with the cis with HA versus PCOS is that there's more than 25 follicles with PCOS between 2mm and 9mm. and then with HA, there's actually going to be less [00:07:00] cis. So that's why it's commonly mistaken for PCOS, because it does technically meet two out of the three criteria for that Rotterdam scale.
But it's actually super important to get the right diagnosis for HA and not to be misdiagnosed for PCOS because the treatments are actually completely different.
With PCOS, the treatment is having more smaller servings of carbohydrates, making sure you also pair it with protein and fiber and vegetables and increasing physical activity. And sometimes it's recommended to have weight loss in some women. but then on the other hand, treatment for HA is actually the opposite.
It includes Increasing the serving of carbohydrates and fats and decreasing exercise and many times weight gain is needed. So if somebody is going to be diagnosed with PCOS but really has HA, the treatment they could be doing can actually make HA worse.
So interesting and as you were talking, I was just thinking that like, gosh, if you get this diagnosis wrong, your treatment [00:08:00] plan is completely wrong and not helpful at all. at all at recovering their period or helping with fertility. So I think getting this diagnosis correct is very, very important because there are other things that mimic it, like you had said.
So let's talk a little bit about BMI. Does BMI play a role in fertility? And is there like a perfect fertile BMI range.
BMI does play a role with fertility, but a lot of times, what we see is women who have like a normal BMI are typically told you don't really have to gain any weight because you're at a normal BMI. But. normal BMI doesn't mean, that you're not gonna have to gain weight to get your period back.
So just as like a baseline, A BMI of 22 to 23 is technically considered like a fertile BMI range. And some women may need to have a BMI even higher than that to be in a fertile range for them. So each woman is actually kind of different. So, it is important though to recognize that. The body [00:09:00] needs to be in a surplus to feel safe again, to be able to regulate their reproductive hormones again.
This might be a silly question, but maybe some of my other listeners are thinking, cause I thought of this as you were talking and we're talking about BMI and kind of, you know, gaining some weight. Is this a true statement to think that all patients with HA are underweight?
That's a great question. not all women with HA are going to be considered underweight. I think that that's one of the things that, can hold a woman up from getting an, an HA diagnosis is because they may have a normal BMI and not underweight, and then they don't get that HA.
Diagnosis and instead we'll get like a PCOS diagnosis or something like that, or it's completely overlooked. So a woman with HA can be at a normal BMI and still lose their period and it all has to do with that under eating, over exercising, and their stress that's causing their hypothalamus to shut down and not let their period regulate those [00:10:00] hormones.
So interesting. now I love when my guests have professional. experience with this, but also personal experience, because I just think it makes your recommendations and your guidelines that much sweeter. So, you were diagnosed with HA and previously struggled with fertility issues.
So what are some, main challenges that as clinicians, we need to be sensitive to and aware of that, women suffering with HA might be going through?
it's such a good question because for me personally, I didn't get an H. A. diagnosis for years and I remember when, I did have some doctors in the past before I was diagnosed with this disease. say certain things to me like, you know, maybe, you just need to gain just a couple pounds or, you know, maybe you are exercising too much.
and that actually really scared me because I found it as part of my identity to work out a certain amount of times a week. You know, I went running a lot, almost every day. [00:11:00] Every day. And it was something that I did with my husband at the time. I did it with friends and it was almost like this scary feeling of like, if I give that up, what am I going to do?
And also I saw exercise as a way to relieve stress. I didn't realize that the exercise that I was doing was actually putting stress on my body. So having that mental fear of. you're being told to stop something that you truly love, or even that it's a hobby for you, that can be really scary.
Another thing is gaining weight. So, a lot of times, women with HA have a really hard time with the thought of even gaining weight, because when you're trying to look a certain way for so long and you get to that weight that you're so proud of for so long, that's the last thing that you want to hear is to gain weight
so I thinkWhether a woman suffers from HA or not being told that you need to, exercise less or tone down your exercise routine and gain weight. I really don't know any woman who's like jumping for [00:12:00] joy at that recommendation to be like, Oh great.
I should gain weight. Like none of us want to really hear that So I can see how that can be very, very challenging and a very hard recommendation to swallow because like you said, exercise is our stress relief.
It's our social hour and I think being empathetic to how a diagnosis changes a patient's life. is really, really important for the clinician to just be aware of that. So thank you for bringing that up.
I wanted to move into some of the specifics on treatment. So hopefully my clinicians are aware that we need to be getting this diagnosis. correct in order to provide the appropriate treatment and management. And I'm curious, regarding birth control or other synthetic hormones out there, if that is going to help HA patients or if this is not really part of the guidelines for treatment.
Yeah. So many times I have clients who have been put on the pill to regulate their cycle or start their cycle if it's been missing, but then once they go off the [00:13:00] pill, they still don't have a period. So going on the pill does not actually give you an actual period. in order to have a true period, ovulation must occur.
So without ovulation, we call this a withdrawal bleed. So what happens is with withdrawal bleeds, it's when your body has like an elevation of estrogen, which helps in thickening your uterine lining. And then when estrogen falls during the week that you take like the sugar or the placebo pill, your body sheds this uterine lining and you have a bleed.
But when you have a period, your body has an elevation in estrogen and progesterone to prepare the uterine lining for the egg. And when pregnancy does not occur, both the estrogen and progesterone fall, and this is when your period begins. So, it's kind of like a similar idea, also with this synthetic Progesterone, like Provera.
Provera is given for like about five to ten days, and then once the patient stops taking the medication, a bleed is [00:14:00] expected to happen up to two weeks from like your last dose. So many women with HA, When it's severe, they don't even respond to this treatment at all, which means that they don't even get a bleed or if they do, it's usually a light bleed and it doesn't actually kickstart their period.
so with the pill and Prevera, they're not actually a cure for your missing period. It's not really going to kickstart the period, especially when we haven't, actually treated the root cause for HA, which is having a change in their nutrition and lifestyle.
So really the best treatment for HA is really getting to that root of the issue. So that way we can really truly get their body to regulate hormones naturally and have a period.
So then, based on what you just said, I'm assuming that fertility treatments aren't really going to work either in this population of individuals. Is that correct?
Yeah, so a lot of times, fertility treatment isn't always the answer. and I know for [00:15:00] myself as well, I was told, to go on fertility treatments. So many women will be put on treatments like Clomid and Femara to help them ovulate. but because these medications rely on, a functioning hypothalamus, a lot of times women with HA won't, actually ovulate with these medications, or they'll need increased dosages to help them ovulate.
And when oral medications don't work, injections IVF are the next step. So, with my personal history of HA, I was actually put on multiple rounds of Clomid and Femara, and I never ovulated. So then, my doctor recommended me to see a reproductive endocrinologist. So, At the time, I saw two different specialists, and then I was told that since I didn't respond to the Clomid and the Femara, I would either not respond at all to injection treatments, or I would be overstimulated, which increases the [00:16:00] risk of multiples.
So I was told IVF would be our best option. When I first went through IVF, I actually thought that it was going to be like, the easy option, and like have a guaranteed baby at the end of it. but unfortunately, I was wrong. it actually was anything but easy mentally, physically and financially.
and unfortunately I didn't have my baby at the end of it all. so in a lot of ways, I wish I had known more about recovering my period prior to going through IVF because it could have saved me and my husband. Like a lot of time, a lot of heartache and a lot of money because it's not cheap
but at the same time, even though I had to go through all of that, I know that I did go through it for a reason. And it's not in vain. and all that I've been through. I know that, It has helped me have more, empathy for those who are struggling, and I'm so grateful now that I get to take my experiences and help other women too, so actually this, in a weird way, I feel [00:17:00] like I've come to a point where it's been rewarding for me to be able to give back to women who are struggling with the same thing and help them out.
I love that. And thank you so much for your transparency and your vulnerability and just sharing your journey with us.
So I wanted to get to the meat of today's discussion and that is how nutrition impacts fertility. So, Are there certain foods that can promote fertility and kind of what are the steps that we need to do to help our patients with HA gain their fertility and ultimately hopefully have a baby.
So, with HA, some of the main food groups that help with getting your period back and improving fertility is, number one, carbohydrates. So, for many women with HA, carbs have been seen as like a bad food, and they've been restricting them for a long time. But the body does use carbohydrate as its main source of energy in the form of glucose.
And so we need more of these types of foods to give the hypothalamus more energy, so that it can [00:18:00] start regulating those reproductive hormones again. So, foods like breads, breads, Pasta, rice, tortillas, starchy vegetables like potatoes, peas and corn, and beans. Those are all types of carbs. The second type of food group that I like to focus on is also fats.
So fat is also another nutrient that I see women with HA restricting when their period goes missing. And it's really important to replenish this so we can get fat in different ways. So I like to recommend fats such as nuts and seeds, whole fat dairy products, avocados, oils. Salad dressings and condiments such as like mayonnaise.
on top of having a focus kind of on those food groups, the other thing is really just on eating more because for so long women with HA have been restricting their total intake.
So making sure that we are eating more and a lot of times for these women to eat more, it can be kind of scary [00:19:00] because they've been so used to restricting. So this is what I work on with recovery is, not just focusing on food groups, but also focusing on having a mindset shift of increasing your total food intake.
That's okay.
I'm sure it's really scary to be told, Hey, eat more carbs and eat more fat. Because you're right. They've been restricting that all along. So talking about social media, because although it's super beneficial, we're both on social media. And if you aren't following me, you can find me at Instagram at exam room nutrition, and you can find more information from Chelsea, at fertility period recovery.
So social media is. It's so helpful in so many ways, but the reverse of that is it's so harmful in so many ways and social media can promote all kinds of fad diets and fake news and dieting that is not helpful and actually very harmful and can worsen fertility issues.
So, I wanted to just kind of clarify any of those things that might be shared on social [00:20:00] media of like, eat this and you're guaranteed to have a baby in, 10 months. Is there one food that is like the fertility god of foods out there?
Oh, it's so funny. It's so true because I feel like we're so bombarded with social media all the time with Telling us different messaging and I would say that there's not one food that's gonna really be that magic food to increase your fertility. It really is a big picture when we're getting to nutrition for fertility. A lot of these women don't intentionally get to where they're at because they're just trying to be healthy. But a lot of the, social media that's out there, To promote these like healthy eating habits are not healthy, especially when you don't have a period. I always say that eating for fertility is a diet of inclusion and not exclusion because we're trying to add food to our diet so that it's going to help our body to [00:21:00] feel safe for reproduction. a lot of times I try to encourage my clients who are struggling with, you know, having certain messages being told to them through social media is.
To try to start following more body positive accounts and trying to diversify, what your social media feed is.
Thanks. So that way we can really help you focus on appreciating your body and learning how to love yourself and not feeling like you have to compare yourself all the time. I feel like a lot of times with H. A. A big part of the recovery process is just reframing our mindset and Trying to get over those hurdles that have caused our period to go missing in the first place.
I love that. What an encouraging place to end to because social media can be so So hurtful to our mental health and especially women and young women, especially comparing body images [00:22:00] and the bounce back culture after you do have a baby or the weight loss culture. And I love that you also include that in your counseling. And I think that's a really great take home piece for our clinicians listening
So thank you so much for sharing again, your journey and just being vulnerable with us and for really impacting and transforming. Other women who struggled with fertility issues and to get their periods back. So I'm so grateful for the gift of your time. Thank you so much for all the information that you shared with us.
Thank you so much again for having me, Colleen. This was so awesome.
All right, guys. Now it's time for my nutrition notes. So today I want to leave you with an encouraging quote, and this quote might encourage you, or you can relay it to encourage one of your patients, especially if you work with individuals who are struggling with fertility.
And it's a quote by Martin Luther King Jr., and he said, We must accept finite disappointment, but never lose infinite.
I'm going to read it again. It says, We must accept finite disappointment,[00:23:00] But never lose infinite
disappointment and failures and struggles and sadness are all part of this life and this world that we live in. Unfortunately, it is just a reality and all of us and all of our patients go through some very, very hard and dark times, but that is not a reason to lose hope. So just keep that in mind with your patients, remind them to continue to have hope and to be able to see the light at the tunnel because the sad and lonely and dark days will end.
I hope you found value in today's content as always. If you have a question or you would like any specific topic featured on the podcast, I'd love to hear from you. You can find me on Instagram at exam room nutrition.
Well, that's all for today, Thanks so much for joining me and let's continue to make our patients healthier one exam room at a time. I'll see you next time.