[DR. CRISTINA CASTAGNINI] Behind The Bite podcast is part of a network of podcasts that are good for the world. Check out podcasts like the Full of Shift podcast, After the First Marriage podcast and Eating Recovery Academy over at practiceofthepractice.com/network. Welcome to Behind The Bite podcast. This podcast is about the real-life struggles women face with food, body image and weight. We're here to help you inspire and create better healthier lives. Welcome. Well, hello everyone. Okay, we have a very fascinating show today. Not that they all aren't fascinating, but I am so excited because I never really realized how much there was to know and think about when it came to our periods. Really, there is so much, and I would actually love to hear what you think about today's show after you've listened to it. If you've learned anything or want to discuss anything more about a topic that we just couldn't deep dive into, or even if you hated it, I am down to hear anything you have to say. Remember, there's a lot of ways to get in touch with me, but I have that new website up now at www.speakpipe.com/behindthebite. Go there, send me a voice message, love hearing from you guys. That being said, I am really excited to introduce today's guest. Cynthia Donovan is a registered dietician nutritionist with over 10 years of experience in the field. She serves women with Hypothalamic Amenorrhea, mouthful and helping them get their period back, restore their health, and find balance with food and exercise. It's her passion and main focus in her practice. Since founding the Eat to Regain Your Period program in April, 2020, she's worked with hundreds of women in helping them get their period and their life back. When she's not serving women across the world with period recovery, you can find her with her two loves of her life, her sons, Brian, and Braden. Well, Cynthia, welcome to the show. [CYNTHIA DONOVAN] I am so excited to be here, Cristina. [DR. CRISTINA] Well, I am too, and I have to say, I have not had this topic on the podcast, and so how exciting, I always get excited when we have like a whole new topic on. You are the expert at this and it's so unusual to find someone who's like the expert in period. So yes, and people probably like, how much can you talk about a period? There's a lot, right? [CYNTHIA] So much, like so much. Wherever you want me to start, I am happy to do that. But yes, I am an expert mostly in hypothalamic amenorrhea. So we're going to just use the term HA and I guess the textbook definition of that is, and I'm going to read it actually from a definition off of Google and then I'm going to break it down in like more simplistic terms. Hypothalamic amenorrhea is a condition whereby a woman does not get her period due to abnormality of the release of the Gonadotrophin-releasing hormone. Sorry, I don't usually come out with the very sciencey definition, so excuse my language, but it's also short for GNRH. Anyways, to say what this really is, HA, hypothalamic amenorrhea is pretty much a condition attributed to poor diet, so lack of eating enough, stress, and usually too much exercise. We're going to just use the very easy term of it, and we're going to call it for context. Yes, I'm definitely an expert in periods but I don't talk much about like painful periods. A lot of times that is, I can't even remember, endometriosis. I am not a specialist in polycystic ovarian syndrome, even though I do know stuff about that. Missing periods in relation to not eating enough and exercising too much and mental stress is my area of expertise. [DR. CRISTINA] Yes, that was like a big mouthful. I'm glad you said that disclaimer because I have had the topics of PCOS on here. So this is something, people you have eating disorders, this is something that we use as a diagnostic criteria is typically for anorexia nervosa, like the missing period. Usually when the period comes back, we say, okay, so maybe they're more nourished, they're feeding their body again and when it's the period's gone, they're not feeding their bodies enough. That's a sign and a symptom. So much like you just mentioned, they're not feeding their bodies enough and that's related, so maybe some people listening can relate to that. [CYNTHIA] Absolutely. Do I do want to say Cristina, that PCOS, many women that have HA are often, I don't have percentages, but it happens a lot, especially in my practice. It happened to me that they're diagnosed with PCOS, but it's really HA. So if you're listening, you're like, oh my doctor diagnosed with me with PCOS and you are really in alignment with what you're going to hear me talk about today, then it's worth exploring that diagnosis. It's also worth exploring if you can't get your doctors, I guess okay with it or diagnosis or whatever that it's something that you need to put in yourself. Like, all right, well this all lines up, this makes sense. Do I really need somebody else to confirm this? Or do I feel in my gut that this is something I am struggling with? Because unfortunately a lot of, a lot of medical professionals aren't aware of HA and what it really means. Just like you said, it is often used as a diagnostic criteria for women with anorexia nervosa. However, many medical professionals will say, oh, you're a normal BMI, you're healthy, you, no, no, no, no, you can't have HA, which you can have HA at any body size, whether it be BMI less than 19.5 or BMI above 25. I just want to put that disclaimer out there that a lot of women, if you feel, again, you resonate with what I'm saying, don't take that PCOS diagnosis because a lot of times that PCOS diagnosis, old school treatment of that is restriction of carbohydrates, more exercise, really watching your diet, which as women with HA or disordered eating or eating disorders don't need any more of that. [DR. CRISTINA] Even the topic of BMI coming up on here's, like, if anyone has listened to it, was like, I have such a beef with the BMI, but I know the medical doctors and communities still use that as criteria for determining all sorts of things, unfortunately, which is awful. [CYNTHIA] Yes, and that's a different podcast episode because we can go on and on about that. [DR. CRISTINA] Absolutely. But I know people hear these criteria and that's what determines all sorts of things out there in the world. But that, like you said, another topic but interesting. Probably people are like, okay, hold on a second, if I was diagnosed with PCOS, how do I know that's not true? Or if I have HA, what are you meaning? How do I know? [CYNTHIA] Yes. They're very, actually it was a couple weeks ago I recorded a podcast with a PCOS dietician. I'm not sure when this podcast is going to air, but if you go to my podcast, the Period Recovery Podcast, you might be able to catch my episode and we'll go into more detail because I don't want to spend our whole episode on diagnosing or what one is what. But a big one is do you have an absent period? Not, are you getting cycles every now and then, but do you have an absent period? PCOS is actually diagnosed based off of two out of the three criteria of heritage wisdom or elevated androgens, so testosterone levels. Typically, a woman or person with PCOS will have elevated androgens or testosterone levels and also will have abnormal hair growth. Women with HA won't have elevated testosterone levels, will not have abnormal hair growth but both of them, so this is where it gets a little confusing and this is where a lot of women that are diagnosed with PCOS when it's really HA is because the doctor is going off of the ultrasounds of seeing all these tiny little cysts in their ovaries. They're seeing cyst, which are also, or excuse me, which aren't really cysts, they're follicles. So what happens with a woman with HA is that those follicles will remain in her ovaries because they can't go anywhere else because there's no hormones there. Like there's no hormones to progress them to the next phase in your menstrual cycle. So the next phase in your menstrual cycle, you have your follicular phase, then you have your ovulatory phase, and then your rudial phase. So you can't get past that follicular phase because there is not enough hormones flowing through your body to grow those follicles to an appropriate side to release an egg. Now someone with PCOS can also have these multiple follicles, but what they will usually have accompanying with them is the abnormal hair growth and or the elevated androgens, so elevated testosterone levels. That's a diagnostic criteria and the doctor should be diagnosing you out of two out of three. The last one I didn't mention is an absent or irregular period, which you can have both with H HA and PCOS. So many women with HA will have normal to low levels of FSHLH and estrogen. Women with PCOS tend to have normal too, high FSHLH and estrogen. They're very similar. So what I want to get more into detail in talking is more of the physical signs and symptoms and the mental signs and symptoms of what is usually accompanying with HA or disordered eating or eating disorders. [DR. CRISTINA] Because all that step you just mentioned probably went over people's heads, like, what is that? That's all stuff honestly that you probably need to go to a doctor to get your hormone levels tested and really get more diagnostic testing. As anyone's listening to the podcast knows, I had PCOS. That's all stuff that I found out in the fertility clinic and found at all the levels. It takes a lot of diagnosing and a lot of testing. So if any of you listening are really curious, it does take a lot more than just listening to Cynthia here. [CYNTHIA] Yes, absolutely. None of which I'm giving is medical advice just based on what I've seen in my practice and both with PCOS and HA they're both diagnoses of exclusion, meaning you want your doctor to rule out other things that could be causing an abnormal or missing period as well. So I just want to put that out there. [DR. CRISTINA] Okay, so getting into yes, what are people seeing in their day-to-day lives? Like, what's happening? [CYNTHIA] So much. I just want to give a little bit of background. My, and I know you're, you have already explained my bio, but I was a woman who suffered from HA and this was over 10 years ago, and there was nothing around. Like, it was the textbook like, oh, you don't have an eating disorder. I mean, I went to school, I was, I'm a dietician, I went to school for nutrition. It's like, well, how didn't I know that I had this? Well, what I learned in college was that you need to have a very low BMI, you need to be anorexic. You need to either be a like really crazy athlete, low body fat percentage, X, Y, and Z. So when I found this out, I was like, no, no, no, this doesn't fit me. I don't fit this criteria. My BMI is normal. I exercise on a regular basis, but not too much. Mind you, I was exercising like two hours a day and I eat really healthy. Well, that's what society tells us. We must eat lots of vegetables and very clean. So I was caught up in, I would say I was orthorexic never diagnosed with an eating disorder. But as a dietician, I can say I had, I was either orthorexic or had very orthorexic tendencies so that's really the want and need or fixation on being really healthy. Of course, I had this image to uphold as a dietician so I couldn't gain weight. Anyway, I thought this could never be me. I ate 1500 calories each day and I wasn't losing any weight. So I thought, no, no, no, no, no, if I wasn't eating enough, I'd be losing weight. Isn't that how it works? No it doesn't. I finally, after being misdiagnosed with PCOS and taking my HA deeper because I thought back then PCOS diagnosis was to make sure you eat carb controlled, you exercise daily. really was super, super healthy. So this fed my behaviors of my timing of eating. I couldn't eat if I was hungry unless it was 10 o'clock and it was time for a snack. I couldn't not miss a workout each day. These things that I'm going to go into or something I experienced myself and are quite normal in our society today. Sometimes it's hard to really distinguish that your behaviors are truly making you unhealthy and making your period go missing. I'm going to name a few things and if any of this resonates with you, I don't want you to feel guilty because you only know and you know it, don't know if that was too many nos. But our society preaches eat less, move more and do more and so it makes it really difficult to know that it doesn't have to be that way and it's really not normal to be eating 1500 calories and working out two hours a day or when you go to the gym if you miss the day the next day that you're feeling guilty by it. Some of the behavioral things that I see in my practice and I've also experienced in the past was definitely this regular exercise. When I say regular exercise, there was a time where I wasn't working two hours a day. Maybe it was an hour a day, but I never had any rest days. My rest days were still walking or doing something that was not as intense as my sweaty hit workouts. So rest days is one of the things, feeling guilty if you don't work out or your day is completely ruined if you don't work out. Choosing exercise over other things in your life, so I could remember back in the day where on a Friday night where I should be having fun with my friends, this is before I had children, I should be hanging out with my friends, having fun. But instead I was in bed by nine o'clock so I could get up on Saturday at 5:00 AM to go work out for two hours, things like that. It it's not to say that that's a bad thing if you have exercise in your life and it's a part of your routine, but if I stayed out late and I didn't get to go to that workout, I mean my whole Saturday would've been ruined. Like I wouldn't have been able to enjoy my Saturday. That's where the red flag comes in. I'll flash forward today if I don't even work out on Saturdays anymore, but if I did plan a workout and I end up missing it, I'd be like, heck yes, I had fun with my friends. This is way better than working out. That's a little bit of a red flag in counting exercise only if, so what do I mean by that? Only if is like you get a sweat in only if it's a hit workout, only if you feel like you just got beaten to a pulp after. So exercise should be something where you're like, oh, I'm going for an exercise and it doesn't have to be anything. It could be low intense. That's a little bit of the behavioral side of the exercise component. For those of you that are listening and are like, well, I exercise for stress relief, which was totally me, I exercise for stress relief. I, at one point, found myself going to the gym for two hours in the morning working an eight-hour, nine hour shift as a clinical dietician, which was, I was on my feet most of the day and then coming home and running three or four miles. Oh, I had a stressful day at work, I got to go for a run. So that using exercise as a stress relief or as your only form of stress relief is going to worsen your missing period if you have one. I do want to take a quick side note. People that are on birth control pills will tend to get, unless their HA is very severe or eating disorders very severe, they'll still have a bleed on birth control pills but that bleed is not a real bleed, it's a synthetically induced bleed. So many women, myself included, will go years with a missing period and not know because they're on the pill. I just want to throw that out there because that's a big thing that I see. Now into the component of healthy eating. So healthy eating looks different to a lot of people, but for those that are, if you want to say caught up in diet culture, healthy eating is really limiting calories, limiting portions, limiting food groups, only eating at certain times. Again, I can use myself as such a great example. When I used to work in the hospital as a clinical dietician, I would get breaks at certain times, but I can make my own breaks. But if it wasn't 10 o'clock for my morning snack, like if I was hungry at nine, there was no eating at nine. You had to wait until 10 o'clock. That's what, that's the rule I had for myself, so lots of rules around food, around tyings of food things like, oh, I can't have a bagel twice in one day, or I can't have strawberries twice in one day. Those are some that's just scratching the surface with certain food rules. A lot of times some people will save their calories all for the end of the day because they're scared to eat throughout the day, so intermittent fasting is another thing. I'm doing this for health, it's intermittent fasting, there's been studies on it and blah, blah, blah. Don't get me started there. I see your face laughing along with me. So things like that may start out really innocent for us or potentially not so innocent. Once we start seeing and hearing people say, oh, you look so good, or you're so disciplined and we get all this positive reinforcement, it really makes it hard to hear, like, if you're hearing this or the first time, you're just learning about HA that wait, what? Because what I'm going to tell you and how to heal it you're going to be like, no, this doesn't make sense. This doesn't make sense at all. Stay tuned. We'll talk more about how do we overcome this? Really a big behavioral aspect who is avoiding social situations and whether it's avoiding them not going to them or like I was just talking to a client of mine, she said in the past if friends randomly invited me to lunch, I would not go. It just was just too random. I didn't plan for it. Now if they asked me a week ahead of time, I might have went because then I could have researched the menu ahead of time. I could have made sure I was eating a certain way throughout the day to plan for this. Luckily now she's like, they called me that day and I went and I had pizza, which is awesome. But those little things that I've mentioned, which really add up to a lot of big things are something to be attentive to because it's extremely normalized in our world today to be like, oh, I'm so hungry and I just ate. Well. Instead of someone saying like, you should eat if you're hungry, they're like, oh, chew a piece of gum or drink some water. Like, you can't really be hungry. You just ate. The fact is, if you are hungry and you just ate, you really are hungry. If you're thinking of food, maybe your belly isn't even growling, but you're just merely thinking of food, that is another huge sign that you really are hungry. Some will call it mental hunger. Mental hunger is real hunger. It's the same thing. Your body's just being really smart and not making your belly growl because that costs more energy, more burning of energy to the body and it starts to strategize, I'm like, oh, I'm going to just get her to think of food now. So yes, mental hunger is a real thing. Yes, so those are just probably scratching the surface of behaviors and things that could lead to HA, definitely not all inclusive, but those are some definitely red flags to look out to. Some of the other physical signs and some of which you would have to go to the doctor to see, but like I mentioned in the beginning low to normal lab levels, so your estrogen, your FSHLH, your LH, and your uterine lining typically is very thin with HA, which they can tell by an ultrasound, those polycystic appearing ovaries, no cervical mucus or lack of. That's if, I guess another term for it would be discharge, so not seeing any in your underwear or when you go to the bathroom. And even though some women with HA can still have cervical mucus or discharge but if you're not getting a period that's a red flag even if your doctor says it's not, because a lot of doctors will say, "Oh you're fine. Just go on the pill. You're a healthy weight, you're normal weight. This only happens in athletes or you're an athlete, this is normal." Missing period is not normal no matter what, no matter what, unless you are like maybe like 75 years old and we can confidently say that you're in menopause. But other than that, oh, or if you're pregnant, other than that, a missing period is never, never ever, ever normal. Undiagnosed infertility, so, so many people out there that are wanting to get pregnant can't all because they are not eating enough and they are not resting enough. Thus, it impairs ovulation and the proper hormones needed to produce an optimal level of sex hormones. Unfortunately, many fertility doctors, and I don't think I've met, I've had a couple clients that have said, oh yes, my doctor said I had HA and as a fertility doctor, but fertility doctors are in the business of fertility, not of trying to help you figure out why you're infertile. So you're undiagnosed infertility, I've had so many clients fall pregnant just by eating enough and resting their body enough and that helped them avoid IVF, fertility meds, because that's a whole nother mental part to that stuff too. So no libido. If you're, I know I was one of those women back in the day where I'm like, oh, like I don't, I wouldn't even care if sex didn't exist. I don't, had no desire. I just thought that was my personality, like, I'm just not into it. Well, come to find out was because I had no sex hormones and my body wasn't going to give me any libido because it thought it wasn't safe enough for me to have kids. So it's really, your sex hormone shutting down is a survival mechanism for your body. Also another thing I want to throw out there progesterone. A lot of people will be put on progesterone to see if they get a withdrawal bleed, which can be beneficial in sometimes diagnosing HA. But also too, regardless if you get a bleed or you don't get a bleed, you're not getting a natural period anyways so you still have to do the required work to get your period back, which I'll talk about in a few. Another thing, sometimes these things happen, not all at the same time or sometimes none of them will happen at all. Sometimes all of them will help them happen but osteoporosis, osteopenia, stress fractures, feeling cold all the time, tiredness, digestive issues there's a, I think a trend going, I don't know if it's on TikTok or on Instagram, but hot girls have IBS. I don't know if you've seen that. Yes, hot girls have IBS. [DR. CRISTINA] What is that? [CYNTHIA] I know. So pretty much it's just saying like, these hot girls that are like super fit and like what sexy bodies are, idolized as being thin, having abs that all these girls have IBS. And here's the thing, these girls that are experiencing this IBS are likely, which, there's real I S, but a lot of IBS and digestive issues are induced from not eating enough and having a low energy availability from too much exercise. So digestion issues is definitely usually something that comes along, not caused by HA, but it's caused by under fueling. I know I still see her face as a hot girl. Yes, I know. It's like, what, I mean, it never seems to amaze me things that are happening. Of course, tiredness, but tiredness, let me say doesn't always happen because we are jacked up on stress hormones like cortisol and adrenaline. A lot of times women that will start to recover from HA and start to eat differently and rest more, they'll find themselves become even more tired, which is super frustrating because it's like, well, I was less tired, but you are running off of adrenaline, cortisol, sex hormones, not like actual real energy. So brittle hair, skin nails, thinking about food often, and low to normal body weight. Those are just again, me scratching the surface with lots of the physical signs and symptoms. But the last component that I wanted to chat about was the psychological component. That's really important because most women, I like to say, and I've said this on a few podcasts, that all as women with HA or disordered eating are so very alike in our perfectionist tendencies. Type A personalities that if we went to a tropical island, well, I want to go to the tropical island, but, we all went to an island together, we'd be the most efficient perfect island out there and we'd all get along so well because we're just so structured and just so type A. So that perfectionist tendencies, not being able to relax, always feeling like they have to move and someone with anxiety, many struggling with disordered eating, eating disorders or HA have more anxiety and that it could be an underlying disorder of course which I'm not there to diagnose, but I can tell you many of the women I work with, after they start to eat enough and rest more, their anxiety levels start to go down and in part two, their stress hormones, their fight or flight mode has been turned off. So if you're someone that's stressed out really easy, I remember a client just telling me, she's like I used to get really mad when there was something on my coffee table that was not in the right place, like even off an inch. It would bother the heck out of me. Now I can sit there, it could be across the table where it usually is and I'm okay with it. So these little simple things, which sounds so silly feel a lot bigger than they really are. So, of course body image issues and past trauma, which many of us suffer from that have had an eating disorder disordered eating in some context. That is like HA in a nutshell of some of the things to look out for and I'd be happy to go into detail of any of them or we can talk about, all right, well, now that I think I might have this, how the heck do I get rid of it? [DR. CRISTINA] It's just, you were talking, I'm just going, it sounds, I mean, so much of it sounds like everybody who's got an eating disorder. Like it's just a lot of it, just the perfectionism, the compulsion with the exercise, the need to exercise if you don't, the ramifications of feeling guilty and needing to exercise more. I mean, I'm sure a lot of people listening are going, yes, yes, yes. And so it does get confusing because society does really praise and just support people engaging in so much of this and so it does get confusing. People in my office going why it's so confusing, it seems like society's saying, much like you were saying you can read my face, like intermittent fasting seems like it's a "healthy" thing to do, or exercising so much seems like it's healthy to do. So how do people really tease out like, what's healthy for me to do and what's actually hurting my body? [CYNTHIA] I know, it is so, so confusing. I mean, it was confusing for me for a really long time, and when I was diagnosed with HA, I was just like, no, this doesn't add up. Especially as a dietician, like, I went to school for five years and learned all this stuff and I'm like, this just doesn't make sense and gosh, I hope they changed curriculum. But anyways it just, it didn't make sense and it was really confusing really for a really long, long time. Some things that have helped me obviously, furthering my education continuing education, learning about the other side of dieting, which is called anti-diet or not diet culture. So you might, I don't know if you talk about that a lot Cristina [DR. CRISTINA] Oh yes. [CYNTHIA] Not diet culture. So things like that I just really filled myself with the other side of nutrition, the side where there can be unicorns and butterflies that you can still maintain a "healthy" way of eating, healthy way of exercising and be free of all of those thoughts that occur in our minds on a like secondly basis. So I hear you. If you are feeling confused start to educate yourself and seek support from people that can help you. I'm not talking like your best friend or maybe your husband, but somebody that can professionally support you in really debunking, in giving you the truth behind a lot of things that you hear in the world. I do want to say what even makes it more confusing, Cristina, is our healthcare community. I don't want to say everybody, they're not, not everybody, but in my practice and my experience, more medical professionals than not are unaware of HA and will tend to treat with a birth control pill, which now studies show that it doesn't protect the bones like we once thought if the person is under fueling, or telling the patient like it's no big deal, or telling the patient like, oh, you keep exercising and eating healthy. You sound like you're doing really great, come back in three months or come back in six months. This HA, disordered eating, eating disorder problem is bigger. It's starting from so many different places. We could have a separate podcast about this, which I'm sure you have a million different episodes, but our medical community definitely makes this a little bit harder to navigate, especially if we were raised with the school of thought that we listen to what our doctors say and if our doctors say one thing that means that they are 100% right when they're just humans, like you and I. I know for you Cristina, like if someone was asking you to educate them on kidney disease or like talk about it, you'd be like, okay, like I maybe know about it. Same thing for me, if someone was like, oh, Cynthia, I want you to help me with nutrition for gout and gout, it's just a, I'm not even going to go into what it is. It's the first thing that came to my mind. I'd be like I am not an expert in that. So everybody isn't an expert in everything and you know your body best and if you're not sure if you know your body, then reaching out to someone who could support you and help you figure out and advocate for yourself to find out what's really going on because, oh, I didn't even get into the fun part of what happens if you let HA, a missing period go on for a long time and osteoporosis, osteopenia, infertility, heart disease. They're now studying a lot of how lack of estrogen is playing a critical role in women's heart health and cognitive disorders later on Alzheimer's. That's just the biggies. Those are like the big, big, big health problems. Then there's the smaller ones where digestive issues, which maybe not be, it will be so small, lack of libido, just things that are affecting your everyday life, but that estrogen that you don't have if you don't have a period is so crucial in your health, so crucial and can just affect so many things in a negative way. Those are some of the downfalls. There really is no benefits to having HA. I'll get comments on my Instagram sometimes and they'll say, oh, I'm so glad I don't have my period. It's like, okay, so you're so glad that you're putting yourself at risk for this, this and this and this? I once too thought way back when, because nobody taught me about periods and menstrual health and all that and how important it was. Because I too was like, oh, nice, I don't have my period. Like, awesome. This wasn't, before I knew I had a problem was like, oh cool. Am I having a period, like this is convenient when it's just, it's so much more than convenience. I think anyone who has suffered from a lack of and know now that it's a problem are going to be so excited to have a period each month. I know I do. I know to this day I've had a regular period for a really long time now, and each month I'm like, yes, this is awesome. Well, not when I'm getting cramps but yes. So aside from that do you want me to get into, all right, how can we, how can we resolve this? Because it's definitely resolvable. [DR. CRISTINA] Yes, but before we get into that, just really quick, because I know some people might be asking, what if I'm on that pill that I just keep taking and taking and taking and I never get my period? I like that. I want to keep doing that because I like having no period for forever and ever and ever. [CYNTHIA] Yes, that is a great question. Again, I can't tell you like to go on or off the pill. I'm not a doctor, but I can tell you that without being off of the pill, you're not going to know if you're progressing to get your period back. So if you're like, all right, I know I have a problem, this sounds like me, I'm going to go off the pill to see, do talk to your doctor first, discuss this with your doctor. You should always review stuff with your medical, but it's hard to tell. What I tell my clients, it's you can continue on the pill if you want to, but it's really hard to tell if you are making steps towards getting a regular natural menstrual cycle when you're on the pill. So things like, what I look for in my clients is cervical mucus, increasing different changes breast tenderness, libido those are just a few of the things that I'll look out for, which is, you can't tell on the pill because it's suppressing ovulation. If like not getting a period, I hear you. It is like not the most fun thing to have, but if you feel like you can resonate with a lot of things that I'm chatting about in your behaviors of around food and exercise it's worth exploring. Because again, the pill does not protect your bones like we once thought it was if you are under fueling, if you are truly under fueling. You have to have adequate levels of energy availability for the pill to even protect. Does that answer your question? [DR. CRISTINA] Yes, absolutely. Yes, absolutely. Let's get to like what on earth do people do? Like what? [CYNTHIA] So what I'm going to explain is just going to be more from the dietician component, the nutrition component. I believe there's a lot more that should go into HA recovery because again, we lost our periods because we were not eating enough and we were exercising too much. But why were we not eating enough and exercising too much? What are the behaviors behind that? So exploring that is important and sometimes, depending what it is, it may take external help along with a medical professional that knows about HA such as a therapist because a lot of times it is very behavioral and it's more than just the food and the exercise component. So I'm going to just talk about the food and the exercise component because that's my area of expertise. eating enough is one thing. You might say, well, how do I know if eating enough? Everybody is different. There is a book called No Period. Now What by Dr. Nicola Rinaldi. Have you ever heard of it before? [DR. CRISTINA] No. [CYNTHIA] It's a really great book. Dr. Nicola Rinaldi, also now known as Dr. Nicola Sykes, she wrote the book, it's called No Period. Now What? It has like, everything you need to know about HA, the science behind it and it's a really great book. In that book, and I'm just going to use calorie levels for contacts. I'm not a fan of counting calories. I don't encourage my clients to count calories. [DR. CRISTINA] Thank you for that [CYNTHIA] Yes. In contexts, I'm just going to use it just for numbers and I don't like to talk numbers, but I want to give you guys a better picture of how much you need to eat. Recommendations, and this was Dr. Nicola Rinaldi, she compiled some studies and found that 2,500 calories is like a good generalized amount of food that a person might need to recover. Regardless, you need to eat more than you are. It could be double the amount, it could be triple the amount, it could be just a few minor tweaks and changes, but eating enough is cornerstone because we need to build up our energy availability. Low energy availability is pretty much what you have if you have HA. Your body is shutting down all non-essential functions like your sex hormones, sometimes your digestion and preserving it for your breathing, for your heart beating. So we need to build up this energy availability. That means not only eating what our body needs to eat each day, but eating, I can't even call it surplus because you're in a deficit already, so it's not even surplus, it's enough. We'll just call it enough. You need to eat enough for your day-to-day functions and also think about putting money into a bank. If you keep on drawing money from a bank, you're going to eventually have no money in there to take from so you have to build that bank back up and that requires eating what you need to for day-to-day activities, then some. Just using that 2,500 for context likely will mean not eating as many vegetables. Vegetables are another cornerstone where it's like, my gosh, got to eat vegetables every day to be healthy. No, you will survive, people, a day, even a week, even a month, without eating vegetables. So switching up, and what I encourage my clients to do is focus on the carbohydrates, focus on the fats and some protein. A lot of us are heavy on the protein, the lean proteins, the protein powder, and we really need to meet more cognizant on the carbohydrates. Those are the main energy source for the brain. Fats are so important in hormone production. So focusing on carbs and fats, eating consistently throughout the day, so not saving all your calories for nighttime, not skipping lunch, not skipping breakfast. I often encourage my clients to eat every two to three hours. I also encourage them to eat, even if they just ate, meaning if they just had lunch and an hour later, they're hungry. But my recommendation was every two to three hours that trumps it. If you're hungry, you need to eat. For those of us that are out there that don't have an appetite back yet, that eating consistently in eating more of the carbs and the fat sources will eventually turn your appetite back on and you will eventually become hungry again. Those are some cornerstones. Eating, of course, breaking the food rules, challenging yourself and then the exercise component. We really want to cut out anything intense and that I'm going to just define as anything that's getting your heart rate above a hundred beats per minute. You might say, well, I don't know what my heart rate is. I know most of us wear a tracker on our wrists, so we can probably tell by then but rule of thumb is if you're taking a walk with a friend and you try singing a song and you can't like sing it normally or at a understandable song, then you're probably walking too fast or doing something too intense. But then we run into the problem of, okay, well I heard some say I just had cut out my cardio, my intense, well, I'm going to go for two hour walks every day, no, no, no, no, no. We also have to be cognizant of the frequency and the duration. So not only the intensity, it's the frequency and duration. I work closely with my clients on that to reduce and eliminate intense exercise because it's cornerstone also. The food component, the exercise component, what are bodies looking at exercise like? Because I know all those say, I mean, I know this is me too. Well, I just feel so good after I get a run in or I do a hit training. You do, you absolutely do but what you're not seeing is the physical stress that's happening to your reproductive hormones while also increasing your stress hormones, which our sex hormones will never turn back on if we continue to keep our stress hormones high, the cortisol adrenaline. That's the importance behind it. I'll work with them to say like they're like, well, what am I going to do with my extra time? I used to work out two hours a day, I used to work, so we work together in exploring like, what are some other things that you'd like to do? What are some other things that bring joy in your life? Because eventually we want to have this balance where we are able to exercise, we're able to do things that make us happy and not feel guilty about not exercising on a daily basis. Those are the biggies. Then working on that mental stress component is another huge cornerstone. But that too is not my area of specialty. I am not a therapist, I'm not a psychologist, psychologist whatever doctor that works with mental health, I'm not that person, but I can certainly help you make mindset shifts. But if it's deeper, if you feel, all of my clients working with a therapist is like, awesome. It is such an enhancement to your period recovery journey. Those are really the three biggies is enough food, enough rest reducing that intense exercise or eliminating it, then the mental health component of it all. And then to not spend too much time fixating on period recovery because we were used to fixating on food and exercise and now we have this other issue so taking time to take a break from period recovery too as well. Again, that's in a nutshell. Easier said than done. I can tell you if you haven't gotten this book either doctor, no, no, she's not doctor, Lisa Hendrickson Jack, it's called The Fifth Vital Sign. It's another book. It's all about periods, like if you want to learn about painful periods endometriosis, like anything, it's all in that book. But she has a special few pages on HA and she really emphasizes the importance of getting the right support with HA treatment because again, what I just said is you need to eat more, you need to rest more, you need to pretty much do the opposite of what the rest of the world is doing, which makes it difficult, really difficult to do alone. [DR. CRISTINA] I'm so glad you said that because I know a lot of what I talk about on this podcast is so counter to what the rest of the world says. It's so hard to implement some of these things because I know anybody listening, I know when I was in my eating disorder, I would've been like, oh, that's so scary. How the hell do you do that? [CYNTHIA] Seriously. [DR. CRISTINA] But I'm just sitting here thinking how great would it be for somebody to work with you and then somebody like me and have that support of like you, the expert will be like, this is what you need to do. I know it's scary. Go get support for the anxiety or the fears that come up and learn some other coping skills, some ways that deal with the stress and really just do that. Give yourself that gift to be able to have a team with you as you're going through it, because you really can't do it on your own, especially living in this world and in this society, which is bombarding you constantly with the messages that everything we're saying to do and you're saying to do is like not okay and counter to everything you want to be doing that maybe you're doing in your life right now that's so reinforced by everything you're reading or hearing. Because it's hard. It's so hard. [CYNTHIA] So hard, so hard. I still, I'm like, how, I mean, how did I recover from HA and I was able to do that, but I also sought other professional help for my mental status as well in conjunction with. I think it's possible to recover from HA by yourself but I find the people that do that don't make a full recovery. What I mean by full recovery is the ability to live life without constant thoughts of like, should I eat this? Should I not eat that? Can I exercise? Can I do this? Can I, oh my gosh, I just eat that and I get these million thoughts that are going through our head. Because you can have a period and still be having all these thoughts, but wouldn't it be so much more amazing to have a regular cycle, know that you're physically healthy but also mentally healthy and you're just able to live the life that you were put on this earth to live. [DR. CRISTINA] Absolutely. That is, I think, a great way to end this because, that's such a positive, positive message. So people probably like, how do I work with her? How do I find her? If they want to find you, if they want to work with you, how can they do that? [CYNTHIA] I say the best place to find me is usually on Instagram. I have tons, a tons and tons of content there for you guys to comb through. If you're like, sign me up yesterday, Cynthia, we need to talk, there is a link in my bio on Instagram that will give you a direct link to my calendar and we can set up a coaching, or excuse me, discovery call where I'll tell you a little bit more about me. I'll want to learn a little bit more about you to see if my coaching would be a good fit for you. Then also if you want to go to my website, it's periodnutritionist.com and I have more information about things that I offer. I also have a podcast which I know so many people find helpful because, just being able to relate, like you said, like in a world that is doing the opposite of what we need to be doing to truly be living a healthy life, knowing that others are going through it and hearing their stories are really powerful. Yes, those are some places that you can find me, but I am so appreciative that I was able to hop on the podcast with you, Christina, and share this information that is just so important that we don't normally talk about or hear about in the world today. [DR. CRISTINA] No, and I'm so grateful for all of the information you shared. I know we could talk for forever. Seriously there's so much to share. I'm just, I'm so grateful we finally got this topic on the podcast. It's so needed and I know that whoever's listening today got so much out of everything you shared. So thank you, thank you so much. I'll have all your information in the show notes, so if you didn't get that all written out when she shared it, don't worry, I'll have it all there for you guys. So thank you again so very much. [DR. CRISTINA] This podcast is designed to provide accurate and authoritative information in regards to the subject matter covered. It is given with the understanding that neither the host, the publisher or the guests are rendering legal, accounting, clinical, or any other professional information. If you want a professional, you should find one.