Macronutrients and Hypothalamic Amenorrhoea

Written By Holly Dunn

Macronutrients and their role in HA recovery

Hypothalamic Amenorrhoea (HA) is a functional disorder characterised by chronic anovulation and loss of menstruation without an identifiable organic cause [1]. Whilst the causes of HA may be complex, it is well documented that undernutrition is one of the most common triggers and drivers of this hormonal circumstance.

The good news is that HA can be reversed by identifying and rectifying the factors that led to its development. The next few blog posts will look in more detail at the nutritional aspects that may need to be considered when it comes to HA, starting with macronutrients.

There is so much information out there about diet and nutrients, with many supplement companies promoting products to help women balance their hormones and achieve optimal health. However, no supplement can fix a diet that is lacking in essential nutrients. As there is little doubt that our diet influences the health of our menstrual cycle [2], I’d like to explain how changing the amount, timing and types of food we eat can have a direct impact on our periods.

It can’t be overstated that the first step towards recovering and sustaining a healthy period is getting the basic foundations of nutrition in place, starting with macronutrients.

What are macronutrients?

Dietary macronutrients are nutrients needed in large amounts and are those that provide us with the energy and basic building blocks our bodies need to function. They include carbohydrates, fats and proteins. Micronutrients, such as vitamins and minerals, are also crucial but needed in much smaller amounts. Foods that contain macronutrients will also contain micronutrients. For example, meat is rich in protein and contains micronutrients like iron and B vitamins. I will be covering macronutrients in this article and micronutrients in the next.

Nutrient status and the menstrual cycle

The fact that girls on a typical western diet, high in protein, fat and carbohydrate, are getting their first periods (menarche) younger and younger is perhaps the most compelling proof that macronutrients have a direct influence on the menstrual cycle. Studies have shown that this ongoing trend for the past fifty years is due mostly to modern dietary factors [3, 4, 5, 6]. The same can be said for girls who have delayed or missing periods with malnutrition and low-calorie diets [7] defined as key factors.  

Research has shown that hormone fluctuations during your cycle influence not only the levels of nutrients in the body and what extra nutrients you may need [8, 3] but also your appetite, dietary choices and behaviours [9, 10] including:

  • Changes in appetite-regulating hormones [9]

  • Emotional eating and cravings [8, 10]

  • Changes in carbohydrate [11], fat [9] or protein [12] demands and intake

  • Depletion of mineral stores, such as iron during menstruation [13]

Yes, there are scientific studies that demonstrate a clear relationship between food and your menstrual cycle. In fact, an obsession with chocolate right before your period may not be ‘all in your head’.

Fluctuating hormone levels can mean different nutrient needs at different times of the menstrual cycle

Your diet and nutrient status can influence your menstrual cycle and vice versa and these changes will be different for everyone, depending on individual physiological and psychological demands. This is why I work one-to-one with clients to assess their unique needs with detailed clinical analysis, including testing where appropriate. If you’re curious about what kind of laboratory tests I can run for you, please get in touch for a quick free call so we can discuss.

So, what does this mean for you if your period is missing?

Food is energy

Macronutrients in food, especially carbohydrates and fats, are what provide our bodies with energy. Low energy availability is the simplest and best-understood cause of HA. Menstruation is an energy-intensive process, so it makes sense to ‘turn off’ this function during periods of energy scarcity. Without enough energy to sustain the total work required by the body, a metabolic ‘survival mode’ is induced whereby non-essential physiological processes are rendered dormant to preserve energy.

Recent studies have suggested that there is no ‘threshold’ of energy availability below which menstrual disturbances are induced [14]; the energy threshold is different for everyone. Subsequently, it may not possible to give accurate estimations of energy (calorie) needs for HA recovery. Requirements are also very individual and dependent on a wide variety of complex factors, including genetics, metabolism, physical activity and dietary composition [15]. Therefore, a ‘one size fits all’ approach does not work well with HA clients, and I encourage anyone with HA to work with a qualified practitioner to get targeted support.

Research has identified that energy balance across the day can also be important in the context of menstrual disturbances. In a study on athletes [16], it was found that participants suffering from menstrual dysfunction spent more time in a catabolic (fasted) state compared to participants without menstrual disturbances, even though both groups displayed a similar energy balance and availability on the day as a whole.

More time spent in a catabolic state was associated with a lower resting metabolic rate, lower oestrogen and higher cortisol (stress hormone) levels. GnRH (a hormone regulating reproductive function) is released hourly from the hypothalamus and so reduced energy availability at specific intervals during the day could be enough to cause menstrual dysfunction.

What all this means is that the timing of meals and snacks is as important as overall energy consumption. For a handy reference of all the nutrient factors in relationship to HA, check out my overview on Instagram here.

Those in recovery from HA should avoid long periods of time without eating and this is consistent with improvements I see in clinic. Timing food intake may have positive effects even without an increase in total calories.

What are carbohydrates?

Carbohydrates are the body’s preferred energy source, particularly for the brain and red blood cells. Eating enough carbohydrate is essential to ensure sufficient energy availability for all bodily functions, including menstruation. The most concentrated sources of carbohydrate are foods high in starch, such as baked goods, pasta and rice, or foods high in sugar like fruits, sweets and honey. Technically, the fibre found in some of these foods is also a type of carbohydrate, but your body can’t use or store fibre as energy.

When we eat carbohydrates, our bodies break them down into a simple sugar called glucose, which can be used immediately or stored in the form of glycogen. Depletions in glycogen due to low carbohydrate intake reduce the availability of easily accessible fuel to the body. This has been shown to lead to disruptions in normal ‘pulses’ of LH or luteinising hormone [15], as well as elevations in cortisol [17], both of which are commonly associated with the development of HA.

We have been living in a ‘carb-phobic’ society for the past few decades with the food industry embracing and promoting this trend. In fact, many of us have been convinced that ‘carbs’ are unhealthy. At one time I also believed that carbs were to be avoided and it took me a while to lose my ‘carb-phobia’.

Today, a lot of my work in clinic involves unravelling the science behind various food trends and helping women feel safe about re-introducing certain foods they have been convinced are unhealthy.

Observational studies have shown that individuals with HA often have a low intake of carbohydrate-rich foods, combined with a higher intake of fibre [18]. These two factors together can contribute to a diet that is lacking in overall energy density and availability. Whilst fibre certainly provides a plethora of benefits to our overall health, too much fibre in the diet can contribute to excess bloating and gut distress, whilst contributing to factors that may drive HA, namely:

  • Reduced energy density and availability (fibre is indigestible, so provides no energy)

  • Increased fat excretion, further reducing energy resources

  • Prolonged satiety (feeling full), decreasing hunger and appetite

  • Fibre may also bind to oestrogen [19] causing it to be excreted instead of recirculated, causing lower oestrogen levels (a characteristic of HA)

Consuming carbohydrate-rich foods may also contribute to normal levels of brain chemicals tryptophan and serotonin, both of which have a positive influence on mood, emotions and sleep. Whilst research is poor at present, this could mean that low carbohydrate intakes may be detrimental to mental health and stress. As stress is a known factor contributing to the development of HA, this provides further support for the importance of adequate carbohydrate intake during recovery from HA.

Simple vs Complex

While I encourage most clients on ‘low carb’ diets to increase their intake gently, I generally recommend that complex carbohydrates are favoured over more simple ones. Complex carbohydrates are digested more slowly and have a favourable effect on blood glucose levels, avoiding the highs and lows associated with the ‘sugar crash’. Furthermore, high consumption of highly refined carbohydrates and sugar can, through the modulation of the gut microbiota amongst other mechanisms, promote a pro-inflammatory state in the body [20, 21] which may slow recovery from HA. 

My favourite carbohydrate foods:

Fat – your high energy super nutrient

The most energy-dense macronutrient is fat and foods high in fats may be advisable for HA recovery as an efficient way to restore energy balance.

Fats also supply the necessary building blocks for hormones, including oestrogen and progesterone, and are the bedrock of the nervous system. All of these are involved in regulating the menstrual cycle, so it makes sense that diets low in fat may be problematic in the context of HA and menstrual health.

Like carbohydrates, fats fall into different categories, according to their structure and physiological function. Given the specific hormone environment associated with HA, certain fats may be more beneficial than others, but it is important to retain a balanced understanding of why this is the case. It is also important to remember that there are several subtypes of fats not covered here and most food sources of fat are made up of a few different types of fatty acids. Below, I’ve covered the ones I think are most important to highlight.


Omega-3 Fatty Acids

Omega-3 fatty acids have a role in reducing inflammation associated with a variety of mechanisms relevant to women with HA [22, 23]. These healthy fats contribute to the formation of anti-inflammatory signalling molecules and have numerous physiological effects in the body. There is also evidence to show that omega-3 may improve menstrual dysfunction and fertility [24].

In HA, low oestrogen and high cortisol may lead to the development of a pro-inflammatory state. Although direct evidence in relation to HA is lacking, a 2014 study [25] found elevated levels of pro-inflammatory cytokines (signalling molecules) amongst menopausal women and suggested that this was due to impaired functioning of monocytes and macrophages (immune cells) resulting from oestrogen deficiency. These pro-inflammatory chemicals are also thought to be associated with the development of several chronic diseases including osteoporosis and cardiovascular disease. Given a relative dearth of comparative studies, these findings are interesting in the context of HA – a condition characterised by low levels of oestrogen.  

Whilst ovulation is known to be an inflammatory process, the levels of pro-inflammatory and anti-inflammatory cytokines are tightly regulated throughout the body. Emerging evidence, although limited, suggests that elevation of certain inflammatory cytokines above normal physiologic concentrations could have the potential to inhibit ovulation [26].

Omega-3 fatty acids have also been suggested to reduce perceived stress and anxiety during pre-menstrual syndrome and menopause when sex hormones are lowered as they are in HA [22]. A large body of evidence supports that omega-3 fatty acids play a role in limiting neuroinflammation via several mechanisms including downregulation of genes involved in inflammation and induction of lipid mediators that aid its resolution [27]. Moreover, there is evidence to suggest that omega-3 plays a role in menstrual cycle events, including egg maturation and embryo implantation [28].

Currently, UK public health guidelines recommend eating at least one portion of oily fish weekly to obtain adequate omega-3. If you don’t eat fish, it may be important for you to take a high-quality algae-based omega-3 supplement. Please note that vegetarian sources of omega-3 need to be converted to the longer chain EPA and DHA (fatty acids derived from oily fish and algal sources). Since this process is not very efficient, supplementation may still be necessary. I often help my clients assess their needs by analysing their intake and through lab testing when necessary.

Saturated Fats – helpful or harmful?

Saturated fats are ones with a rigid molecular structure and therefore generally are solid at room temperature, e.g. butter, coconut oil, and fats in meat. Unsaturated fats have a more fluid structure and therefore are more liquid – olive oil and fish oils fall into this category.

Many have labelled saturated fats as ‘bad’ because high consumption has been linked to higher levels of cholesterol and therefore increased risk of heart disease. Despite the controversy in this area, recent systematic evidence suggests that reducing saturated fat intake for at least two years does cause a potentially important reduction in cardiovascular events [29].

One of the consequences of oestrogen deficiency in women with HA (and post-menopause) is a potential change to blood cholesterol levels, including elevations of LDL (“unhealthy”) and total cholesterol, alongside reduced levels of HDL (“healthy”) cholesterol. This, alongside other changes to the vascular environment, is one of the several reasons that those with HA may be more at risk of cardiovascular disease [30, 31].

Unfavourable changes to blood cholesterol levels are something I see a lot in clinic, and this can understandingly cause alarm. Especially when conventional advice is to increase exercise and decrease intake of saturated fats (dairy products, red meat, coconut oil and fried foods). But this is not best practice or the “nutritional” priority when recovering from HA unless there are other risk factors that have been carefully assessed by a healthcare practitioner.

Nutritional recovery involves incorporating a wide range of foods including a variety of fats with an emphasis on polyunsaturated fatty acids (omega-3 and -6) and monounsaturated fats (olive oil, avocados and olives), alongside moderate amounts of foods rich in saturated fats including dairy and red meat. I hope this offers some reassurance and peace of mind if you are working towards recovery.

It may also be helpful to remember that cholesterol and saturated fats are important for our overall health. Cholesterol creates the steroid base that hormones are made from, including oestrogen [32]. In fact, when cholesterol is absent in the diet, our liver takes over production. Both cholesterol and saturated fats are also found in the membranes of our cells and help maintain structure, whilst unsaturated fats facilitate membrane fluidity [33].

For an overview of this topic, please watch the video I posted on Instagram here.

 

My favourite fat-rich foods:

  • Oily fish for Omega 3’s  – e.g. salmon, mackerel, anchovies, sardines, herring (if you are vegan you can take an algae-based supplement)

  • Nuts  – raw or gently roasted

  • Flax, chia, pumpkin, sesame and hemp seeds – great to add to smoothies

  • Avocados and cold-pressed olive oil – source of oleic acid, great to use in salads or for sauteed, lightly baked dishes. Cold-pressing preserves more of the antioxidant content of these oils, but regular oils can also be used

  • Full-fat dairy – source of calcium, phosphorus, iodine, B vitamins, potassium and vitamin D. Despite their saturated fat content, dairy foods like milk, cheese and yoghurt appear to have a more neutral effect on cholesterol levels, whilst consumption of full-fat dairy is associated with positive fertility outcomes [34]

  • Red meat and poultry – the fat in red meat adds more flavour and is healthy in the right quantities, especially if the animals were grass-fed and organically raised. However, if you can’t afford to buy your meat this way, life (and health) goes on!

  • Butter – butter is rich in retinol (vitamin A) and is about 3-4% butyrate, an important fatty acid used by our gut cells for fuel. Again, you may choose organic/grass-fed dairy… but you are still a good person if you don’t!

Protein – the building blocks our bodies need

Proteins are true multi-taskers. When eaten together with carbs, they keep our blood sugar and energy levels stable. They also provide structural ‘building blocks’ for our bodies, helping to synthesize hormones, enzymes, neurotransmitters, antibodies, muscles, skin, hair, nails and more.

Adequate protein is important for menstrual cycle regularity and requirements have been found to increase during the luteal phase of menstruation due to an increased protein turnover helping to build the endometrial lining in preparation for a possible pregnancy [9]. Therefore, protein intake may be especially important during this phase to prevent menstrual disturbance.

Did you know that protein makes up roughly 50% of the volume of bone and about one-third of its mass?

Many don’t realise that healthy levels of protein are also necessary for strong bones. HA may impair attainment of peak bone mass and/or lead to bone loss due to a combination of undernutrition, oestrogen deficiency and other endocrine disturbances [35]. Therefore, optimising bone health is a key consideration in HA recovery to reduce risk of fractures and osteoporosis. Getting enough protein, in addition to calcium, magnesium, vitamins D and K2, is key for bone health for everyone, and especially important in HA where the microarchitecture of the bone can become vulnerable [36].

Stress may be associated with increased protein breakdown. Studies have suggested that the presence of cortisol leads to a diminished glucose uptake from muscle cells, combined with an elevated rate of protein degradation in an attempt to ‘free up’ amino acids to be used as an energy source [37]. As chronic stress is often present among individuals with HA, it may be important to ensure adequate protein intake to support protein turnover. 

When it comes to protein in HA recovery –  can there be ‘too much of a good thing’?

Protein-rich foods promote satiety and protein has a well-known ‘thermic effect’, meaning there is a higher energy cost for its digestion. In the context of HA, high protein intakes are perhaps counterintuitive considering that recovery often aims to improve energy balance and/or body composition via an increase in adipose (fat) tissue mass.

Conversely, increased protein intakes have been associated with an increase in lean tissue mass and a decrease in fat mass, which may drive disruptions to hormones like leptin (a hormone that controls appetite) [38] and to a lesser degree, oestrogen. Caution should be taken to make sure protein in the diet doesn’t crowd out the other two necessary macronutrients, fats and carbohydrates, especially in those with HA who are trying to recover their periods.

Finally, protein-rich foods are often good sources of micronutrients, many of which have important roles in the context of HA, but more on that in the next post!

My favourite sources of protein:

  • red meat including beef, lamb, pork, venison and duck

  • organic free-range chicken and eggs

  • oily fish (salmon, mackerel, anchovies, sardines, herring)

  • seafood (muscles, clams, crab and oysters)

  • white fish (cod, haddock, sea bass)

  • beans, lentils, chickpeas and other legumes

  • organic, non-GMO tofu

  • nuts and seeds

  • full-fat dairy

  • collagen and other quality-assured protein powders when necessary

Take-home messages:

  • Each of the macronutrients has an important role to play in HA recovery, so we should aim to get a good balance of all three

  • It is not just what or how much we eat that is important in the context of HA, but also when we eat. Try to avoid long periods without eating

  • The source of macronutrients is also important, please refer to the lists above for my favourite food sources

  • Carbohydrates should be embraced and not feared as they are your body’s preferred energy source

  • Whilst excessive protein intakes are discouraged in HA, protein is needed in adequate amounts to support a healthy, regular menstrual cycle and to mitigate side effects and health consequences associated with HA

  • Adequate intakes of Omega 3 fatty acids may help protect against inflammation associated with HA and provide other clinical benefits

  • Even those with raised cholesterol can still benefit from healthy saturated fats in the diet – there is no need to exclude them

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This article was researched with the help of Emily Boorman (BSc Human Nutrition), a Band 4 Dietetic Assistant Practitioner and a wonderful intern at Holly Dunn Nutrition.

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Holly Dunn
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