More than 15 percent of American women develop hypothyroidism during their adult lives.
A fair number more, says the American Association of Clinical Endocrinologists, suffer from symptoms of hypothyroidism without ever being diagnosed.
Thyroid hormones, as many of you know, are responsible for delivering energy to cells in the body. Their role in good health cannot be understated, as they are some of the most powerful engines the body has to work with.
Hypothyroidism is the condition of having sub-obtimal thyroid performance. I have talked extensively about how poor thyroid function impairs fertility (see Carbohydrates for Fertility and Health, for example). I also, in the post 19 Signs You May be Hypothyroid, discussed how poor thyroid function can cause hair to fall out, nails to grow brittle, the body to feel constantly cold, concentration and mood to falter, and digestion to slow down enough to cause constipation. Thyroid hormone is absolutely crucial for good health and energy.
It should come as no surprise then that thyroid hormones play a critical role in maintaining a healthy gut lining. Without adequate thyroid supply, gut health can suffer. The good news however is that overcoming hypothyroidism – or supplementing with thyroid hormone – can have powerful healing effects on the gut.
Here’s what we know:
Hypothyroid rats experience increased rates of stress ulcers
Rats which have previously had their thyroid glands removed respond much less positively to digestive stress than healthy rats. Researchers discovered this by subjecting both these hypothyroid rats and healthy rats to something called “restraint stress” – which is basically the most humane way researchers claim to be able to think of to stress animals out without causing them pain or stressing them too much. They tie them down.
When stressed, the rats which have had their thyroid glands removed have a significantly increased incidence of stress ulcers when compared to controls – nearly three times as much. However, and very interestingly – if these rats are given T3 thyroid hormone replacements before being stressed, then their ulcer rates fall down to the same level as healthy rats.
Having robust thyroid levels appears to protect the rats’ guts from ulceration.
Hyperthyroidism prevents stress ulceration
In this study, researchers administered excess thyroid hormones to healthy rats two days before inducing stress, and these rats were also found to be fairly immune to gastrointestinal ulcers. It was found that both T3 and T4 (the precursor to T3) reduce the length and the depth of stress ulcers. This is an important point: not only do the ulcers decrease in terms of quantity, but also in terms of severity.
Administration of thyroid hormone in early stages of stress helps heal stress ulcers
This study investigated the efficacy of thyroid hormone when applied not prior to the stress, as was the case for the previous studies, but rather at the beginning of the stress.
In previous studies that gave the rats extra time before the stress, the surplus of thyroid hormones could strengthen the gut barrier before the stress attacked it. Instead, in this study, it was impossible for the gut to be “prepared.” Thyroid hormones needed to be able to support or “fix” the gastrointestinal lining after the stress had already started to abrade it.
The researchers found that rats administered either T4 or T3 during stress suffered significantly fewer lesions than those which did not receive any hormones.
T3 and T4 prevent and help leaky gut because they protect mucus in the gut
Each of the studies I cited above refers to gastric ulcer formation. It is quite well established in the literature that ulcers are related to stress and can be in part remediated with supplementation or (most likely) improvements in thyroid health.
What about “leaky gut”?
T3 and T4 appear to be protective against leaky gut and irritable bowel syndrome. This is in part because these hormones have “anabolic” and “trophic” effects on the mucus that coats the gut lining. “Anabolic ” and “trophic” are fancy ways of saying “growth promoting.” They promote the growth of gastric mucus by increasing RNA and protein content within the mucus cells.
Basically, they provide more energy to the mucus in the gut so that mucus cells can develop, perform, and proliferate. This helps the gastric mucus to be strong prior to stress, and can also strengthen the gastric mucus during stress. Gastric mucus coats the intestinal lining and protects it from irritation, abrasions, and permeability.
Moreover, Thyrotropin Releasing Hormone (TRH) increases stress and plays a role in stress ulcer formation. TRH is produced by the hypothalamus in a response to a perceived thyroid hormone deficit. TRH is known to increase stress and high levels of it have been found in the gastric mucus of stressed out rats. Thus, TRH may act in a “paracrine” manner in the gastric mucus, causing it to decrease it in quantity and production. TRH levels only increase in response to low T3 and low T4 levels. Researchers in this study suggest that TRH levels may be a significant culprit in gastric mucus deterioration; therefore, supplementation with thyroid hormone or restitution of thyroid health may help prevent the gastric mucus from deteriorating.
Implications for thyroid and gut health for women
One problem women often run into when trying to heal themselves is the vast interconnectedness of various health problems.
For example, curing thyroid problems may be able to remediate gut issues, but the vast majority of women with clinical hypothyroidism have Hashimoto’s Thyroiditis, which is an autoimmune disease thought to be caused by leaky gut. This leads us to a bit of a chicken-and-egg question: does poor thyroid function cause the gut problem, or does the gut problem cause poor thyroid function? does healing thyroid function fix the gut, or does healing the gut fix the thyroid gland? should we focus on healing the thyroid gland, or should we focus on healing the gut?
Many women, especially those with Hashimoto’s Thyroiditis, may find that they need to first and foremost prioritize steps they take to heal their guts (an Autoimmune Protocol Diet, for example, or a low-FODMAP diet, or being sure to supplement with fermented foods like these or a probiotic supplement I recommend like this one). If women who have Hashimoto’s do not heal their guts, then their bodies will continue to create antibodies that attack the thyroid gland and make thyroid health worse and worse.
Women who do not appear to have Hashimoto’s Thyroiditis but instead simply have low thyroid levels due to stress, a low carbohydrate diet, or undereating or overexercising, may wish to take this news from today to heart and get serious about rectifying their diet and lifestyle choices. If you subject yourself to too much stress, if you eat too few carbohydrates or too little fat, or if you undereat or overexercise, this may make you more susceptible to leaky gut. Leaky gut may cause nutrient deficiencies, irritable bowel syndrome, gastrointestinal symptoms like diarrhea, bloating, and constipation, and any of the several hundred autoimmune diseases that are plaguing the Western world at an increasing rate.
You may also wish to consider supplemental iodine in the form of kelp and selenium, both of which are critical for robust thyroid functiono.
Women who do not appear to have thyroid problems or do not know if they have thyroid problems but do have gut problems may wish to consider getting evaluated for the state of their thyroid health. These women may find that their thyroid health is sub-par. Rectifying that either with thyroid hormone supplements or with any of the methods I mention above could be a great way to boost their gut problems.
If you wish to get tested and see if you have a thyroid issue, it is absolutely crucial to have each TSH, T3, T4, and TPO tested. TSH is a pituitary hormone that signals to the body to make more thyroid hormone and rises when thyroid hormone levels are too low; T4 is the body’s reserve amount of thyroid hormone; T3 is the critical “end-of-the-line” hormone that actually functions in cells in the body; TPO are the antibodies the body makes when it has Hashimoto’s thyroiditis. Many doctors may only test for TSH or T4 since that can indicate if Hashimoto’s thyroiditis is at play, but it is possible to have other forms of thyroid dysfunction, so it is best to cover all the bases.
There are two great thyroid books that I like to recommend that can help you get a better picture of how your thyroid is working. Those are “Stop the Thyroid Madness” and “Why do I Still Have Symptoms When my Lab Tests are Normal?”
Finally, hypothyroidism is alarmingly often associated with two issues I address often on this blog: PCOS (learn more about PCOS here) and hypothalamic amenorrhea (more on which here). If you suspect you may have one them than your thyroid may also require attending to.
So far as the best estimates go, upwards of 15 percent of American women develop hypothyroidism during their adult lives.
So far as my best guess can contribute to those numbers, I think perhaps a whole hell of a lot (specific, eh?) of additional women suffer from ‘sub-clinical’ hypothyroidism. Sub-clinical means that your blood test results do not meet the official requirements for a thyroid disorder as determined by the medical community, but you still experience symptoms as a result of thyroid deficiency.
So hypothyroidism is rampant. Another statistic even more striking than those I’ve already discussed is the number of women who SHOULD suspect they’ve got a thyroid problem and/or get treatment for it but do not. The American Association of Clinical Endocrinologists say the number of women undiagnosed is equal to the number diagnosed. So if 8 million American women know they have hypothyroidism, then 8 million of us also have it, but do not know.
There are two great thyroid books that I like to recommend that can help you get a better picture of how your thyroid is working. Those are “Stop the Thyroid Madness” and “Why do I Still Have Symptoms When my Lab Tests are Normal?”
Thyroid function is complex. Your thyroid gland works only after receiving a “green light” signal for production by the pituitary gland, which comes in the form of Thyroid Stimulating Hormone (TSH). It then makes T4 in high amounts, and then T4 is converted to T3 by the liver. T3 is the final form of thyroid hormone and is responsible for delivering energy to all of the cells in your body.
The consequences of developing a problem somewhere in this production process can be dire. They include extreme fatigue, weight gain, mental disorders, and infertility…for just a few examples.
Rectifying hypothyroidism can be genuinely lifesaving.
So it’s important to know if you’ve got it! Experiencing one of the following symptoms or engaging in one of the practices may not be enough cause for you to leap into concern, butseveral in conjunction may indicate it’s time for you to get a thyroid check-up.
Here are 19 tests for hypothyroidism:
1) You’re tired.
Unfortunately, fatigue is one of the most common complaints for just about every health condition out there. It is particularly strongly associated with thyroid disorders, however. The thyroid system’s entire job is to provide energy to your cells. If you’re extremely tired even though you are well-rested, your thyroid may be to blame.
Because fatigue is so common, it may be best to see if you meet any of the other criteria on this list before proceeding.
2) You suffer menstrual disorders or hormone imbalances such as PMS or PCOS.
The thyroid gland is a part of a delicate team of glands in your body called the HPA (and T, and O) axis. The hypothalamus, pituitary gland, thyroid gland, ovarian tissue, and adrenal glands all work in tandem to produce hormones that run your body. Reproductive hormone irregularities are a big red flag for disruption anywhere in the HPATO axis.
If your estrogen levels are high, then there’s a decent chance your thyroid levels are low. How do you know if estrogen is high? Best of all, get your blood tested. If you cannot do that, you can perhaps infer your estrogen status from your menstrual symptoms. If you suffer from cramps and PMS, there’s a decent change your estrogen levels are high. Estrogen is the primary cause of PMS, cramps, heavy bleeding, and lengthy periods.
Estrogen and thyroid hormone are antagonists to each other in the bloodstream. When one goes up, the other often goes down.
Additionally, if you have Poly Cystic Ovarian Syndrome, you may also wish to consider hypothyroidism as a cause, as low thyroid levels are one of the easiest ways to cause the reproductive system to slow down.
If you do have PCOS, you may want to read my delightfully helpful book PCOS: Unlocked.
3) You are constipated
The purpose of thyroid hormone is to deliver energy to cells. If you have insufficient thyroid function, then bodily functions slow down.
Digestion is one of them.
Combined with other symptoms, constipation is a red flag for thyroid disruption.
Another way your gut may be involved in your thyroid health is via an autoimmune disease.
90 percent of hypothyroid cases are actually caused by Hashimoto’s Thyroiditis, which is an autoimmune disease. Autoimmune disease originates in an unhealthy gut. Unhealthy guts often have perforations in their lining, which allows toxic particles to pass into the bloodstream. The immune system mounts an attack against these particples. This is generally a good thing, except that your immune system can be so panicked that it accidentally starts attacking your own human cells – like thyroid cells – too.
If your digestion is significantly impaired in any fashion, this may be directly related to your hypothyroid problems. Get tested for this by asking a doctor for a test for Hashimoto’s antibodies. These are the molecules in your blood that mount the immune attack on your thyroid gland. If you have elevated amounts of these antibodies, then your hypothyroid problems are likely from your unhealthy gut.
Your gut can be supported by taking a probiotic supplement, eating probiotic rich foods like sauerkraut, and by consuming gelatin.
4) You are cold.
Ever wonder why women are so much colder than men? Thryoid hormone is a furnace, keeping cells firing at the right energetic rate to stay warm. If you are constantly cold, especially relative to the people around you, this may indicate a thyroid issue.
It’s best to keep track of your basal body temperature. This will help you tell if you are consistently cold. A mercury thermometer like this one is suggested because it is much more accurate than a digital.
5) You have low blood pressure and/or poor circulation
Because having low thyroid levels slows down most body functions, it makes sense that the blood would slow down a bit, too. Slowed blood movement means low blood pressure, which itself can cause dizziness and fatigue.
Low blood pressure ad poor circulation can also cause numbness or coldness in the extremities. This happens via the simple mechanism of decreased blood flow to the extremities as well as decreased energetic rate.
This is another one of those “womanly” things – have you ever snuggled with a person who was shocked by how terribly cold your feet are? Your circulation and/or thyroid health may be to blame.
6) Your skin, hair, and nails are dry and brittle
The thyroid gland helps skin and hair cells stay connected, lubricated, and being produced at a steady, happy pace. When thyroid levels are low, the quality of your “external” cells decreases. (This oil can help support healthy hair, skin, and nails)
7) Your voice is hoarse
This is one of the markers of hypothyroidism I personally do my best to forget about, since I often have a hoarse voice – most particularly when I am stressed out or not sleeping well.
The reason your voice becomes hoarse on hypothyroidism is that the thyroid gland is located very close to your vocal chords. The thyroid gland swells and produces excessive “nodules” when under duress, which press on your vocal chords.
8) Your neck is swollen
The medical term for this is “goiter” and is directly related to having a hoarse voice. When unhealthy, the thyroid gland swells. This can be small and only detectable via touch (your doctor is trained to do this), or in massive proportions that can make it quite obvious.
Most cases of goiter worldwide are caused by iodine deficiency.
9) You experience mental issues such as brain fog or poor memory retention
Here we have more “slow-down.”
If your thyroid levels are low, your brain gets sluggish. It’s hard to remember things and to focus. More thyroid hormone could make you sharper, more aware, and more appreciative of your surroundings.
10) You experience mood issues, particularly depression
Depression and hypothyroidism are linked via the neurotransmitter serotonin. Serotonin is largely responsible for feelings of peace, calm, contentedness, and being happy enough to get out of bed in the morning. Thyroid hormone regulates serotonin production. Less thyroid means less serotonin. It also means less of other good stuff, like dopamine, which is another neurotransmitter that makes you feel happy to be alive.
Depression and thyroid can also be linked via gut permeability, like we discussed earlier. How? If your underlying problem is poor gut health, then serotonin will be impacted, too — as 95 percent of the body’s serotonin is located in the gut (!).
11) You experience relentless weight gain or extreme difficulty maintaining a healthy weight
Given that lots of body processes slow down when you are hypothyroid, it should come as no surprise that fat burning is one of them.
In fact, it is one of the primary systems affected.
Most studies indicate that thyroid hormone levels go up when one becomes overweight. This is because the body is attempting to burn off that fat as quickly as possible. So you may be overweight and have “healthy” thyroid levels.
But you may also be under-, normal-, or over-weight and have hypothyroidism making your weight maintenance difficult. For anyone of any size, decreased thyroid activity directly decreases caloric expenditure.
My new book Weight Loss Unlocked can help you to healthfully lose weight while supporting your body’s hormonal balance and thyroid.
12) You have a low sex drive
Low libido is another indicator that your hormones simply are not up to snuff. Sex drive is always one of the first things to go when the reproductive system is stressed. Any dysfunction in the HPA axis likely means there’s dysfunction elsewhere, such as in the thyroid gland.
13) You are stressed
If you are psychologically under any kind of duress, your thyroid hormone levels will most likely drop. Your hypothalamus is highly attuned to stress and happiness levels.
If you are physically under any kind of duress, such as by exercising excessively or undereating, your hypothalamus will also know this, and it will detect this as a sign that it needs to shut it all down.
Both psychological and physical stress are major thyroid buzzkills. Know this well, and do your absolute best to reduce stress as much as possible.
14) You eat a very low carbohydrate diet
Very low carbohydrate diets – such as those that only have vegetables as a source of carbohydrate without starchier varieties like potatoes or fruit or rice in the diet – can hinder the conversion from T3 to T4.
Your liver needs carbohydrates in order to produce T3 adequately. So beef up your carb intake if on a VLC diet — up to at very minimum 80 grams a day (about three servings of fruit or starch), and perhaps you may see your thyroid levels tick back up.
15) You do not eat seafood or consume iodized salt
Iodine is necessary for thyroid function.
Goiter was sweeping the nation in the early 20th century. Iodine was added to table salt in 1924, and this helped a lot of Americans. The vast majority of hypothyroid cases worldwide are in fact due to iodine deficiency. This isn’t the case in the states precisely because of the iodized salt, yet iodine deficiency remains a potential threat. Without iodized salt iodine is quite rare in the diet, except for in fish or seaweed.
If you suffer hypothyroid symptoms and also do not consume iodized salt, consider adding some back in to your diet, as this could be hindering your thyroid hormone production. Consuming fish can help, and especially seaweed, if you choose not to go with the iodized salt.
Note: While a diet low in iodine can cause hypothyroidism, supplementing with iodine in the case of a thyroid problem is not always the best idea. Iodine supplementation can aggravate autoimmune disorders associated with the thyroid gland. So nourish your thyroid gland as best you can, and be sure you do not have an autoimmune condition before considering significant iodine consumption. Iodine in natural foods and some salt should be fine for most.
16) You eat a lot of greens
Leafy green vegetables such as kale, spinach, Brussels sprouts, and broccoli all contain high levels of a group of molecules called “goitrogens.” Goitrogens are known to cause goiter, largely because they interfere with iodine uptake by the thyroid gland. This makes it impossible for your body to synthesize sufficient levels of thyroid hormone.
In reasonable doses for a healthy human being, goitrogens are not a problem. Yet for someone predisposed to thyroid issues or who eats a high quantity of greens (think: in excess of a few servings every day), these can actually be a problem. This is especially true if you eat them raw. Cooking greens neutralizes the goitrogens, to an extent. But consuming them raw, or fermented (think: kimchi or sauerkraut), then you are in for a hefty dose of goitrogens.
17) You take a lithium-based mood stabilizer
Lithium directly inhibits thyroid hormone production.
Lithium can be salvific for people who suffer from bi-polar and other mood disorders. In this case, it may be worth the trade-off.
The trade-off is not all that clear-cut anyway. The thyroid gland can be supported by iodine supplementation or thyroid hormone dosing if you are also taking lithium. So there’s no saying you must come off of lithium in order to eliminate thyroid symptoms. This is just one known, very real cause of hypothyroidism.
18) The outer third of your eyebrows is unusually thin
This one symptom may seem a bit off the wall. Really? Thin eyebrows?
In fact, I have had vanishingly thin outer eyebrows my entire life. In the last year or so they have grown thicker… and I am not alone in this.
Me in 2011. Please ignore my hand gesture – this is the best photo I could find of my eyebrows. Even here, my brows are penciled in. I’ve been penciling in outer eyebrows since junior high school.
This study found that 24% of hypothyroid patients have thin eyebrows. Hypothyroid patients tend to lose hair generally, as the body just becomes less good at producing it. Eyebrow hair is particularly at risk, so skinny eyebrows are a good if harmless red flag for investigating your thyroid health.
19) You do not have these blood test results
A blood test is one of the best ways to know if you have a thyroid issue. Of course, blood tests aren’t bulletproof, but then again, nothing is.
Here is a list of blood test results where one of my favorite experts Dr Amy Myers and I both believe the healthy ranges are. Ideally, you want:
- TSH 1-2 UIU/ML or lower (If TSH is too high this means the body is trying to get the thyroid gland to make T4 and T3 but it isn’t happening)
- T4 >1.1 NG/DL (High T4 can also signal hypothyroidism if T3 is low)
- T3 > 3.2 PG/ML
- Reverse T3 (something you produce under stress) less than a 10:1 ratio Reverse T3:Free T3
- TPO (these are antibodies) – <9 IU/ML or negative
- TgAb (also antibodies) – < 4 IU/ML or negative
… Which concludes our list! To read more about thyroid disease, stay tuned for more in this series, and be sure to check out Chris Kresser’s articles, which are comprehensive and very, very smart.
Far back in the very beginning weeks of this blog, I wrote a long series of articles on the sources of infertility. In terms of the kinds of infertility caused by diet and lifestyle, there are two primary categories: PCOS and Hypothalamic Amenorrhea. Long time readers of this blog know that I believe the relationship between these two disorders is much more complicated than regular doctors and medicine would have us believe. Nonetheless, while I was writing about PCOS and HA (read more about HA here and here and here), I promised to write a post on how to overcome HA.
I never did.
The reason I didn’t write it is because the answer is both way too complex and way too simple. I couldn’t come up with anything coherent to say.
Hypothalamic Amenhorrhea is the fancy way of saying “stress-induced loss of menstruation.” The hypothalamus is the part of the brain that determines if you are in a safe enough environment to bear children. If your body receives signals that you are not “safe” enough, then your hormone production will decrease and you will stop menstruating. You may also suffer symptoms of low libido, depression, anxiety, insomnia, acne, and fatigue.
“Safe” means both physiologically and psychologically. Mental stress can hurt your fertility just as much as physical stress. Unfortunately, these two stressors commonly occur in women today, and commonly in paleo dieters. Mental stress comes from pressure and ambition and work and life as well as body image issues, low-self-esteem, and disordered eating. Physical stress comes from low body fat levels, rapid fat loss, excessive fat loss, fasting, over-exercising, under-sleeping, and under-eating. It’s no wonder that so many women struggle with this.
Estrogen, progesterone, LH and FSH — all female hormones — decrease with hypothalamic stress. LH and FSH come directly from the pituitary and fall off the wagon, and then estrogen and progesterone, which take their cues largely from LH and FSH, fall off of it, too.
Can it be overcome?
Is it easy?
The thing about HA is that its severity and “cure” are different for each woman. The trick is to address all of the kinds of stress that play a role in HA, and to focus on the type of stress that caused your problem in the first place.
For example: say you recently dropped from 130 to 110 pounds. The primary problem — the thing that if it looks like a duck and quacks like a duck, it’s a duck, so stop fighting the reality of your weight loss — is that you lost too much weight too fast. Your body couldn’t keep up with your changing leptin levels. And you likely underate calories and gave your body starvation signals while you were losing. So that needs to take precedence. You also, however, exercise a fair bit and have a fairly stressful life. To that end, you should also reduce your exercise, work on your priorities and your stress level, and be sure to eat as much as you need to. Address all of the ways in which you can increase your body’s detection of “safety.” Focus on perhaps gaining a little bit of weight back, however, since that was your primary “problem.” The faster you can convince your body you are no longer starving, the faster you’ll regain hormone balance and fertility.
Other women, on the other hand, might have to focus on stress, or might have to give up marathoning for a while.
HA is all about convincing your body that it’s no longer in danger. It doesn’t need to stress. It doesn’t need to shut down hormone production to prevent a poorly timed pregnancy. So you have got to nourish it as best you can. Err on the side of over versus under eating. Dial down your exercise — particularly the sprint based kind — and do only what feels comfortable. Stop pushing through being so tired. Don’t wake up in the morning to an alarm after a short night’s sleep to go for a run. Be sure to eat plenty of carbohydrates — at very minimum 100 grams of carbohydrate a day — and make sure to eat even more if you are an athlete. Learn to move more slowly, to eat more gently, to be less hard on yourself. Relax, eat, relax, eat, relax, eat, repeat. Don’t eat garbage– no way! Some women do, and find that their fertility comes back. But go wild with your diet, and eat as much as you are craving. Your body has been starved, and it’s important to respond to hunger signals when you have them. That is, if you want your fertility back.
To that end, there’s a simple answer to HA:
-Eat more. Relax more. Repeat.
On top of that, we can get more specific:
-Focus on nutrient-rich foods that support healthy hormone production. Liver, egg yolks, other organ meats, bone broth, leafy greens, fruits, and vegetables are all great.
-Make sure to eat plenty of fat. At minimum 40 grams a day. This amounts to approximately three tablespoons of your favorite paleo oil (such as coconut oil) — one for each meal. Including saturated fat is particularly helpful since it is the backbone of hormone production.
-Make sure to eat plenty of carbohydrates. Your body can think it’s starving if it doesn’t get enough for a significant period of time. Eat at least one piece of fruit or serving of starchy carbs with every meal. Make sure to do more on active days.
-Eat when you are hungry. Do not go hungry. Ever.
-Only exercise when you feel energetic and excited to do so, and refuel appropriately afterward.
-Do not sprint more than a couple of times a week.
-Consider eating a fuck ton of calories. Many women have spent ages on different forums learning about what works, and debating how many calories should be eaten at any given point in time. Some argue you need as many as 3000 calories a day to recover. Others assert 2000. I wouldn’t go crazy, but consider the fact that there’s a good chance you are undereating relative to your needs.
-Consider weight gain. Anywhere from 1 pound to 10 might be necessary, or 30, depending on where you are. How much did you weigh when you stopped menstruating? Is it much more than where you are now? How much more? What else was going on in your life? You may need to close the gap a bit between where you are now and where you stopped menstruating in order to do so again. Each woman’s body is different and requires a different level of fat to feel safe and be fertile.
-Sleep as much as possible. 9 hours a night!
-Consider supplementation. Magnesium supports hormone production. Calcium is helpful with the magneisum. Take the magnesium and calcium in a 1:1 or 1:2 (at most) ratio. Vitamin D can support functions with magnesium and calcium. Fermented cod liver oil will never hurt.
Which is all that I’ve got. I know it’s a lot and also a little at the same time. Hypothalamic amenorrhea is all about you and your body and your own particular needs. You’ve got to think deeply about the kinds of stress you might be dealing with, and then go ahead and rectify it.
And then give it time.
It takes time to recover from this sort of thing. Hormones don’t leap ahead of us, they follow behind, peaking around all of the corners, making sure it’s safe before they come out and play. I can say, however, that your recovery will be faster the more you nourish yourself, the more you eat, and the more you relax. You can go more slowly if you are fearful of the process. This is what I did. And it’s good — the body learns to adjust to new leptin levels over itme. But know that it takes longer the more slowly and cautiously you move forward with your hypothalamus.
I highly recommend checking out the Fertile Thoughts forum on hypothalamic amenorrhea. It contains 108,000 posts and counting. Women all across the world come to this forum to share their experiences with HA and infertility. Definitely worth the read if you’re interested in HA at all.
I spend a disproportionate amount of my time telling women to eat carbohydrates.
In the paleosphere, it is incredibly common to eat a low carbohydrate diet. Plenty of people use low carbohydrate diets to lose weight, to sharpen insulin sensitivity, and to reduce appetite in the short term.
A low carbohydrate diet can also be therapeutic for people with cancer, migraines,and chronic infections or psychological disorders.
On the other hand, low carbohydrate diets can be a significant tax on people, women especially.
Because low carbohydrate diets are so popular for weight loss, it is common for women trying to lose weight and to “look good” to exercise often, eat very few carbohydrates, fast, and restrict food intake. The more of these restrictions a woman undertakes at once, the more and more her body reads this as living in a starved, stressed state.
The effects of this are significant: adrenal glands work overtime, livers get tired from performing so much gluconeogenesis, insulin sensitivity drops, body fat levels fluctuate, sleep quality decreases, and libido and fertility decrease.
The problems that come from a low-carbohydrate diet of course don’t affect every woman. Each of us is different. But women who experience stalled weight loss, low-thyroid symptoms, menstrual dysregulation, sleep and or mood and mental health related issues may find significant relief from adding carbohydrates back into their diets.
If you are trying to lose weight, take a look at my program, Weight Loss Unlocked, which will help you lose weight in a healthy, safe, and balanced way. Check it out here.
Also, this is my favorite paleo cookbook with plentiful carbs in it. It’s by Russ Crandall, and he’s an amazing chef, as well as one of my favorite people of all time.
Carbohydrates are beneficial for fertility and health because…
-Glucose is necessary for the conversion of T4 to T3 in the liver.
Without adequate glucose, the liver struggles to make enough T3, which is the form of thyroid hormone critical for healthy thyroid function.
Without sufficient T3, hypothyroidism results. Hypothyroidism is implicated in mood disorders, reproductive irregularities such as PCOS and amenorrhea, in skin conditions, and in weight gain, among other things. (For more on how to figure out your particular type of PCOS and how hypothyroidism may be at play, see my program PCOS Unlocked or read my post on the causes of PCOS)
Many women, contrary to popular paleo belief, in fact lose weight once they add carbohydrates back into their diets. This is because the carbs help the body produce more T3.
(Now, low carb dieters might be quick to point out that the liver can manufacture its own glucose. Certainly, the liver is capable of producing its own glucose with gluconeogenesis, but that process can become taxed over time, particularly if the liver is already taxed from poor eating habits in the past, mineral deficiencies, stress, or calorie restriction.)
-Glucose elicits an insulin response, which in turn spikes leptin levels in the blood.
This is a short-term spike, so eating carbohydrates should not be used as a replacement for body fat, which is the primary long-term secretor of leptin.
However, moderate, regular consumption of carbohydrate spikes leptin frequently enough to help signal to the hypothalamus that the body is being fed. Leptin is absolutely crucial for reproductive function. Without leptin, the hypothalamus does not tell the pituitary to produce sex hormones, so it doesn’t.
–Insulin is also an important signaler of the “fed” state.
In addition to leptin, the hypothalamus also responds to insulin. These two hormones are largely responsible for the female body determining whether it is in a “fed” state.
Being in a fed state is critical for convincing the body it is in a healthy enough environment to reproduce, have a libido, and also lose weight.
–Moderate carbohydrate intake is associated with better mood, stress-reduction, and sleep quality.
I see this in my work and in anecdotes, as well as in many controlled studies.
Carbohydrate intake boosts tryptophan levels in the brain, and tryptophan is the protein precursor to serotonin. Getting at least some carbohydrate in the diet helps with the vast array of issues associated with serotonin deficiency which include moodiness, stress, and insomnia. People have been shown to sleep better if their dinner includes carbohydrates in it.
This is especially true for women.
For a look at the details and complexities of the issue, see Emily Deans writing here and here. The primary takeaway of this point being that while the exact mechanism of carbohydrates boosting mood and sleep quality is unknown, carbohydrates still appear to be a healthy, and in many cases necessary, macronutrient.
Carbohydrates for fertility and health
The main point here is that carbohydrates are not just okay but important. For women who have appetite control problems, sugar addictions, and a lot of weight to lose, absolutely I believe a low-carbohydrate diet can do them wonders. For women who struggle with menstruation, fertility, stress, exercise performance, or any other hormonal oddities, carbohydrates help assure the woman’s body that she is healthy and fed. This is crucial for reproductive health.
In all cases, diet is a matter of personal physiology and experimentation. If a woman’s body works better on carbs, she should eat them, and delight in those joys rather than worry needlessly. At the very least, they are not harmful, and at their best, they are life saving.
This concept is central to my program Weight Loss Unlocked. If you are interested, it will help you figure out which path to weight loss is best for your unique body and metabolism.
Carbohydrates to eat:
-Starchy tubers such as sweet potatoes, batata, jerusalem artichoke, cassava, tarot, and bamboo. Regular potatoes are fine, too, but they contain fewer vitamins than their sweet counterparts. Of the sweet potatoes, Japanese sweet potatoes are the most delicious, in my opinion, followed by white sweet potatoes and then yams and regular orange sweet potatoes.
These starches are composed primarily of glucose.
–Fruits. All fruits! Berries and cherries tend to have more glucose than fructose, other fruits tend to have more fructose than glucose. This is not a huge point of difference but I have noticed that some women tend to do better on glucose-heavy or fructose-heavy carbs. I personally have an easier time with weight maintenance with fruits than with starches. I talk about this idea more in depth in that Weight Loss program for women I use with my clients.
-Rice Both white and brown rice are fine, but are fairly nutrient-poor.
Brown rice contains anti-nutrients in it’s shell, so white rice is more innocuous in terms of nutrient absorption. Wild rice is another option that I like. Pink rice is something that my friend Noelle from Coconuts and Kettlebells really loves and is a unique way to incorporate rice into the diet! (By the way, if you haven’t listened to The Paleo Women Podcast featuring myself and Noelle, you need to! We are the BEST and we will explain to you ALL THE THINGS. Find us here!)
-Vegetables of course are great, but they do not count for carbohydrate consumption. I know that most of the carbs in vegetables are glucose, but much of it them are also tied up in fiber, which is broken down and turned into short-chain fatty acids by gut bacteria. For this reason, vegetables alone cannot make up a woman’s carbohydrate consumption. Instead, starchy tubers and fruits work the best.
How much carbohydrate to eat for women:
For a woman recovering from stress, metabolic distress, and hypothalamic amenorrhea, I recommend eating between 100-200 g/day. That goes for athletes as well. And for pregnant women. At least 100 g/day.
I typically recommend that women start with 100 grams of dense carbohydrate like starches and fruits and experiment from there. You can definitely eat more than that – I know that I do. But you could also eat a bit less, especially if you prefer a lower carbohydrate appraoch to health.
Remember, you do not necessarily need to eat high carbohydrate. You can, but you don’t have to. It is only that a diet with at least some carbohydrates can really help with fertility, hormone balance, thyroid, and weight loss problems.
Carbohydrates elsewhere in the paleo blogosphere:
Chris Kresser and Chris Masterjohn: Cholesterol, mostly, also: Telltale signs you need more carbs
Jimmy Moore: Is there any such thing as a safe starch?
Jamie Scott: A Week of It
Paul Jaminet: Higher Carb Dieting Pros and Cons (includes a discussion of the “longevity trade-off”)
Cheeseslave: Why I ditched low carb
Beth Mazur: Why I don’t eat low carb
Julianne Taylor: Okay, People, Carb’s Don’t Kill
Melissa McEwen: What the bleep do we know about carbs
While you’re at it, go read Melissa’s post on Why Women Need Fat.
Don’t forget this is my favorite paleo cookbook full of good carbs.
And especially don’t forget to check out Weight Loss Unlocked if weight loss is one of your main goals right now, The Paleo Women Podcast, which is just so much fun, and my best-selling book Sexy By Nature, all great resources for all things women’s health, happiness, and fertility!
The volume of emails I receive from women who start having menstrual problems on a paleo diet is staggering. It is not an enormous volume, no. But it is enough to give a woman pause. What gives? Aren’t we supposed to be healthier on a paleo diet?
Yes, we are, and really, we are. In the vast majority of women who eat a Standard American Diet, specifically those who are overweight, a paleo diet does wonders for balancing hormone levels. It is usually only when a paleo/whole-foods diet is coupled with restrictive norms that women start running into problems. Too little food, too much exercise, and too much stress are really what it all boils down to. The whole foods are not to blame– not in the slightest. What are to blame, instead, are the obsessive ways in which people interact with these foods.
There are several mechanisms that may be at play in the physiology, depending on each woman’s genetics and how each woman undertakes her paleo diet and lifestyle.
What happens in the body when it stops menstruating
The female reproductive system runs off of a sensitive fleet of circulating hormones. When one or several of them is disrupted, many of the others fail at their jobs, too.
During the menstrual cycle, hormone levels in the blood signal to the hypothalamus to signal to the pituitary to release FSH and LH, two hormones that in turn tell the ovaries what to do. FSH–follicle-stimulating hormone– is released in the first part of the menstrual cycle to incite egg development. LH–luteinizing hormone–is released in the second part of the cycle and prepares the endometrium to be shed. Without proper FSH and LH levels, the female body can never convince the ovaries to do their job. FSH and LH are crucial, and they rely on proper functioning of the HPA axis.
This job of the ovaries is to produce the follicles and the eggs, but in doing so it also produces estrogen and progesterone. This fact is important for signalling menstruation, because it is partly the rise and fall of estrogen and progesterone levels throughout the month that signal to the hypothalamus to release FSH and LH at different times. This is, in essence, a circle of signalling. LH and FSH from the hypothalamus to the ovaries, estrogen and progesterone back to the hypothalamus, and so forth.
Hormone malfunctions that cause amenorrhea
–Decreasing estrogen levels stop the pituitary from being able to send out FSH and LH.
–Decreasing leptin levels stop the pituitary from being able to send out FSH and LH. This is because decreased leptin levels signal to the hypothalamus that the woman is lacking energy stores and is, in essence, starving. When the hypothalamus thinks the woman is starving, it puts a halt to normal reproductive functioning. Leptin levels decrease proportionally with fat mass decreases. On the other hand, leptin can also go undetected when an individual is leptin insensitive. Insensitivity is in general a larger problem for overweight women, and low absolute leptin levels are in general a greater problem for thin women.
–Increased testosterone production interferes with estrogen levels.
–Increased stress and cortisol levels put a halt to hypothalamic and pituitary function.
Cause 1: Weight loss
Both estrogen and leptin are produced in fat cells. These are the two blood serum hormone levels necessary to signal to the hypothalamus that a woman is fed and happy, and that it should go ahead with normal reproduction. Without these two hormones, reproduction ceases. It is well known in the medical literature that the low body fat of anorexic women, models and athletes is what accounts for their amenorrhea. Without fat, a woman simply cannot menstruate.
What is discussed less often in the literature, but is still true (see Wenda Trevathan’s Ancient Bodies Modern Lives) is the fact that a woman’s reproductive system is set up to run on the nutrient basis she has as a young girl. Throughout puberty, if a girl has a higher-than-average or higher-than-healthy body fat percentage, her ovary to hypothalamus signalling may develop as ‘handicapped’ by these fat stores. Because fat cell estrogen is so high, the ovaries do not have to produce as much. For example: If the body’s estrogen set point is 100 units, and fat cells produce 80 units, then the ovaries only need to produce 20 units. Then, if the woman loses weight, the set point remains around 100 or falls a bit to a healthier level (unique to each circumstance), and the fat cells production falls to around 30 units, such that estrogen from the ovaries is then expected to make up for the rest of the estrogen deficit. Many women have no problem with this. Their ovaries jump into higher gear. Many others, on the other hand, do struggle. Their ovaries never end up rising to fill that gap. The thing is– the set point is not stuck precisely at 100. It will decrease to a healthy level. But it might not decrease as far as a woman bent on meeting social expectations of body image is hoping.
The alignment of a woman’s sex hormone levels with the amount of nourishment she has during puberty accounts for why women who live their whole lives on the edge of starvation can still have babies, but women whose body fat percentage decrease from 28 to 21 cannot.
This is not to say that an overweight woman will stop menstruating when she loses weight. Each body is capable of menstruating within the healthiest range of body fat percentages, from around 20 percent to 30 percent. But a woman who has always erred on the side of heavier might find that she cannot dip below 23 or 24 percent body fat without losing her period. 23 or 24 percent body fat is healthy, so this is fine. It might not fly is the woman is trying to meet ridiculous standards of Western body image, but it is optimal for her to have the appropriate serum hormone levels.
Other factors that can hurt estrogen and leptin signalling may also play a role. If a woman can correct those, then she may be able to decrease her body fat levels without hurting her reproductive system. For example, chronic stress hurts hypothalamic signalling. So a stressed out overweight woman is going to have a harder time with reproductive fitness while losing weight than a totally relaxed overweight woman. This is a fact. For menstruation to take place, estrogen and leptin levels must be high enough. Body fat plays a significant role. There are some other factors that can be addresssed and help as well.
Cause 2: Exercise
Weight loss can cause decreased leptin signalling, but exercise can, too. Body fat is the major player in leptin levels, but energy deficiency in general hinders leptin. When a woman is burning more calories than she is consuming–or when she is burning a high quantity of calories while under emotional and physical stress–her body calls it quits. Instead of directing energy towards reproduction, it conserves it for other functions.
Cause 3: Low Calorie Diet
A low calorie diet performs the same function as both weight loss and exercise. It stresses the body and puts the woman in a state of energy deficit. The hypothalamus does not like being in energy deficit, so it tells the ovaries to stop working until it can get itself out of the energy deficit.
A low calorie diet is more of a problem for thin women than it is for women trying to lose weight. Leptin levels first and foremost are reliant on fat stores. The body can eat it’s own fat. That is in fact how weight loss occurs. So if a woman is eating her own fat, she is not starving. Once her body fat levels dip too low, however, and if she is maintaining a low-calorie, starvation-type diet, then she may stop menstruating.
Cause 4: Low Carbohydrate Diet
Many, if not most, women have a real need for carbohydrates. This cause is the most common cause of amenorrhea in the paleo world next to weight loss, in my experience.
Carbohydrates are necessary for the conversion of T4 into T3 (the active form of thyroid hormone) in the liver. The liver is capable of producing its own glycogen when it’s not being fed sugar, but this process can become fatigued over time, especially if the woman is under any kind of stress, or restricting calories, too.
Hypothyroidism, or sub-clinical hypothyroidism, is one of the primary causes of ovarian malfunction. Without sufficient levels of T3, organs shut down, and the reproductive organs are the first ones hit. Without T3, estrogen cannot be produced, and follicles cannot develop. Without T3, a woman cannot menstruate.
For this reason, many paleo women supplement their diets with iodine and find that their amenorrheic symptoms ease. However, many others do not. Instead, they have to add carbohydrates back in to their diets.
Another role that carbohydrates play is spiking leptin levels. Whenever insulin spikes in response to blood glucose, leptin levels rise, too. This means that carbohdyrates help signal to the hypothalamus that the woman is fed. However, this is a short-term elevation. It only spikes in bursts and with meals, so it cannot be used as a long-term solution to health. It is important to note, however, that a high fat, low carbohydrate diet is consistently associated with the lowest leptin levels possible.
Cause 5: High-Dairy Diet (an influence, at least)
Dairy is full of hormones. Even cows raised on pasture cannot help but produce certain hormones that influence a woman’s reproductive system. Dairy is the most androgenic food. It contains a protein that inhibits normal inhibition of testosterone in an individual’s body, such that when someone ingests dairy their testosterone levels can rise unchecked. This is in fact why so many people experience acne when they eat dairy. Even men. It really can increase testosterone levels that much.
Moreover, much of the dairy consumed in today’s world is not organic and grass-fed but is instead choc-full of unnaturally injected hormones. Farms and the US government are touchy about telling the public what goes into their animals, and they claim that these hormone profiles are insignificant. However, anecdotally, myself and with some other women, it seems as though these hormones really can influence women who already have compromised reproductive function. Conventionally raised animals can cause real problems. This goes for dairy, and this goes for eggs and meat products as well.
Cause 6: Altered Phytoestrogen and Hormone-Ingestion Profile
This cause is related to the cause above. We ingest hormones on a regular basis. With a healthy reproductive system, this is not a problem. Hormones from food are far less potent than hormones from the ovaries. Please keep that fact in mind. A healthy reproductive system has very little problem with phytoestrogens in foods. But some women have struggling reproductive systems for one reason or another, and they need to be aware of what hormones they have been and what they are now consuming.
Phytoestrogens are plant estrogens. They look a lot like estrogen, but are not identical. This is why phytoestrogens should never be consumed as a replacement for estrogen. Sometimes they relieve certain symptoms of estrogen-deficiency such as hot flashes, but they also fail to act exactly like estrogen does in the body. This means that other signals and connections are not being made, potentially crucial ones. Hot flashes may cease, but acne may continue to run on unchecked. And other problems can ensue. For example, breast cancer.
Phytoestrogens are primarily in legumes, nuts, and seeds. Soy is the most potent phytoestrogen, and should be avoided at all costs.
There are other sneaky ways in which hormones can infiltrate a woman’s diet, especially if a woman undertakes a paleo diet with compromised reproductive function and inattention to the quality of her food. For example, if a woman goes on an egg-heavy diet when starting paleo, but the chickens are fed a soy rich diet, she is actually eating a soy-rich diet. This is not normally a danger, but with a compromised reproductive system and a soy- or hormonal- influence from poorly treated animal products, it is worth taking into consideration.
These effects, I need to emphasize again, are not usually relevant for women with healthy reproductive systems, and should only be considered in severe cases. Only when hormone levels have dipped so low or have skyrocketed so high that the body becomes sensitive to these normally tolerable and easily managed fluctuations from food. Certainly, conventionally-raised cows are not optimal, but I would not discourage anyone from eating them (in terms of their health) at all if they have no other options. Sincerely. Far, far more important is the quality of hormones being sent through leptin and estrogen signalling within the body.
Cause 7: Stress
The final cause should come as no surprise to anyone. Stress halts reproduction: stress from toxic foods, stress from eating disorders, stress from social life, stress from exercise, stress from work, stress from existential despair… the list is vast. The physiological result of all of the possible stressors is roughly the same, however. Cortisol levels rise and these levels prevent the hypothalamus from sending the appropriate reproductive signals to the ovaries. This may, in fact, be the most important of all the factors I’ve discussed. There is no way to quantify it, and it burns ubiquitously throughout the Western world. What if all of us calmed down? What if we all lived in harmony, and peace, and did not fret? Stress is significant, and stress is real. Hundreds of thousands of American women do not menstruate because they are stressed. How many more experience hindered reproductive function because of stress? I suspect the number lies in tens of millions.