How long will my cycles be?

Have you just had your first period party? The utter thrill when you are working to recover from hypothalamic amenorrhea (HA) and you see blood in your underwear is indescribable. I got my first bleed when I was on vacation. It had been really tough because my sister was announcing to our family in South Africa that she was pregnant; we were supposed to be pregnant together but I hadn’t even gotten a period yet, and here she was – Kate and 2/9 as my Uncle put it. I went upstairs to the bathroom and there was my first glorious period. I felt like a million bucks, I had *done* it!!!!  I could finally start trying to get pregnant myself!

After that celebration, though, comes another wait. This one is so tantalizing; you got a period, you hope that if you just to keep up what you’ve been doing you will  ovulate again and get another… or if you’re trying to get pregnant, you’ll get that oh so magical positive test instead. But for many women newly recovered from HA, cycle day 14 (when ovulation happens in a “normal” menstrual cycle) comes and goes, with nary a fertile sign. This can feel incredibly defeating (I know – in my case I randomly had an ultrasound scheduled on CD13 of my next cycle and we saw a nice juicy 13mm follicle which had my heart soaring, until I went back two days later and it hadn’t grown, and my doctor told me we’d need to do injections…).

But it is extremely common in women with HA for it to take a few cycles for the length to normalize, and this is one reason we say in No Period. Now What? to wait at least three cycle before making any changes in terms of eating, exercise, or stress.

I think that it is helpful to know exactly how common longer cycles are, and how long it typically takes for them to normalize, so I graphed the cycle length data I had from the surveys I did for NPNW. I took the data from each person who had at least one natural cycle, and ended up creating four graphs, split by number of cycles to get pregnant (most of the women who took the survey were trying to get pregnant).

Occasionally a woman will get pregnant on her very first ovulation–before getting her first period–in which case I do not have cycle length data (this happened in about 5% of women who ovulated naturally prior to any treatment). Other than that, in the data from my survey respondents, it took between one additional cycle to up to 12 to get pregnant the first time (in the women who provided cycle length data), so I split the graphs into one cycle to get pregnant (so these are women who had one period then got pregnant on their next ovulation), between 2-4 additional cycles, 5-7 cycles, and 8-12 cycles.

Here’s the first one – those women who took only one additional cycle to get pregnant. You can see that the cycle day of ovulation ranged from CD13 to CD63. (These were natural cycles as my requirement for using data for these graphs was that there was at least one natural cycle; there were certainly people who got pregnant on their first oral med, inject, or IVF cycle, but I will leave that for another day.)

The next graph shows those for whom pregnancy took 2-4 cycles… oh, but first here’s the figure from the book that shows the cumulative pregnancy rate by cycle so you have an idea of how long it is likely to take (if you desire pregnancy at the moment). Not everyone supplied cycle length data, so the numbers on these cycle length graphs don’t give a good sense of how long it took on average. Of my survey respondents, 56% achieved pregnancy within the first three cycles, and 84% within the first six. This is very similar to other studies of similar nature.

Back to those who took 2-4 additional cycles after their first period to get pregnant. This graph is a little more complicated, but if you just look at the first versus second cycle you can see a significant decrease in time to ovulation for those who had long initial cycles. The one case where cycle length increased, the woman in question decided to increase her exercise amount. You can see why we suggest not doing that right away, her cycle length increased from 45 to 60 days. This graph also includes some information about cycle lengths for those who used either oral medications (i.e. Femara or Clomid), or injectables. Some started with treatment but then after failed cycles got pregnant naturally (like the one woman who had ovulation on CD12 with injects, red triangle, on her first cycle, also used injects for cycles 2 and 3, but then got pregnant naturally cycle #4). Others had a natural cycle but then moved to treatment, like the woman whose first post-period ovulation was on CD70, reduced to CD24 with Clomid (and pregnant, filled blue square). Another example of this is the woman whose first post-period ovulation was at CD45, increased exercise and up to CD60, decreased exercise again and ovulated CD45, then used Clomid, ovulated CD18 and was pregnant.

The next graph shows those for whom pregnancy took between 5-7 additional cycles after their first period. Again you can see the commonality of a marked decrease in cycle length for those who had long initial cycles, and also a trend toward shorter cycles when oral meds were used. In this group were seven women who initially used Femara or Clomid to ovulate, but then after failed cycles stopped taking the meds and cycled naturally. Note that the filled red triangle indicates a pregnancy achieved on an injectable cycle (adding the legends to the graphs was taking me too much time).

Finally, those for whom it took between 8-12 cycles to achieve pregnancy. In this case the bump down to “CD 0” indicates no ovulation on that particular cycle. Here you see somewhat of an anomaly, with one woman whose first post-period ovulation was on CD63, which didn’t decrease until she started on oral meds, and another whose subsequent cycles were longer than her initial one. However, as you can see from the other graphs, this pattern is definitely not the norm. In either of these cases I probably would recommend oral meds (assuming that eating and exercise were not more restrictive). And again, filled red triangle indicates pregnancy achieved through injectables, black triangle shows a miscarriage on an injectable cycle.

I know that this is a lot of information, kudos if you’ve made it this far 🙂 I am happy to answer questions, please leave a comment if there’s anything unclear or another way you’d like me to analyze the data.

<3 Nico

Femara or Clomid for Ovulation Induction?

Summary: If you are not ovulating naturally even after working on recovery, and want to use medication to induce ovulation for pregnancy, Femara (letrozole) is preferable to Clomid (clomiphene)*.

letrozol3d

 

 

Letrozole, By MindZiper – Own work, CC0, https://commons.wikimedia.org/w/index.php?curid=15991603

 

In No Period. Now What? (NPNW), our book on hypothalamic amenorrhea recovery, Chapter 21 covers the oral medications that can be used to encourage ovulation. We discuss how soy isoflavones, Femara, Clomid, and tamoxifen reduce estrogen levels to encourage an increase in follicle-stimulating hormone (FSH) that in turn leads to growth and maturation of eggs. These medications can be used when pregnancy is desired, but also to “jump-start” menstrual cycles*. It is really important to note that these meds are unlikely to work without progress having made toward recovery in the form of increased eating, reduced exercise, and reduced psychological stress – all of which you can read about in earlier sections in our book.

clomifene_ball-and-stick

 

 

Clomiphene, by MarinaVladivostok (Own work) [CC0], via Wikimedia Commons

 

 

We also cover research comparing pregnancy rates, likelihood of a multiple-gestation pregnancy, uterine lining thickness, and other metrics between Femara (letrozole) and Clomid (clomiphene citrate) to help women decide which choice is optimal for them. (Tamoxifen is an alternate that is rarely used, so there is not a large body of research to reference, although in many ways it is preferable to Clomid based on fewer effects on the uterine lining.) We also discuss dosing recommendations, what to do if the first cycle doesn’t work, and much more. 🙂

Our conclusion in NPNW is that if one is trying to get pregnant, Continue reading

Reader Questions

I thought that now that my kids were back in school I’d have all kinds of time to post here – but somehow between being PTA president, starting a PTO at my youngest’s preschool, getting involved in local politics, reading a bunch of books and starting to lift weights again (because I was feeling weak NOT for body sculpting purposes), and yes, getting a little mired in the national election coverage too… not so much. But hopefully this will start a new routine!

I asked in my facebook group for questions people would like answered. If you have anything else you’d like me to address, pop it in the comments and I will do so on another post!

1. What do you think about soy and other estrogen increasing foods?

Many people think that the issue when one has HA is low estrogen. This is not the case. The issue is that your hypothalamus is not sending the signals to your reproductive system. Once your hypothalamus turns back on again, your estrogen will rise appropriately. So as far as foods go – I advocate moderation on all fronts. It’s fine to eat some soy but I see no need to specifically increase the amount you’re currently eating. If you’re eating a “lot,” I’d advocate cutting down and substituting with other protein and fat sources simply in the interests of eating as many different types of foods as possible.

2. Does color and length of your period indicate anything?

This one actually comes up a lot! Many women are afraid that their period is “too light” when they start cycling again. My ‘normal’ post pregnancy has been one heavy day (which I define as filling a regular tampon every 2-4 hours), a medium day (filling a tampon every 6 hours or so), two light days (a tampon every ~12 hours) and then a day or two of spotting. Something around that seems to be reasonably common. Some women obviously have much heavier periods, some have significantly lighter periods – but anecdotally I haven’t noticed a correlation with ease of getting pregnant. Also, interestingly, it seems that not all the lining is shed as “blood” but some can actually be resorbed into the uterus. So I think that really what is important is what is normal for you. If your periods after recovery are much lighter than before, that may indicate a need to relax a little further on the exercise, eat a bit more, or see what you can do about relaxing (all of which we cover in our book :)). If they’re much heavier, you may want to check in with your doctor, just in case there is another issue at play like endometriosis. If they’re normal for you, however heavy or long that may be – chances are excellent that everything is fine. If you are trying to conceive and not getting pregnant, you can discuss with your doctor, but barring that – go with the flow. (yes, pun intended ;))

3. How long will it take to recover?

In a previous post I discussed whether time to recovery was associated with length of time without a period, and the answer in that case seems to be no. The median time to recover is about six months – some shorter, some longer. In general, the more quickly you are able to go “all in” the more quickly you will recover your cycles. I wish there was a formula I could plug your information into that would spit out an answer – but unfortunately life doesn’t work like that. Your particular recovery formula will depend on what your BMI was/is and how quickly you’re able to increase that to a ‘fertile’ BMI of 22+, how much exercise you did and what you’re doing now, what your food intake looks like (hint: the more variety the better, assuming sufficient energy), and what your daily stress and anxiety levels are (and unfortunately this is a vicious circle because stressing out over how long it will take to recover can make it take longer!).

4. I can’t go all in. I don’t trust the process.

From my experience what really helps here is seeing other women recover. (Read the success stories in our book and join my facebook group!) When you find someone just like you and read about what they did to restore cycles or get pregnant, it makes it that much easier to believe that it can and will happen for you. Keep reading the successes, keep listening to the other amazing resources that are out there (I cannot recommend Meret Boxler’s podcasts enough, she will introduce you to everyone you need to know in this arena), do as much as you can to work toward recovery (fake it ’til you make it) and one day it will click for you too. I have seen it countless times. It will come.

5. How do you track food while in recovery and know you’re eating enough?

This is a tough one because really, tracking is a big part of the problem. So it’s hard to see it as part of the solution too – but I know that when you’re starting on this path from a place where you are tracking it is hard to let that go. What I did initially was to increase the amount of calories I was allowing myself each day (“allowing”…that’s a whole different topic) and I continued meticulously tracking as I had been. I’m a numbers person so that was hard for me to let go. But there came a time when I’d skip a day… and that quickly grew to two and three and then to not tracking at all anymore. At that point I had a good sense of how much I needed to eat each day and I was much better at listening to my hunger signals. If you’re not tracking now I wouldn’t suggest starting unless *maybe* you log your food intake for a day just to see where you’re at. Really the best way to know you’re eating enough is two-fold: 1) if you’re under a fertile BMI to make sure you are gaining, and 2) notice your fertile signs (chapter 16) and obviously return of your period. And yes you often have to go beyond what feels comfortable for you, both in the amount you’re eating and in how much weight you gain… but I *promise* you, the return of your cycles and your fertility is worth that discomfort. Again – seek out success stories and read about how little women care about what their body looks like when they see that first sign of red, or get their positive pregnancy test.

6. If a period was lost with no exercise, will adding exercise while eating more calories, fat, carbs delay recovery?

Abso-freaking-lutely yes. I was over in a different facebook group today and a women commented on how she had just started a new exercise routine, going five days a week instead of the one she had been doing, and how her ovulation was six days late (and still nowhere to be seen). Especially if your body isn’t accustomed to it, the increased cortisol from exercise can do a number on your hypothalamus. Walking and yoga, *light intensity* are probably okay but I would add even those slowly. Also, I noticed a big effect of exercise on my own cycles (p. 162 in our book) even while gaining weight.

I hope you found this helpful, and if there’s anything else you’d like to know, drop a comment!

Embracing the New You

I just went to see the movie Embrace with my new friend and fellow HA warrior Kate. It was lovely meeting her in person and we spent a lot of time over dinner before the show bemoaning how our society has encouraged us toward the predicament of treating our bodies so harshly in an attempt to be healthy – and also how much more common hypothalamic amenorrhea is these days with the latest trends in “clean” eating and strength and endurance training for women.

embrace_showing

Anyway, the movie was utterly fantastic and I cannot recommend it enough. Whatever your personal situation is, I can pretty much guarantee that Embrace will speak to you. I love the idea that is becoming more and more commonplace: that we should love ourselves and others for what we accomplish and *think* instead of what we look like (and heck, let’s do our best to pass this idea on to the next generation!). I know, not really a newsflash anymore, but at the same time it’s an idea that is easy to give lipservice to without truly believing. Embrace took me even further than I was down the path of believing. Find a way to see this movie! #ihaveembraced

Along the lines of switching your outlook, a woman recently posted in a facebook support group of which I am a member (join mine here) about how she was struggling with feeling frumpy and not hot when she went into a fashionable store to try on some new clothes. The responses were amazing, insightful, and inspiring, which is why you should join too if you’re working on recovery. Who doesn’t need an army of HA warriors at their back?

Lindsay said, “I’m so sorry you’re having a rough day. I understand; I had MANY of them. The next time you go shopping and you don’t like how something looks when you try it on, try to shift your mindset from “This fabulous shirt doesn’t fit my body” to “My fabulous body doesn’t fit this shirt“. There is nothing wrong with your body; it’s the shirt that doesn’t work. Take it off, and try on a different style. Do you remember the show What Not to Wear? I like to think of that show every time I go shopping, because Stacy and Clinton could always make ANY person look fabulous, no matter how big/small/short/tall. It’s just a matter of finding clothing that really flatters you. Body love and acceptance takes time… you’re just getting started here, and the changes are fresh and new. Over time, you’ll get used to your new self, and you will grow to love it as much as you did your old self. Maybe even more. Remind yourself daily that you are a multi-dimensional person… you are not just a body. And truly, the other aspects of your being – your personality, your sense of humor, your wit, your charm – are what people are most drawn to. Don’t let any perceived ‘imperfections’ of your physical body spoil the rest of that.”

Yes, yes, YES!

<3

How long will it take to recover???

One of the unique aspects to our book on recovering from hypothalamic amenorrhea is the data we include from our survey of over 300 women who have experienced missing periods. I also love having the data set because when people ask me questions that I didn’t address in the book I can go and get the answer pretty quickly.

A question that was recently asked was Is there a difference in time to recovery depending on how long one’s period has been missing? The range of time for which periods were missing for the women who took our survey was from three months to over twenty years!

However, I found that there was hardly any difference in time to recover based on length without a period. Note that the start of working on recovery was defined as the time at which eating more / weight gain commenced. The data are shown below (note that the scale is logarithmic, not linear):

MonthsWithoutCycleVsTimeToRecovery

Each point represents one woman, with the amount of time she was without a cycle on the Continue reading

Getting the word out!

Helping women with hypothalamic amenorrhea / female athlete triad / missing periods to recover–regain their cycles and realize how much needless energy has been spent on food, exercise, and appearance–has been my passion for the last ten years. For many years I helped women on the HA forum at FertileThoughts.com, but since 2012 my posting there slowed down as I worked on the book.

Now that the book is done… it’s really time to get the word out. We’ve gotten so many positive reviews and comments on our work, like what Amanda said recently,

I want to take a moment to thank you from the bottom of my heart. I’m almost done your book and can see that you’ve poured years and years of your life, heart and soul into that book and raising awareness around HA. I can’t tell you how much I’ve learned and how motivated I’ve become to continue to work on my health and hormonal integrity and to incorporate BALANCE into my life. Not to mention that this book will spearhead an increased awareness of HA and hopefully a new understanding of the importance of maintaining female health……THANK YOU!!!

Meret Boxler, whom I met on a hypothalamic amenorrhea support group on Facebook, has been working on being compassionate with herself, redefining her view of what healthy is and looks like, and focusing on the positives in her life. As a former radio DJ creating a podcast series seemed a natural next step – and she wanted to interview ME!  So I am super excited to share that interview with you. Take a listen, and if you enjoy, please subscribe to her feed, give her lots of likes, and reviews would be fantastic.

LU 003: Nicola Rinaldi – No period. Now what? Health issues from overexercise and too little food.


Subscribe on iTunes (Apple), or on Stitcher (Android)

Shortly thereafter, having gained some confidence from the interview with Meret (on top of which it was a really enjoyable conversation), I was directed to a video on YouTube that contained misinformation about HA and its causes. So I immediately thought that doing my own video would be another fantastic way to get the word out about our hypothalamic amenorrhea recovery book along with basic information about HA that it’s important for people to understand. That video is below – and again, if you could like and comment that would be stellar – the more likes, the more people will be able to find it and educate themselves about missing periods and the effects on our health.

Thanks so much!!! xox Nico