You're listening to Food is Food, the podcast that will support you to ditch diet culture, break free from food rules, and debunk nutrition misinformation. I'm your host, Talia Chiquelli, specialist eating disorder dietitian and founder of the TC Nutrition Clinic. If you would like to learn more about our one-to-one nutrition support and group program, or download your free portioning guide, head to www.taliachely.com. Each week we will cover topics that delve deeper into nutrition, intuitive eating, psychology, diet culture, and the consequences of under-eating. Our relationship with food is so complex and is influenced by our thoughts, emotions, and life experiences. Which is why healing from disordered eating is about more than just food. Welcome back to Food is Food. In today's episode, I will be chatting to Dr. Nikki Kay, a medical doctor who has been referred to as the Hormone Whisperer Online, which is kind of cool. Nikki specializes in exercise endocrinology with a focus supporting people experiencing relative energy deficiency in sport, also known as REDS or Red S, and women experiencing perimenopause and menopause. In this episode, I pick Nikki's brain on bone health, DEXA scans, the impact of amenorrhea, and lots more. Please check out the show notes for the links to Nikki's books and availability questionnaire. Thank you so much, Nikki, for joining Food is Food today.
SPEAKER_01Well, thank you for inviting me.
SPEAKER_00You're very welcome. I'm really excited to pick your brains today about the, I guess, the consequences of under-eating and over-exercise on our bone health and our hormones in particular. So I thought that we could maybe get started with you sharing what are those consequences of when we're not eating enough andor over-exercising.
SPEAKER_01So starting maybe with the hormones. So hormones are really important chemical messengers in our bodies that direct the expression of DNA. So that's pretty cool. It is. And so hormones have a big influence over many aspects of our health, from mental health to physical health. But you mentioned bones there, and that's an example for sure. The bones are very receptive to all hormones, but in particular, probably the estrogen really is the key one, the hormone, the hormone that the bones love the most. They really love that hormone, right? And so in women, we're talking about estrogen produced from the ovaries, especially during the menstrual cycle, for example. Men also have some estrogen, but men have to convert some of their testosterone to estrogen. Basically, estrogen is the top hormone for bone health. That's sort of undisputed leader, as it were. I mean, the other hormones are also important. For example, thyroid hormones produced by the thyroid gland also support bone health and also uh growth hormone. There's a lot of hormones that influence bone, but particularly that estrogen. So now, stepping back from that, what are the things that we can do to support a good production of these key hormones? And it's actually, in some ways, quite sort of straightforward in theory, anyway. So we influence our hormones through our choice of behaviours, the balance of our behaviours in terms of exercise, nutrition, and sleep or rest. So those are the key things we have under our control. And if we have a good balance of these things, um, as Hippocrates said, if we could give every individual just the right amount of nourishment, just the right amount of exercise, not too little, not too much, we'd have found the surest way to health. So that's what we're aiming for.
SPEAKER_02Yeah.
SPEAKER_01That just right situation. But on the other hand, if we do excessive amounts of exercise, you know, which is is possible, like, for example, exercising every day really high level or even more than twice a day, or not having any sort of rest days or positive adaptation days, as I call them, if you're overdoing the exercise, this puts extra stress on the body. And if that's coupled with not fueling sufficiently for what you need to do the exercise and just stay healthy, something's got to give. And so the body is very, it's it knows how to cope with any situation. And so in this situation, it will adapt by looking to save energy. And one way to save energy if you're a woman is to switch off the menstrual cycle, because that takes a lot of effort and energy to support the fluctuation of the hormones and ovulation, etc. Going back to your original question, what are the consequences? So, say you are overexercising, under eating, your hormones will respond to that, adapt, and they will look for ways to save energy. And so often your periods will switch off. So now you're going to have low levels of estrogen, and the key hormone for bone health is estrogen. So, therefore, it's a sort of a sequence of events. It's one thing follows this, follows this, and that's what happens. So you might not initially realize this because this is the thing about hormones, they they are fascinating, so also beautiful, so delicate, intricate in their choreography, wonderful. But you but it's kind of you can't see them, you can't touch them, so it's difficult to appreciate that. And also the same with the bones to a certain extent, because bones they're continuously turning over. I think the problem is initially somebody might be overscising under eating, her periods might stop, but then she's like, Well, you know, nothing dreadful has happened. So, oh well, I'm it must be okay. I just carry on like this, but ultimately this will catch up with you. It definitely, although you might not see it, obviously your bones will be deteriorating, and sometimes this can end up with the person experiencing a bone stress injury, which could include a bone stress fracture. There's a clear link, a sequence of events that happens. Yeah.
SPEAKER_00I think that's one of the hardest things when we're thinking about bone density, and definitely in my experience, is that you can't see it happening. Um, and that's what a lot of people that I support really struggle with before they've had a DEXA scan or if they get their first DEXA scan back and the results are fine, but we still know that they're overexercising and underfueling, it can be hard for them to have that evidence.
SPEAKER_01And actually, if I could just pick up on that point. So a DEXA scan is this type of scan we typically do to assess bone health. But it only measures one thing. It measures bone mineral density, which is very important, by the way, absolutely very important, bone mineral density. But as the name suggests, is how much mineralization have you got of the bone. So it's an important metric and a nice standardized objective measure of the bone health. But it sometimes doesn't tell the full story. Sometimes, for example, the DEXA scan might come back, you know, being being sort of okay. But actually, it hasn't really told you about the bone, the microarchitecture of the bone, the structure of it, that that doesn't show. So that as you say, it can be difficult to accept or realise that there were there is a problem if you haven't had a bone injury yet. Yeah. I do stress that word yet. And it maybe you won't, but the point is that the bones will have suffered to some extent. And so looking forward, this will put you more at risk later on, even in life, when your bones, as we get older, they do decline in in bone mineral density, just naturally physiologically. Why so not you might be sort of storing up a problem for the future as well. But I think this idea that you know you can't see it or you can't feel it, as it were, it's it's a little bit of a yeah, I it's difficult to appreciate that. But what I always say is that we should treat a hormone injury, which is what this is if you're over-exercising under eating, as seriously as we do treat a physical injury. If you do actually have a fracture and you're hobbling around with a cast on your leg or on crutches or whatever, it's obvious for everybody to see and for you to see.
SPEAKER_02Yeah.
SPEAKER_01Yeah, I can't exercise. It's clear you can't do that, or at least you can't run. Anyway, so you're limited in your exercise, let me put it like that. And we know you typically keep the cast on for about six weeks, that's how long it takes the bones to heal. But then once the bones have healed, this is the equivalent of, say, your hormones healing and your menstrual cycle coming back, then no one in their right mind, after a fracture, would you expect them to go back to the full training load that they're on before? There's a thing called the rehabilitation process. You do some physio exercises to strengthen, and then you're gradually, week by week, going to gradually slightly increase the training load. So I think we should use this same model principle that we do to physical injuries that we do to a hormone injury. We need time to heal the hormones, as it were, and then after that, it doesn't mean that, oh, you can just go back exactly to what where you were before because that's where you you ended up in this prop this situation in the first place. So you've got to make some modifications and uh adjustments.
SPEAKER_00Thank you. And when we think about the DEXA scan, I guess what we're we're really looking for there is if the bone density is within a normal range or if people have started to develop osteopenia osteoporosis. Are you able to just explain in terms of the DEXA as a diagnostic tool and what the difference is between osteopenia and osteoporosis?
SPEAKER_01So when you get a DEXA scan, which is very low radiation x-rays, dual X uh X-ray absorptiometry, if you really want to know. So if anyone's had this, they'll know it's uh you just lie flat and there's a very small uh machine that passes over you about the size of a suitcase and it's totally painless and pretty quick. Anyway, they look at two sites. They look typically at the lumbar spine and the hip. So two areas that are the sort of the gold standard areas to look at. And when you get the report, you'll see it will give a measurement of your bone mineral density, a number. But it's like, well, what does that number mean? Is it good, bad, whatever? So we have to use some other metrics to put that in perspective. So when you get a DEXA report, there will be two key things you want to need to look at. There's something called the Z score and something called the T score. If you're under 40, we look more at the Z score. And this is an HMAT score. It hasn't got any units, it's expressed in terms of standard deviations. For example, if your Z score is zero, that means that you're exactly on average for your age. So thumbs up, good. Obviously, if you're positive, it means you're above the average for your age, which is also very good. If it's negative, then this means you're below. Whereas the T-score is looking at your measurement relative to what we estimate your peak is, and the peak for bone density is at your early 20s. So kind of by definition, if you're after 20, it probably might start to go down. But it's only really used more for if you're over 40. But the T-score is what uh we define osteoporosis osteopenia on. So if the T-score is negative up till from zero to minus one, then that that's a little bit of a concern, it's a negative, but it's when it's minus one to minus 2.5, even more negative, that's what we call that's the osteopenia range. Okay, so it's like, mmm, yeah, definitely not great. And then osteoporosis is if the T-score is even more negative than minus 2.5, and that's osteoporosis. So that's how we define osteopenia osteoporosis on this on the T-score compared to what we estimate your peak was, but the Z score is also, depending on your age, quite an important one to look at. And another point on the DEXA, when you get your DEXA report, as I said, they do the lumberspine and the hip. And why do they do those two sites? Because the lumberspine is a certain type of bone, it's very rich and trabecular type bone, the one with all the honeycomb structures. Yeah, honeycomb structures. Right, and that's that is that like a sponge, exactly. And that type of bone particularly likes estrogen. So that gives us an indication if there is a concern about low estrogen levels, that's really very, very closely linked to the lumberspine uh measurement. Whereas the hip, of course, it still likes estrogen, no doubt. But the femoral neck, so the the if you look at the x-ray of a of a hip, there's a sort of it's literally looks like a neck, a thinner bit, which is where which potentially can get snapped. When you hear about people breaking their hip or fracturing their hip, that's where it will snap because it's the thinnest bit. Anyway, that sort of bone is more rich in what we call cortical bone, so the more uh solid, densely packed stuff. It still likes estrogen, like I've said, but it's more receptive to weight-bearing exercise. So not only are we going to look at the the scores you get for these two sides, but also relatively speaking. So, for example, a woman in her 20s is who is undereating, over-exercising, periods have stopped. We're gonna look at that Z score and see if it's negative. And we're also gonna look at the difference between the Z score at the spine and the hip. Because if she's a runner, for example, I can guarantee you her hip probably won't be too bad. But the lumbar spine will no doubt be more negative. So that's the measurement, but also those two sites give us some extra uh detailed information.
SPEAKER_00And when someone is losing their bone density, is it happening to both the trabecular and the Yes it is.
SPEAKER_01It is happening to both bits. So the cortex, it's like the the peel of uh an orange, I suppose. The stuff around the outside, which is sort of dense, and then inside it's that trabecular. So all bones are made up that way. They have like a an outer layer, if you will, the cortex. They have the inner layer, the trabecular bone. But there's different proportions of that. Uh, there's more of the cortical, the outer shell, if you will, in the hip, and more of the squidgy stuff in the spine. Okay. So, yes, but both cortex and trabecula will lose bone mineral density, but it's the trabecular one that is particularly sensitive to low estrogen, and that's why, because that's at the lump spine, that's the one that's really going to show up. And from a practical point of view, we know that if you do have poor bone health, and I I'm thinking about my mother here. My mother used to be taller than me, but now she's shorter than me because the vertebra has squashed down, you see.
SPEAKER_00Yeah.
SPEAKER_01So that's why we look at that because actually it's quite an important site to look at to see is it going to squidge down. I mean, by the way, bone is, if we go aside, bone is absolutely amazing. It's structure, it's got to be really strong, but it's got to be light.
SPEAKER_00Yeah.
SPEAKER_01And actually, having this so-called crumple zone, I'm going to call it this trabecular honeycomb sponge-like thing in the vertebrae is really good. Um, so it's bone is amazing. Yeah.
SPEAKER_00The way it's designed. No, I definitely remember in anatomy playing with bones. They are very light. I was just thinking as a random question. Do you know how much our complete bone structure weighs? Like on for an average human?
SPEAKER_01That's a really good question. I wouldn't like to say just like toss a number at that's complicating. But yeah, we're gonna have to look that up. I'm really, really curious.
SPEAKER_00It just came to my mind because the area that I work in terms of eating disorders, there's um a lot of people so fearful of weight gain, and I sometimes I'll spit out the fact of well, our gut carries two kilos of bacteria.
SPEAKER_01Yeah, that's well, that's exactly, and that's a really good point. So if we're adding all these things up, the gut itself is really long. Yeah. It's a massive tube, and if you pull it out, it will cover the tennis court or whatever the statistics are. With all the villain stuff. So there's a lot of stuff, but certainly bone mass is a thing. And if you aren't eating enough or you've got an eating disorder, you will lose obviously you're gonna lose weight, but you're going to lose it from all of these things. Yeah. I mean, often you lose the muscle. You definitely lose the bone, we know, right? Um, and scarily, if you're really in a bad situation, you might even lose your um heart muscle, your cardiac muscle gets eaten away and used and metabolized. So the weight loss is is from everything. And but when you hopefully restore to a healthy weight, then initially some of people think, oh my goodness, I'm gonna put on lots of fat. But actually, initially, what happens is it's just gonna try and restore some of these key tissues, and also the cells they want to replenish their glycogen stores, their store of carbohydrate, and that takes a lot of water to store it. So, which is why the liver, one of the reasons the liver is quite heavy, because it's got some glycogen in it. Anyway, we we've uh definitely digested that it's really interesting.
SPEAKER_00And so, with the the DEXA scan, what in your recommendation or what are the current guidelines around when we should be referring people for DEXA scans?
SPEAKER_01Well, I think maybe some people don't realise that it's not DEXA isn't just restricted to older people, menopause or women, right? So, for example, in the younger for menopause, definitely male or female with a uh clinically diagnosed eating disorder that's been going on for some time, and or um, even if it's not like a full-blown eating disorder, if you are under fueling, so I'm talking about relative energy deficiency, for example, and a woman and your periods have stopped, uh, a severe primary indicator of red relative energy deficiency is no periods for a year or more. So at that point, absolutely, I will be referring somebody for a DEXA, whatever their age, in whether a woman in her reproductive years, if her periods stop for significant time. I mean, amenorrhea is defined by no periods of three months, but I agree after three months, maybe you wouldn't be rushing to the DEXA. But certainly, if it gets now to a year and her periods haven't come back, then I would definitely want to know the DEXA because just to see what's going on and to see if there's anything we need to do to protect the bones while we're working to get the um periods back. So it's really based on the clinical history. And obviously, if someone's had a bone stress injury, especially a high-risk one like the femoral neck, or two or more lower risk ones, like in the lower limbs, then again that would be raising questions about someone who's not yet reached menopause. That would definitely warrant a dexa. And then in the older age group, seeing that after menopause, one in three women are at risk of getting osteoporosis, then I think that's an easier one to argue for, especially if they've had their periods of stopped earlier in their life, or of course they've fallen over and got a fracture, then definitely we want to do it. Or if they've got maybe other conditions which might predispose them to poor bone health, like they've had to take steroids during their life for a condition or something like this, or they've got a really strong family history of osteoporosis and hip fractures and things like this. So for the older age group, I think it's easier to come up with those justifications, clinical indications, but for the younger age group, we definitely should not ignore that. Because, especially for women, there's something that you can do to protect the bones, and while you're trying to get the periods back, HRT I'm talking about. So you definitely need to talk about the biggest.
SPEAKER_00Definitely want to talk to you about that. Yeah, I tend to refer people around that 12-month mark. The challenge I I get is that repeating the tests seems to be a bit more of a challenge in in my experience. I tend to sort of wait every two years to repeat.
SPEAKER_01Well, the app the the the closest you can do it is a year. Yeah. That's official. If you ask for it under a year, most places won't do it. Yeah. Unless it's in a research study. In a research study, we did it actually after six months.
SPEAKER_02Yeah.
SPEAKER_01Which interestingly already showed a change. So it's not the fact that there isn't a change visible, but it's actually a year, then you're more likely to see if it's a clinically significant change, which can be really helpful. It all depends on how you explain the referral. If you just say, Oh, do a DEXA scan. Yeah. But if you give a a reason, rationale, clinical indication, well, they say the last one was whenever it was a year ago. And since then, these are the changes that have been made, and we want to see if if there's made a difference and whatever. So it all depends, like as with any frankly investigation. If you make it easy for them to say yes, give as much information as you can on the request form. But you're right, otherwise, if you do, if you just send in or do a DEXA scan, then they probably will you will get a pushback and guarantee that. Probably they'd say we'd do it every three years. But if you give a reason why, a year is reasonable.
SPEAKER_00And so for someone that isn't, you know, maybe it's been 10 years that they haven't menstruated, would the expectation or guidance then be for them to be regularly tested throughout that 10-year period?
SPEAKER_01Well, ideally, but that also depends on assuming that, you know, efforts have been made during that time to try and rectify the situation. Yeah. Otherwise, if the person has just stuck with their behaviours which got them amenorake in the first place, all the DEXA scan every year is going to show is going down, which we know that's going to happen. So it would be the person has made some changes, hopefully you've encouraged them and explained to them, and and they're taking it on board and they hopefully are eating more carbohydrate, and they're just calming down the exercise and they're taking some actions, then it would be justifiable to repeat it after a year. And if the periods don't restore after a year, despite them making some changes, then actually then we're definitely talking about HRT.
SPEAKER_02Yeah.
SPEAKER_01And then that would in itself bring the justification for monitoring the effect of HRT to confirm it's helping and whatever. But just to say we're just going to do a DEXA every 10 years, but we're not going to put in any actions in place, then if I was the person deciding, I would reject that because it's like, well, what are you trying to prove? You're just going to prove what we know physiology will show. Yeah, what's the person? Yeah, a reason. Yeah, what's why you're just, you know. So it really depends on the situation.
SPEAKER_00Yeah.
SPEAKER_01You could you could argue for somebody that if they're really reluctant to change and you repeat the DEXA after a year and show them it has gone down, sometimes you could argue that that would be important to persuade them that actually, look, if you don't do anything, it gets worse. But just to say, oh, I'll just go and do it every year over uh ten years, it's like when 'cause when you said ten years, it's like yikes. I know it happens, but we we don't want that situation to be arising anyway. No, we don't, however.
SPEAKER_00I know that I'm gonna live in the real world as well. Yeah, yeah. But uh yeah, anyway. And if we think about osteoporosis just before we go into HRT, one of the I guess most common questions I get when people get their DEXA scan results is is osteoporosis reversible?
SPEAKER_01Well, I think a more general way of framing it is can you improve your bone health? Which I suppose is kind of the same question.
SPEAKER_02Yeah.
SPEAKER_01You can always improve your bone health. House. If there's a reason why it's declined in the first place. Because bone mineral density is about like quite a lot genetically determined, like maybe even up to 75%. So if genetically those are the cards you're dealt with, then so you can still got the remaining bit to work on. And so you can, but obviously, if you are in the situation where you've got poor bone health because of your actions and behaviours, that's even a more certainty you'll be able to improve your bone health. So there's always scope for improvement, depending on the situation, why it's low in the first place. I mean, if you're talking about, okay, so your T-score is minus 2.6, and now we're going to try and get it up to minus 2.4. We just put you over that boundary. So technically speaking, we have reversed osteoporosis. But I would want to know what's the clinically significant, is there a clinically significant change? I know I'm being a little I'm being a little bit fussy about the words, but I know it's a nice head headline grabbing thing. Reverse osteoporosis, it sounds dramatic.
SPEAKER_02Yeah.
SPEAKER_01But actually, we should be more focusing on improving your bone health in general terms, wherever you are. I suppose you could argue the lower you are, the more likely you are to, you've got further to go. Yeah. So that's one thing. But certainly I've seen it many times, not least in myself. If you've had reds when you're, you know, 20s, 30s, and 40s, then definitely we can see marked improvement in bone health, clinically significant improvement in a relative short space of time. I mentioned a research study over six months.
SPEAKER_00Yeah.
SPEAKER_01You could absolutely improve your bone health if you balance your behaviors around the training load and the nutrition. You can definitely absolutely improve it, combined ideally with targeted loading the skeleton. So the two stimuli for making bones is put in the mechanical stimulus and fuel correctly, give some energy, make the hormones optimal. So that you need those two ingredients. So if you just do a load of exercise, but you're under fueling, your bones get worse, like we discussed. So it's that it's not just this one thing, it's all of these in combination. Is that the right balance? You can definitely improve your uh bone health. People often ask, for example, can I improve my bones to where they should be? So say you've got an athlete in her twenties, she's had she's got red, her periods have stopped, her bone health isn't great, her Z score's negative, and she said, Okay, fine, I'll make the changes you suggest. And it's well, like, will I get back? But then I can't say where you were destined to be.
unknownYeah.
SPEAKER_01Unless you've got an identical twin, we don't know what we're aiming for exactly. So that's why I talk about improvement for you personally.
SPEAKER_00Yeah.
SPEAKER_01Rather than hitting a particular range or something. Of course, it would be great if we can say uh get out of the osteoporotic range. I would prefer that terminology. I prefer that way around. I suppose it's semantic. I'm being fussy, aren't I? But I think the message we want to give is that everybody should be encouraged and think positively and know that whatever your bone health is, you can improve it.
SPEAKER_00Yeah. I think that's the most important, most spot on sort of point that I wanted to make sure that we covered because there's so much fear with a lot of people that I work with that they've they've ruined their bone health and that there's not a chance of recovering any more.
SPEAKER_01I guess it, you know, especially as I said, being there, having been there, done that myself, my bones used to be dreadful when I had reds for sure. But then, even to my slight surprise, when everything sorted itself out, my peers came back and da-da-da-da. It's like actually, looking at my bones, it's like, okay, fine, they're they're in in decent shape now, you know. Um, and also, but for any age group, but also we're talking about the older age group, for the post-menopausal woman, there's a beautiful study called Liftmore, which does what it says on the tin. They took a group of women in their 60s, divide them into two groups. One group they just said do general exercise. The other group they gave supervised strength training, weight training, even. Supervised, I do stress, three times a week and everything. And then they brought the two groups back, and the ones that had done the strength training, they improved, improved their bone mineral density. They didn't lose height, and they actually improved their bone mineral density. Whereas the other group didn't do so well because it wasn't so focused exercise. So I think the message is whatever your age, you can definitely improve your bone health if you look at all the factors.
SPEAKER_00Yeah. And from an exercise and strength perspective, so that weight-bearing exercise is the most important for our bone health. Is there a time that when someone's severely underfueling, severely underweight, we would maybe put a pause on particular exercises, but then it's sort of balancing out what is this going to impact their bone health more?
SPEAKER_01Yeah, well, but that's a really important question. So it's this paradoxical effect of exercise. We know that loading the skeleton, doing exercise, is a mechanical stimulus for bone health, so it's an osteogenic effect on the bone. Great. But if you're doing this loading the skeleton and you haven't got enough fuel and you haven't got enough hormones, then actually that outweighs the benefits of exercise. It's all about this balance thing. The thing is, it's an individual thing. I mean, very rarely do I say to someone who's coming to me with reds, very rarely do I say stop all exercise. Well, not least, because I know they won't do it, so there's no point. But also, then it's like, okay, fine, we're going to dial down the intensity of the exercise. That's the important thing. Keep the heart rate low. And we are going to do some focused strength work, but nothing too crazy heavyweights, just really good quality exercise. But how much there isn't a magic formula. It's very much on the individual. Where are they coming from? If they're kind of like a weightlifter, I know it would be unlikely you'd get a weightlifter who's got reds, but still, you never know. Anyway, so if they're really, really used to lifting heavyweights and everything, then you're you're sort of confident that they're hopefully they've got a decent technique, and so you're going to be saying you can do some strength training at a lower level. Whereas if it's someone that's coming and frankly, they haven't done any sort of strength exercise before, the worst possible thing you could say is right, go and do some really hard deadlifts because they will injure themselves, right? So it's difficult to know. It will depend on the individual and it depends on all these little little nuances. And the critical thing is, is it good technique? If they're doing strength exercise, is it good technique? That's really the important thing. In general, we would like to see them doing some in combination with addressing the fueling, etc., because otherwise it's not going to have any effect. But the exact formula, like how much and all this sort of thing, that will depend on the individual. So many factors to consider. Yes, exactly. But but in general terms, we want to be encouraging them to do some because even if they're starting to address their energy balance, etc., and improving their hormones, you do need some loading of the skeleton to support that. But how much and how you're going to build it up, this rehab model we have in our minds, that's going to be very according to the individual. Yeah, thank you.
SPEAKER_00And so let's jump on to HRT. So I guess the two key things that I'm keen to hear about is the updated nice guidelines. I know they're three, four years old now, but I think it's really important that we touch on those and explaining what HRT or hormone replacement therapy is and how it's important. And then we can touch a little bit on the oral contraceptive pill as well.
SPEAKER_01So HRT, it's hormone replacement therapy. So this is a combination of estrogen and progestogen. Progestogen covers all the types of synthetic progesto progesterone and the sort of molecular identical progesterone. Ideally, HRT, it makes common sense. You're going to try and pick the combination that is going to be molecularly identical to your own. So estradyle, most active form of estrogen, and micronized progesterone. So that's what HRT is. I know sometimes people prefer to call it MHT, menopause hormone therapy, but the point is, like we're just going to move on to, is its use is not restricted to menopause or women. So a woman who is in her 20s, has got reds or an eating disorder, and her periods have stopped, she's got amenorrhea, her bones have therefore suffered. So we're absolutely number one, the most important thing we're going to address, rebalancing the nutrition and the exercise. For sure we're going to do that. But if she's had uh bone stress injury, either one at a high-risk site like the femoral neck, or two, two or more at other lower risk sites, and/or she's got the DEXA scan with the Z score less than minus one, that's what's set by the IOC as the sort of warning level. So in those circumstances, we're concerned about her bone health while she's trying to get her menstrual cycles going again. Then in this case, HRT is indicated for bone protection. And you're quite right to say, and I'm so proud of that, that I got nice to change the guidelines 2022, I think. And it's on the clinical knowledge summary section of the NICE guidelines, which are mainly directed at doctors, is true, but anybody can go and look at them if you want to. I've had to send them to a couple of GPs before. So the summary is that the short, what it says effectively is if your periods have stopped, so you've got secondary amenorrhea, and there's a concern about the bone health, this is amenorrhea due to functional hypothalamic amenorrhea, in other words, a response to not fueling and over-exercising. By the way, your periods could stop because you're pregnant, so obviously you're not going to be taking HRT then, are you? So it's specifically if your periods have stopped because of FHA, i.e., because you've got an imbalance in your nutritional exercise, and you've got this clinical indication of the poor bone health, then HRT is a really good idea because I mentioned at the beginning weed estrogen being the key hormone for bone health, porting bone formation. So in this case, we haven't got the menstrual cycle for the time being, so we're going to kind of mimic it or replicate it as best we can in a very crude way. So the person will be taking some estrogen every day through the skin, that's really important. So it's a gel or a patch. Generally, I find people much prefer the gel because it's more convenient than sticking something on you and you've got more control over the dose. So you put some estrogen on your skin every day, and then for 12 days over a calendar month. So you can remember, I suggest days 1 to 12 of the calendar month, so you can tick it off. On the evening, you take 200 milligrams of this micronized progesterone. So that's kind of equivalent to the luteal phase of the menstrual cycle when you produce progesterone. It's very crude and rough, but we try and replicate it as best we can. You can't just take estrogen by itself. You might be thinking, well, why don't I just take estrogen? Because you said that that's the important hormone for the bones. It's true. But if you just took estrogen by itself, that could be dangerous because actually the lining of the uterus, the endometrium, could get really, really super thick. So progesterone, you must take it with progesterone so the lining doesn't get too thick, and you might get a withdrawal bleed after the 12 days of the progesterone. It's not contraceptive, important to say that. So if there's a clinical indication specifically for bone health concerns, in this woman we've described, then HRT is the way to go. But for any age group, HRT is now the primary medication for the prevention and treatment of poor bone health. So in this case, this is the young woman, we're giving HRT, but also in the older woman. So regardless of age, uh HRT is really good for that. So what's the story about the combined contraceptive pill? Because up until some time, and even now, I am afraid to say there are doctors, I hate to mention it, who still think that the pill is an alternative to HRT for this young woman with poor bone health.
unknownYeah.
SPEAKER_01The problem is the following: the combined contraceptive pill, by the way, by definition it's contraceptive, and the way contraceptive works, hormonal contraception, is to switch off the production of your own hormones and prevent ovulation. The vast majority of the contraceptive pills, they all suppress all your own hormones and stop ovulation. That's why they're so effective contraception. Even the progestogen-only ones, the majority of them nowadays, they also have the same effect. They squash all the hormones flat. So that's why it's not a good idea to take them. So you might be thinking, whoever thought it was a good idea. The reason is because if you look at the contents of any combined contraceptive pill, it will have some words which look similar to estrogen or estradiol. It will say ethanol estradyl. It's like, well, isn't that the same? No, it's not. It's not the real one. And the by the way, the bones aren't stupid. They know what the real estrogen is. So they see this and they're like, no, that's nothing. That's the problem. There are two types of contraceptor, only two. Out of all the numbers, I don't know how many brands are. Oh, there are two which actually has the real estrogen. So that's good. But the problem is, combined contraceptive pill, by definition, even if it's got these two of that got the real estrogen, they have the synthetic type of progestogen, which suppresses ovulation, because they're contraceptive pills. So you might give some estrogen to the bones, it's true, but you're going to take it away with the other hand.
SPEAKER_00Yeah.
SPEAKER_01You're going to squash any hope at restoring your own cycle. The confusion arises, number one, because of this thing about the molecular structure, but also the other thing that's is a bit confusing, maybe, is that if you take the combined contraceptive pill, like as it's in that sequential way, you will get a bleed. But that's not a menstrual period. That's just a withdrawal bleed that's forced because of these synthetic hormones. But a doctor writing a prescription, giving it to the person, that feels good. And the woman thinks, well, I'm having a bleed, and she kind of would like to believe that that's her period, but it's not. So that's why that's not bone protective at all. And actually it kind of messes up the whole thing.
SPEAKER_00I think I mentioned to you by email one of the young ladies I support, her GP told her to go on the pill to thin her lining, and we're both a bit perplexed because we're like, oh, if she hasn't been mint straining, her lining would naturally be thin already.
SPEAKER_01Yes, if if she has got FHA, by definition her the lining of the uterus will be thin. I think another confusion rises where a woman with amenorrhea, no periods, there are various reasons for this. I mean, basically, in all situations where a woman has amenorrhea, apart from pregnancy and PCOS, maybe, all the other situations, the estrogen will be low by definition. Your lining, of course, it's not going to be thick. There is an argument that if the woman's periods have stopped and you're suspecting PCOS, polycystic ovary syndrome, I mean, could you diagnose that based on the blood test, see what the testosterone is, and her periods have stopped, and maybe you're doing ultrasound, see lots of follicles. And there's an argument that maybe in this case you would give some synthetic external progestogen to sort of force a withdrawal bleed to see is the lining of the uterus got enough estrogen in it. But tell you what, the easiest way to determine that is doing ultrasound. To see how thick the lighting is. The devil is in the detail. Yeah. Right? You really have to know, you can't just make generic assumptions that every woman whose period stops has a PTOS and a thick lining of the uterus. It's like, no, that's not correct. So you have to really understand what's causing, why have the periods stopped, and you'll work that out through the process of discussing with the person and doing some blood tests. And in some cases, the ultrasound scan might be helpful if you're sort of wondering about the thickness of the lining. Yeah. But if the woman has got FHA due to reds or an eating disorder or something like that, you don't even need to do an ultrasound. Lining will be thin. Full stop. That's it. End of story.
SPEAKER_00Glad we were thinking correctly.
SPEAKER_01Yeah, we're absolutely in one line in that, yes.
SPEAKER_00Another common group of clients that I support Nikki is those in recovery from disordered eating and eating disorders in their sort of mid to late 40s. And we're going into the realm of perimenopause, and how are we able to support clients in that age group? Can they get their period back or are they in perimenopause already?
SPEAKER_01Yeah, that age group is a tricky one because, as you say, in your 40s, you might be expecting your periods to become a little bit irregular because that's natural physiology, that's part of the female hormonodysy. But also, if you are in that age group, you might be feeling a little bit frustrated, maybe, maybe you're not getting the same benefits you would expect from your exercise training. Maybe your body shape is changing a bit, and you're thinking, well, I don't like this, I'm not as muscular as I used to be, or something like this. So then that could lead you to develop breads or restrict what you're eating. It's possible you could have both. And so what's going on there? So, in that situation, the best way of distinguishing which is it, or is it a combination of both, is actually just by asking and going through the details of it. And um, I've developed that questionnaire. I think I sent you a link. Yes, I'm gonna call Personal Energy Availability Questionnaire, and it's just a series very quite short, it's about 15 questions, and you can just click on the answers, and that gives you some indication, effectively, a clinical history. What which way are we leaning? Are we leaning perimenopause, underfueling, which way are we leaning? So getting some information on what the woman's doing, what she's thinking. But then the next step, of course, is the blood test. And the blood test that's most helpful to distinguish or tease it apart is the full thyroid function. So T3 is a really good indicator of energy availability. And so if the T3 is fine, but she's getting irregular periods and not feeling so good, there's probably perimenopause if the T3 is okay. Conversely, if T3 is low, then she could have perimenopause, but you've got to address actually the eating behaviours and training. So that's the way to tease it apart ultimately from the clinical history in that T3. You might say, why don't you do female hormones? But the problem is that perimenopause, the definition of that is basically the hormones are all over the place. So that's what it is. And so it's actually advised by the British Menopause Society specifically not to do a blood test in a woman or her female hormones at the least. Uh, don't do a female hormone blood test in women over 45 with symptoms, because it's uh diagnosis perimenopause based on symptoms, not on blood tests, because blood tests could be misleading. But uh doing a full thyroid function test is perfectly justifiable to exclude or look into fueling. But also the other factor is that women are more prone to develop an underactive thyroid, especially as we get older. Symptoms of hypothyroidism overlap with perimenopause, by the way, and to a certain degree even with reds because of irregular period. So there would be justification in doing a thyroid function test. The slight problem we have is that on the NHS generally they only want to do TSH, which will tell you if you've got an you know an UVET underactive thyroid. But the T3 is a little bit of a tricky one to get done. But again, it's all about give as much information as you can if you explain that T3 is the primary indicator of reds, because not everyone will know that. And then they might do it, or otherwise you might frankly have to do it privately. But it's always worth if you give all the information, you're more likely to get the test you want.
SPEAKER_00Yeah. And are there any other specific markers in the context of reds or bone density that you would add to that? Uh in this age group you're talking about, particularly. I'd say across the board, our younger board. The younger ends. Yeah, in this age.
SPEAKER_01In the younger, so let's do the younger woman. Yeah. And my sort of reds blood screening test will be to include all the female hormones, because I want to be sure that this is FHA and rule out anything medical or PCOS or something like this. It will also be the full thyroid function to see what the T3 is, rule out an underactive thyroid. And that part, everything else after the thyroid, so I wouldn't do the female hormones in the older age group, but I would still do the full thyroid in both age groups. I would also, in addition, I always do vitamin D, all age groups, because vitamin D is essential for well-being, it's essential for bone health, muscle recovery, and immunity. And that can be a really simple, easy fix, and that's really important. And it's easy to get that done on the NHS, although I did hear recently someone was declined having it because the rationale was, well, everyone's got low vitamin D in the UK. It's like, what? Anyway, but hopefully, vitamin D I always do. I also, just as extra information, I generally do ferritin, an indicator of iron, and I do vitamin B12, just to be sure we're not missing anything else that's uh going on. And then optional extras are full blood count, just make sure the person's not an anemic and that's the reason they're feeling tired. Those are the ones I would always do. If you can, then throwing in liver function isn't a bad idea because sometimes one of the liver enzymes is raised if you're overtraining. I don't think renal function, frankly, is going to give you a lot extra, but if they're offering that to you, yeah, then take it. So those would be the main ones. There are some optional extras, lipid profile, but we know if you're a young person with reds, your lipid profile won't be very good. So I actually avoid doing it because then it puts them in a flap. Because they're less drunk, it's right. And then you know what I mean. So it's like it's not because you're eating too much fat, it's because you're not eating enough and your furrates have stopped. So I don't feel that adds any more extra information. And HBA1C reflects uh blood glucose control, but this is I wouldn't routinely do this only if I was suspecting um maybe more in the older person that maybe some of their fatigue symptoms, you just want to check on blood glucose control, but these are optional extras. Yeah. So in in essence, I think it's very similar to the age group for reds, uh the blood tests, I mean, although I would find it difficult to justify doing it in a woman over 45, I suspect perimenopause, but I'll always do full thyroid. I'd also always do vitamin D, B twelve, and um heritin. And then the optional extras are other ones, depends. If you're getting those offered to you at your GP surgery, yeah, then sure. Yeah, you can have them. But actually it's more important to try and persuade. To get that vitamin D and ideally the full thyroid function.
SPEAKER_00And I think with vitamin D as well, is that people share their blood test results with me, and their vitamin D is sort of borderline low and they just get their little in brackets, it's normal, so it's fine. Um yeah, that's a good point.
SPEAKER_01Let's just quickly clarify that. I mean, basically the range roughly is something like 50 to I don't know, 180 nanomoles per litre, roughly let's say something in that order. But everybody knows that 50 is way too low. And what you're aiming for, the optimal level for an active person is 100 nanomoles per litre. So don't be satisfied with oh sufficient.
SPEAKER_00Yeah, especially if you're at risk.
SPEAKER_01For bone health, exactly. So people who are coming back with 50, I'm going to say, right, you need to take vitamin D supplement right now. Yeah, or even people who are sort of like scudding around 60, 70. It's like, look, we could do better. Let's make sure we're getting you a decent dose of vitamin D supplement. Let's retest after, I don't know, whatever, a couple of months, make sure you're around about that 100 nanomole level. Because studies, you know, there's clear evidence from studies that's the level you need to hit if you really want to get the max benefit in terms, particularly of bone health.
SPEAKER_00Thank you so much, Nikki. I think that might be a note that we end on today. Just want to say thank you so much. And where can everyone find you? I will add it into the show notes, but just to say it here.
SPEAKER_01Sure. I have a website, Nikki K Fitness, spelled K-E-A-Y. Um, and on there I've got some blogs, my publication books, appointments. So have a look there. And then if you want to come and discuss something, an advisory appointment one-to-one, I'll offer that. That's on my website available. We mentioned the peak, so maybe you can put that in the show notes. So that's a little free questionnaire that you can do just for your own information to get an eye, uh get a feel. Um, I've also written two books available on Amazon, Hormones, Health and Human Potential. And the other one is called Nythumeniople. So there are two books there with plenty of information. Oh, and if you want to look at social media, I'm at Dr. Nikki K. Fantastic. Thank you so much.
SPEAKER_00Thank you for tuning in to Food Is Food. If you found the episode nourishing, hit subscribe so you don't miss our weekly episodes. And just before we wrap up, a little reminder that the discussions in each episode are for informational purposes and don't replace individualized advice. Because every recovery journey is so unique. Please consult your healthcare provider for support. That's all for today. Stay nourished and see you next time.