The Food Medic - S3 E7- Hypothalamic Amenorrhoea

Episode Date: August 20, 2019

The topic of this weeks episode is hypothalamic amenorrhoea (HA) - quite a common cause of loss of periods. Dr Hazel is joined by Renee Mc Gregor, a leading performance and eating disorder specialist dietitian and Dr Nicky Keay who is a medical doctor specialising in sport and dance endocrinology.In this episode they discuss:What is HA?What causes HA?Health consequences of not having a regular period.What to do if you’ve been diagnosed with HAHow to recover and what to expect.Link to Renee’s website: https://reneemcgregor.com/Link to train brave: https://trainbrave.org/Health4perfromance BAsem website: http://health4performance.co.uk/updates/ Hosted on Acast. See acast.com/privacy for more information. Learn more about your ad choices. Visit podcastchoices.com/adchoices

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exclusions, and terms apply. Instacart, groceries that over-deliver. Hello, and a very big welcome back to the Food Medic Podcast. I'm your host, Dr. Hazel Wallace. I'm an NHS doctor and founder of The Food Medic. The topic of the podcast today is quite specialist as we're going to be talking specifically about hypothalamic amenorrhea, what a mouthful, or what's often called as HA. The term amenorrhea means no menstrual cycle and in HA the hormones or signals that are supposed to be sent out by the hypothalamus, which is the brain's control center center are suppressed so that ovulation doesn't occur and therefore there is no period. The reason I feel like this is an important topic to talk about

is because it's becoming increasingly more prevalent and affects a lot of women plus it can be very distressing. So this week I'm joined by two guests who are very well researched in HA and have a lot of experience in this field. Rena McGregor, who's a leading performance and eating disorder specialist dietitian, who we have had on the podcast before. And Dr. Nikki Kaye, who is a medical doctor specializing in sport and dance endocrinology. Before I introduce you to our guests, it's time to share this week's listener question, which is, I've recently switched to a vegan diet and I'm suffering a lot with bloating and wind. What can I do? So if you're interested in finding out what the answer to this question is, don't forget to keep listening to the end of the show. And if you have your own question you want to submit, all you got to do is tweet,

Facebook message or Instagram DM me your question with the hashtag the food medic podcast. So, Nikki, I'm going to start with you. Can you give us a bit of an overview as to what amenorrhea is in general? And what are some of the common causes of amenorrhea before we jump into HA? Okay. So amenorrhea means lack of periods and there are specific medical definitions. So primary amenorrhea means as a woman, you haven't started your periods by the age of 16. Secondary amenorrhea means you have started your periods but then they stop and are absent for six months six consecutive months and oligomenorrhea we should just mention that's infrequent periods such that you have less than nine periods per calendar year so that's what

we're talking about amenorrhea lack of. And there are some medical conditions that can cause this. So any woman of reproductive age should have regular periods. And any woman that presents who doesn't, who has amenorrhea of those types I've just described, then initially you must always run some tests, some basic blood tests, just to exclude there's no medical cause for that that needs addressing. If you come to the conclusion that actually there isn't a medical disease, well, I didn't really want to call it a disease, a medical condition causing the lack of periods, the amenorrhea, then you come to the conclusion that actually it's a functional issue and we're

talking about hypothalamic amenorrhea. In other words, the condition is a result of behaviours of the person. Okay, so it's more of a diagnosis of exclusion. Correct. Exactly. Cool. And HA is very common in athletes and women with eating disorders, but periods can actually go missing at much less extreme levels of exercise and food restriction and while it typically occurs at a low BMI it doesn't always occur in an underweight person. Rini what are the common causes of HA and what are some of the biggest misconceptions about it? So I mean as you sort of said restrictive eating is one of the key causes and and that can be that you you're just

not quite eating enough for the work you're doing. So, you know, we often see in our clinic, a lot of people present and they actually look like they're eating quite well. But then you start calculating what they're having compared to the training they're doing. And it's a mismatch. So it's just not quite enough. We also notice that exercise intensity can be quite critical. So again, often we do find people who look like energy availability is maybe, you know, matched, but the intensity of the exercise means the stress is kind of affecting some of the hormonal productions, which Nikki will probably talk about. But that's, you know, quite key. And I suppose the biggest misconception around hypothalamic main and a rear is that you have to lose weight to lose a period because we see many individuals who are a normal weight. And it's that mismatch of energy availability, the overtraining, the training intensity that causes the kind of deficit, which means that the body will prioritize movement and it won't

prioritize the biological processes. But also what happens is metabolic rate will slow down. So you tend to preserve energy, you tend to preserve body fat, you tend to preserve weight. So sometimes weight doesn't change. And this is what we see a lot. People will come in and say, if I was not eating enough, why isn't my weight going down? And of course, we have to explain the reason why. And I suppose the other thing that's really important specifically for when you're combining exercise and looking at amenorrhea is carbohydrate availability so we've again seen that even if somebody's got good energy intake throughout the day if they haven't got the right carbohydrate availability around their training session so

before possibly during if you're doing a long duration and definitely after you're not going to necessarily get that hormonal regulation yeah we touched on that it affects the hypothalamus but i would love to kind of explore what's happening on a physiological level and then nikki if you could maybe briefly summarize what's actually happening between the different organs and how that miscommunication is happening. That'd be really great. Sure. So the hypothalamus is a gland in the brain. And that's really the boss. It's literally the nerve center. It's the neuroendocrine gatekeeper. So all the internal messages and external messages get fed to that. So, for example, internal, that would be like Rini explains, low energy availability.

There are messages being sent saying that we're really low on glucose, we're really low on fat levels, emergency signals, if you will. Then also there are external inputs, So lack of sleep, stress, I mean, life, you know, we're not just talking about exercise, there's other causes of stress. All those signals get fed into the hypothalamus, this gland, and that's the boss that controls the next in the line of command, that's pituitary gland. And that has been sort of described rather flowery as the conductor of the endocrine system. So that is really the boss boss for all the hormones in the body. But it's depending on the signals from the hypothalamus. And then the pituitary in turn

controls all the glands in the body secreting hormones. So we're talking about the glands such as the thyroid gland in the neck controls metabolism, as Rini mentioned. We're talking about the glands such as the thyroid gland in the neck controls metabolism, as Rini mentioned. We're talking about the gonads, so ovaries in the case of women, the testes in the case of men, which in turn produce estrogen and testosterone respectively. The adrenal glands, top of the kidneys, they're also all in this chain of command. They produce cortisol, the stress hormone. I mean, that's probably enough for now. But in summary, the hypothalamus is the boss, taking all the inputs, internal and external inputs. And that commands the pituitary gland, which is the boss of all the hormone glands in your body. Yeah. So there's three levels going on, the hypothalamus, pituitary, and then your

other organs. And then we have a feedback loop as well into the hypothalamus. I love my feedback loop. So say now, let's take an example of the thyroid gland, for example. So you have all the inputs to the hypothalamus. That in turn says to the pituitary, yes, we'll go. The pituitary sends a stimulating hormone to the thyroid gland. And the thyroid gland responds by producing the thyroid hormones T4, thyroxine and T3. And those circulate in the body.

But how do you know what the level should be? So there's this feedback loop, as you say, it's like a thermostat. So the levels of T4 and T3, they go back, feed back via the hypothalamus and the pituitary, either to say, we're really high, these are high levels. And so then it will, the control message will be tuned down. And conversely, if it's too low, then it will say, please produce more. So it sort of oscillates a little bit around a steady level, more or less, okay? But if you're in low energy availability, then those normal feedback loops are broken, literally. And you would expect the control hormone and the response hormone to sort of work in sync. But you look at the blood test

and you can see they're broken. They're both low, which is very unusual in endocrinology study of hormones. So that's an example of those feedback loops. They get disrupted because of low energy availability. Yeah. And when it comes to HA, obviously you guys see it frequently in clinic. Can we estimate the prevalence in the general population? Do you think it's something that's increasing? Are you guys seeing it more frequently? Well, obviously we started our clinic in april the inspire clinics specifically around endocrine nutrition that was kind of the whole point we've been very busy so we started off with just a clinic in bath and now we've got a clinic in bath and london and i think we've been discussing that potentially we might have to increase days again in the new year just because we're getting a high frequency i think it's really difficult to give you prevalence i suppose because because

nikki and i both work in this field it's all we see so it's hard because obviously pretty much i say maybe 90 of the people i work with have got some sort of hormonal irregulation you know obviously i can't say hypothalamic amenorrhea all the time because we work with men as well so but they definitely have hypothalamic irregularities. Can we put it that way? Hypothalamic low oestrogen. Yeah. Yeah.

I didn't really consider men and how they come into this, but I guess it's part of, you know, the whole picture. And the hypothalamus isn't just looking after our ovaries. It's looking after gonads in general and all of the other organs. So when someone is diagnosed with ha what are some of the steps that they can take or that you take with them to help them get back kind of find equilibrium between their kind of endocrine system so if i walk you through kind of like an assessment with us it's probably the easiest way to do it so an individual

will come into clinic we will have already asked them to do blood test results which nikki will then provide feedback often we do get them to do bone scans as well so we can especially obviously we see quite a high number of athletes or recreational athletes at least so sometimes they come in because they've had and dancers and dancers sorry they often come in because they've had stress fractures or injuries of some description so if they've had a previous stress fracture, we usually ask them to have a DEXA scan or a bone scan of some description. And then once we've gone through

and explained to them what's happening, so in the way that Nikki's just explained to you how it all works, she'll do a similar explanation and we have some brilliant resources that she's put together that actually really help to explain it properly, like how the hormonal cycle should work and where it's broken and why it's broken in the meantime they've

obviously filled out nutrition assessment forms for me so we've got nutritional information and training information and so i marry up what's going on there and it can help them to understand that you know often it's it's quite easy to kind of explain to them that you know you're just not putting enough fuel in at this point or you're just not recovering sufficiently. You know, we all live really busy lives. So sometimes this can happen when you just, it's not a conscious decision. It's like you're not always consciously restricting. You know, some people just don't appreciate how much fuel they need to live life and train.

You know, we're busy, right? We run around, we're trying to train, we might have dogs to walk, we might cycle everywhere. And it uses up a lot more energy than you actually imagine. And I think because we live in a society where we're constantly being scaremongered about obesity and diabetes and cancer and everything else, everybody's so scared of eating. Of eating. Yeah, eating yeah eating it feels like that sometimes yeah you know and these individuals that come to us are people who actually don't need to worry about the diabetes and the the cancers because they're active they generally eat really well they don't

have the they're not sedentary put it that way yeah and so I guess then what I do is try and help them to ensure that they can eat properly. That sounds really simple. But obviously, in a lot of cases, it's not a simple, here you go, here's a nutrition plan, off you go. Because in some cases, there is an element of psychological change and the anxiety around change and the anxiety around food and the whole body image aspect. And so that's a whole different ball game like that's then you know we always look at the big picture and if somebody is physically and medically not in a great place then Nikki and I we try not to but we'd have to encourage them to change their way of training you know it might be they have to stop training

or they definitely usually have to reduce intensity we stop all fasted training because there's no benefits to faster training particularly when you're coming back from low energy availability so you kind of look at the whole picture and then on top of that we're looking at other bloods too so we'll be looking at things like iron vitamin d b12 so we're addressing the whole spectrum it's a combination i guess of nutritional and behavioral counseling with the medical well i think like you said it's a diagnosis of exclusion so my job is to make sure and we've had a few that we've picked up which have got a if i can say a genuine medical condition i mean a medical condition that is separate to the organic cause which needs treatment dealing in a totally different way so once i've dealt with that and said no actually it is

a functional issue then yes as Rini says then the hard work starts it's a positive thing because this is under the person's control yeah this is when all said and done it's a behavioral thing and if they can overcome those psychological barriers, you know, ultimately they can get themselves back to full health and fitness. Yeah. And I guess this will be a difficult question to answer and it will be different for everyone, but how long does recovery roughly take? Yeah.

How long does it take? Yeah, we've had that discussion. I mean, first, and we often get asked that, and I think the first thing to say is definitely will reflect on how long the person's been in low energy availability. If their periods have stopped for a short while because of this functional problem, then, you know, that's kind of probably more straightforward because we haven't got to overcome those psychological barriers. And also, they haven't been in low energy availability for that long. So the system, all those negative feedback loops can reboot more quickly.

However, you know, if someone has an extended period, years of amenorrhea sometimes we're seeing, not only have we now got to overcome the psychological barriers and being in this position for so long, actually, you know, you can understand. It's going to take some more persuasion to prime the endocrine system

to get everything restarted. And of course, we're talking about periods. That's just one of the hormones. So it's not just one system's got to reboot. All of those hormone systems, negative feedback loops, have got to reboot in a synchronized fashion. Yeah. You you know from an

engineering point of view it's going to be more complex to to overcome that and it can take some time and that's actually where we need to really support them because you know listen we all would love a quick fix yeah so you know when reena gets the phone call hey i've been doing what you said for the last few days why haven't my periods come back like, oh, it's going to take a bit longer than that. So that is, it's really giving them, you know, trying to help them be patient, but trying to say, it doesn't mean you're doing it wrong. You're on the right path. You have to continue. And if there's any little signs we can give to encourage them, they'll often feel better. The first thing that happens is like they'll say, oh, actually I can feel better and I'm actually happier yeah the main sign is we see them walk in the door and

they're smiling they came and they're looking a bit miserable now they come in smiling so even if we haven't quite cracked their periods if they're smiling and it's like yuk you're definitely on the right track we've got a few little snippets from their blood maybe we got some signs that things are rebooting um so it's giving encouragement to you know continue on that path yeah and like you said it takes time and even with women who may have been underweight and are weight restored or they've cut down their training yeah that is the hardest that is the hardest we've had so many yeah i feel their frustration it's like i've done what you said but it takes longer than that because you've got to really persuade the body to all those systems to reboot would you agree with that 100 and i think it's

such a sensitive system yeah we had somebody this year she was a runner and she's a slightly older lady but she hadn't had periods i think it was like nine months and incidentally she'd got injured so she'd got injured and had to stop running because she'd got injured and when she came to see Nikki I think she was still like you know you know I don't understand I've restored weight I think she'd restored a good amount of weight as well she didn't you know she wasn't necessarily massively underweight to start with but she needed to definitely restore she changed her eating habits she wasn't training because she was injured and you know nikki sort of went through her bloods with her and her bloods at that stage definitely showed you know low energy

availability hypothalamic amenorrhea and then sort of two months later she carried on and nikki redid the bloods and actually bloods looked really positive like really positive but then she started running again because her injury disappeared so she started running again i put it back a bit yeah and it was as simple literally as simple as the fact that she just it was so sensitive that increase in running even though she wasn't doing very much but it was enough to make the system which is already sensitive to feel stress I'm very pleased to say she now does have her period back and she's a very happy lady but for her it took I think it was about 12 months in total and another thing that a lot of them will say is oh but if I if I stop training I'm

going I'm going to become lazy and it's like well you can't become lazy because you're not inherently in a lazy person yeah right you're not a lazy person so how can you become lazy but it's okay to stop it's okay to rest it's okay to watch box sets on a sunday afternoon if you want to there's there's nothing wrong with that and i think again i know we have a big you know obesity problem a big diabetes problem i understand that but the problem is when these messages are constantly going out all the time it's also affecting a population that doesn't need to be doing the opposite so it's the clinical context is key and for someone like an athlete or that woman who's very passionate about running and it's probably part of her identity and what she does every day i can

imagine it would be very difficult to just you you know, go cold turkey and do nothing. In those instances, do you advise that they do absolutely no activity or that they substitute it for something else? Yeah, we don't, because I think we're both very active people. We understand. We find it really difficult. I mean, to be able to be told to not do anything, it's just not going to happen. But I think it's just the type, like you said, the intensity. So rather than doing running, just doing some, I'm going to call it multi-directional

loading some low-key resistance work do a ballet class there you go you know doing something on the opportunity to do some different type of exercise look on it as an opportunity. Yeah now some people might not actually be that bothered by the fact that they don't have a period. But what are some of the long-term implications of not having a regular menstrual cycle for a woman? Well, I mean, not having regular menstrual cycles, well, we can see the consequences in menopausal women who don't go on to HRT. Bone health is very dependent on oestrogen, so that's obviously number one. Bone health will suffer and you're going to be more at risk of fractures or stress responses in the bone.

But it's not just limited to the bone. It's actually also cardiovascular health. We know that cardiovascular health is affected, not just the lipids, but actually the reactivity of the lining of the arteries, the endothelium. Also, big one, Rini will hopefully explain more of the cognitive effects of estrogen. Again, ask a menopausal woman. You know, your mood changes, you get sudden changes in mood from being really upset to really angry. Sleep is disturbed. Just remembering things, cognitive function. And actually, particularly the dancers, because they're so dependent on proprioception, but also picking up things quickly.

And so once the the dancer can restore their nutritional intake and their periods resume the first thing they say is now i'll walk into a classroom i can pick up the steps quickly and i can put it into practice i can do it so actually there's a whole thing bones cardiovascular cognitive function i mean i can go on but you get the gist yeah i think that's just really important to hammer home because not everyone's aware of those effects bone health may be the one that comes to mind everyone would know about that but the other things especially like reeney said it's interesting the the cognitive effects and the proprioception the awareness so you're gonna your balance is gonna be a bit dodgy and if your bones are already

weak you can see it's not good recipe yeah yeah and i think like the other thing is that you also do start to see poor performance so from an athlete point of view without hormones you're not going to get the results you're looking for you believe you are but you don't and you don't build any lean muscle mass either because again without energy availability without estrogen or testosterone in males, you can't create growth hormone, which means you don't, you know, you can't get the lean muscle mass gains. And I think that that's the other thing. Hormones are interactive. We're talking about oestrogen. It's not wafting around there in isolation. As Renée's just mentioned, growth

hormone is key, key, key, not just for growth in children, by the way. In adults, we need a decent amount of growth hormone to maintain body composition so it's an interaction of all the hormones so we're focusing on oestrogen because in women there's an obvious sign that your hormones aren't right you don't have a period it's a physical sign clinical sign but all the other hormones if you've got functional hypothalamic amenorrhea you're definitely going to have disrupted thyroid disruptive disruptive growth hormone axis, and they all work in unison. Yeah. And something that we spoke about really before this podcast was that some women may be on contraception, which can almost mask the effect that HA is happening because it gives you this

false or artificial bleed every month. So a woman thinks, you know, hey, everything's working great. They come off the pill, they may have post pill amenorrhea, but then nothing happens after months and months. So maybe Nikki, this question would be good for you. Can you explain why a bleed induced by the pill isn't actually the same as a natural bleed and what's happening there? I mean, just to say, obviously, it's every woman's choice what form of contraception they want to use. So let's just say that first of all. And if you've got regular periods and you want to use the combined oral contraceptive pill, and that's your preferred choice, you know, go for it. That's fine.

My issue is that if you, as you quite rightly said, haven't got periods, you've got functional hypothalamic amenorrhea, You know, unfortunately, it's not good medical practice. It goes against the advice of the Endocrine Society. If you give the oral contraceptive pill, now everyone feels better. The doctor, the person, everyone around them, because you've got some form of, as you say, bleeding, but this is a withdrawal bleed. It's not a period. So what do I mean by that? So a menstrual bleed is as a result of the release of your own internal hormones. I like to say the hormones are the female reproductive cycle, menstrual cycle. They're beautifully choreographed. You know, there's ups and downs of progesterone and it's,

you know, it's absolute, as I say, beautifully synchronized and everything but if you've got hypothalamic amenorrhea the lines are flat and low nothing's happening no doing and what happens if you give someone the oral contraceptive pill say they were having regular periods give them the oral contraceptive pill what does it do you get the same thing you get flat lines for all these hormones, because it suppresses all those hormones, because it's a contraceptive, it's stopping you ovulating. But you're already in that situation if you've got functional hypothalamic amenorrhea. So obviously, it's not helping the situation, as you say, it's masking it, we don't know really what is going on with your own hormones. And actually, what is really even more concerning,

maybe, is that my colleague in the States, Kate Ackerman, did a study recently of women with functional hypothalamic amenorrhea. Three groups, control group didn't just, you know, didn't do anything, didn't put in place any intervention. One group, she gave the oral contraceptive pill, the combined oral contraceptive pill, and the other group, she gave HRT, hormone replacement therapy. And she found actually the ones that she gave the oral contraceptive pill, and the other group she gave, HRT, hormone replacement therapy. And she found actually the ones that she gave, the oral contraceptive pill too, it was not bone protective. So not only is it masking what's going on, but actually it's not doing you any favors. It's not helping with the situation.

Yeah. You know, if any woman out there has got functional hypothalamic amenorrhea and being told oh just go on the pill and everything will be fine i mean i'm afraid that you know that's not correct no and for someone who may be diagnosed with it or think that they have it what would your advice be to them you know if they they may not be able to access your clinic if they don't live in this area what would be the best resources to go to what should they say to their doctors or their health practitioners where do they start well um i mean well first of all if if the gp or whoever is saying go on the pill please don't um i would uh suggest they could look at i wrote a website with

reeney's contribution for BASEM, British Association of Sports and Exercise Medicine. And it's called health4, number four, performance.co.uk. And on there, there's all the information about REDS, Relative Energy Deficiency in Sport. And of course, that includes the functional hypothalamic amenorrhea we're talking about. You have to empower people to know what's going on so you know have a look at that and then if you do seek go to your gp and the gp is trying to say i'll go on the

pill then you can say well actually this website which is endorsed by basem um you know says actually this isn't the best form of treatment and you know these are the other things i should be doing so you know I think empowering people so they know what's going on and not to be fobbed off with medication or something like this you know that's really what we're about and I'd also just add don't take no for an answer like we get so many women of all ages who come in and say oh but the gp said it's okay for me not to have a period because i'm active and i'm a bit slim or and that is not okay yeah going back to that thing all women of all reproductive age are sorry to be repetitive all women's reproductive

age should have regular periods give or take a couple of days and so if you haven't don't ever get fobbed off by this is normal or whatever, unless you're pregnant, of course. Fair enough. You know, if you're pregnant, okay, you don't have periods for nine months. There you go. Or breastfeeding. Yeah, but otherwise, there will be a reason. Yeah, you need to nip it in the bud.

So a lot of people who listen to this podcast are health practitioners, doctors, PTs, coaches. And actually, I've had a few of them contact me previously about clients who have lost their periods and they've been like what do you advise from a food point of view and i'm like get them to go see their gp what advice for any pts or coaches who are listening would you want them to have if they come up to clients who maybe on first initial assessment say i don't have my period I think exactly what you said Hazel like this is a clinical condition like the reason why both Nikki and I can work in it is

because we have clinical training right Nikki's obviously a medical doctor and I've got clinical dietetic degree so so that's a really important thing to say and I do know there are a number of practitioners out there who are working in in nutrition from a clinical point of view and they really shouldn't be because it's complex like you know we get clinical training we go on placements we learn to read bloods etc so so yeah i think if a pt is great well i think it's important i think having said all that of course we don't expect these coaches or pts to treat and nor should they frankly but absolutely they have a crucial crucial role and that's why one of the sections on the bayesian website is for coaches because actually

it's the coach as well yeah so you know please i'm encouraging people the coaches and the pts whatever to pick up on it and uh you know encourage that person you can't force them this is a slightly tricky because you can't force them but you could just sort of say look you know or encourage that person, you can't force them, this is a slightly tricky, you can't force them, but you could just sort of say, look, you know, or have a word with the parents if it's appropriate, but you know, encourage to go and seek medical help, advice, just to exclude the other, you know, there's nothing going on, or just so that the person is aware, they may be thinking in the old mindset that it's fine not to have a period. So I think they have a really crucial role and especially physios as well. If they see an injury, often it presents with an injury,

not the full-blown stress fracture, but soft tissue injuries, higher risk of those. You should always routinely ask a woman, especially if it's a recurrent niggly injury, soft tissue. Of course, if it's a stress factor goes without saying you should ask about the menstrual history so i think they have a really crucial role in picking it up and actually you're writing a course yes for coaches yeah so yeah absolutely i think the communication is really critical and we're about to say that yeah you know obviously we rely on

coaches pts physios even like gps we rely on them to pick this up, because you should be asking that question. And you should be looking at the whole big picture. I think learning how to communicate with these individuals, like, you know, we don't want you going straight in there going, well, you've got a problem. So we're not going to train you. And you know, that's not the way to do it. You need a very delicate approach. But actually, you know, sort of approaching in the sense that the fact that you haven't had a period for a few months, that would suggest that there's some sort of imbalance, like maybe you need to get that checked out, like it'd be an important thing. And I said, and again, use the information we provided you today, like, you know, you're not

going to get the performance gains. This is this is an issue that you've come to me, especially for the PT, you've come to me because you're looking for some sort of outcome you won't get that if we haven't got a full picture of what's going on for you i think the other thing the other way of doing it because it could be slightly awkward you could argue for a male coach to be asking a 16 year old girl she's got period so another way of doing it if they feel awkward about the actually saying it is to look at the website and say oh look maybe you should have a look at this website based on website or whatever or maybe it should be part of your training metrics recording your periods just as you would record if you're a cyclist they love recording their power and

heart rate and all this stuff actually for a woman recording your periods that's such an easy no expense simple easy peasy way of checking in if you've got healthy hormones that would be a way maybe the coach could um say hey i've just noticed you're not doing so well can you log your periods and then that wouldn't be maybe so confrontational yeah absolutely so what we've we've definitely the strength coach at our clinic we've definitely educated him on on that and he said to me the other day we were out for a work do and he said i've learned so much in the last few months and i've learned how to approach that and really talk to female athletes about it so i think that's really important and just to add you know obviously nikki and i do a lot of education but we do

as part of train brave you know our campaign around raising awareness for eating disorders and Red S, we do free sessions, these free workshops in these afternoons where anybody, PTs, health practitioners can come along. So we've got one coming up in Bath on the 29th of September. So finally in my hometown, thank goodness. And then we've got one in Leeds on the 10th of November. And we're also going to have an anniversary, first anniversary in December back in London. So all that information about when the events are, I think, are on the website. And these are free events. Nikki and I will talk about this.

So that would be another opportunity if the coaches can come or if they can encourage the coach to come with the athlete they're worried about. And we've also had parents coming with their athletes or dancers. So, you know, everyone is listening to the same message because I think a lot gets lost in translation. Yeah. You know, but if they're all hearing the same thing and they're all asking, you know, questions

and everyone's hearing the answers in the same room, then it makes it a lot easier. Absolutely. So we're all on the same page. I think so. And I can share all those links in the show notes so that people can access them and hopefully check out the events.

Because like you said, it's always better to hear that in person and get the person to hear it from a health professional who's non-biased and giving just out the facts. So if anyone wants to hear anything else from you guys individually, do you have your own websites or social media pages you want to share with us?

So, yeah, I mean, we have our Inspire Clinic, which is actually on my website anyway, but it's at RichardRiniMcGregor.com. do you have your own websites or social media pages you want to share with us so yeah i mean we have our inspired clinic which is actually on my website anyway but it's uh which is renee mcgregor.com and i do a lot of like my whole instagram is all about education so and that's just r underscore mcgregor if you want to learn more about what we do and then my i mean as i kind of on renee's website, as it were. But also I've got my own one, Nikki K Fitness. But also in the Bayes M website is kind of a coming together. Resources.

Yeah, everything is there. Wonderful. Well, thank you for coming in today. It's been so interesting speaking to both of you. And I'm sure it will be invaluable for everyone listening. Thanks for having us. My pleasure. Thanks. Great.

Okay, guys. So that was Rini and Nikki. I know we packed a lot into that episode, but if you want to find out more, don't forget to check out the show notes and I will link all of the websites that they mentioned there. Now, moving forward to today's listener question, which was, I've recently switched to a vegan diet and I'm suffering a lot

with bloating and wind what can I do? Okay so a lot of people experience this problem so don't worry too much when you switch to a vegan diet or simply eat more veggies the reason that some people experience bloating and wind is because of all of that fiber. Most of us don't consume enough fiber. So if you've switched from a diet that is relatively low in veggies to one that is solely made up of plant foods, your fiber intake is likely to have increased quite a bit. Most people eventually adjust to this increased fiber and their symptoms of bloating and wind tend to go down. However, if you're not used to a high fiber diet, I would advise that you increase your intake of fiber very slowly and see how you feel. And also make sure to

drink lots of water. Other tips which may work include rinsing, soaking and cooking your beans and legumes before eating. Eating slower without your phone or laptop or telly in front of you avoiding fizzy drinks and sweeteners and alcohol because they can also exacerbate bloating and wind and also guys just to mention if that doesn't do the trick I would recommend going to speak to your GP as there are many other causes for bloating and flatulence So it's worth discussing with your doctor if symptoms do persist. Okay, guys, that's all from me this week. Make sure to tune back in next week when we're going to be talking about strength training.

Now I've got two coaches in who are incredible and we are going to be answering in all of the questions which you guys sent in via my Instagram. So make sure to listen because it's a really good one.