Ketosis and Menstrual Function: a Canary in the Mine?

In the 1920′s, researchers at the Mayo Clinic used a ketogenic diet to treat adults with ideopathic epilepsy. In 1930, Dr. Clifford Barborka published a paper detailing their findings with their first 100 patients. Among other findings, Barborka notes that 20% of the women involved in the study experienced complete cessation of menstruation during treatment, which didn’t return until a normal diet was resumed. He only reported on menstrual cessation, but given more contemporary research on the subject we can reasonably speculate that many more women experienced menstrual irregularities that stopped short of complete cessation. Subjects were eating appropriate calories to maintain their weight, so weight loss was not a confounder here. He speculates that it may have been related to a vitamin B or E deficiency, but has no clear explanation. (Note that this was many decades before the discovery of Leptin and it’s role in hormonal regulation.)

In 2003, researchers published their retrospective study of 45 adolescents aged 12-19 treated for epilpsy with a ketogenic diet over 8 years. They noted that 45% of the girls involved in the study reported menstrual irregularities, most (2/3) of whom experienced complete cessation of menstruation (the other 1/3 were reported as experiencing delayed puberty or menstrual irregularity). Most resumed menstruation after ending the diet. 2 were treated with hormone therapy to induce and regulate menstruation. A majority of the girls did not lose weight on the diet, so again, weight loss was not a confounder in most cases. Researchers speculated that:

“The diet may mimic the menstrual side effects seen in starvation and certain female athletes.”

In 1999, a group of researchers published a review of a small group (9 women, 2 men) of otherwise healthy adults treated for epilepsy with a ketogenic diet. Of the 9 women involved in the study, 100% experienced menstrual irregularities. Although five of the 11 study subjects initially reported weight loss on the diet, calories were increased to manage it, so again, weight loss was not a confounder in most of the cases. From the researchers:

“All female patients reported menstrual irregularities. This is not uncommon, considering that menstrual irregularities are reported in other high-ketone states such as starvation.”

My friend Batty's menstrual chart before (left) and after (right) experimenting with dietary restriction. Click on image to read her story.

My friend Batty’s menstrual chart before (left) and after (right) experimenting with dietary restriction. Click on image to read her story.

As researchers noted, there’s some reason to speculate that the human body responds to carbohydrate restriction similarly to the way it responds to starvation. Certainly science has shown that leptin levels are sensitive to both calorie restriction (1) and carbohydrate restriction (2, 3, 4) and that women experience a greater leptin decline than men in response to dietary restriction and weight loss (5, 6). More and more research is indicating that leptin is an important endocrine mediator, acting on pituitary, adrenal, thyroid and gonadal axes, as well as playing a role in bone formation (7, 8). Another well-documented side effect of both ketogenic diets and starvation is bone demineralization (9, 10, 11, 12). Starvation and carbohydrate restriction can also both produce thyroid downregulation (13, and read Anthony Colpo’s exploration of carbohydrate restriction’s influence on thyroid function here).

I’ve worked with many women dealing with thyroid and reproductive dysfunction who also have a history of dietary restriction in the pursuit of an aesthetic ideal. My experience, coupled with the science I’ve seen, leads me to take a very cautious approach to dietary restriction in all it’s forms, with emphasis on promoting consumption of as rich a variety of calories and macronutrients as possible while allowing for the maintenance of a healthy weight. I think our culture has taken a myopic view of health, fixating on weight and fat loss, while tending to overlook other important markers of health. Most of the contemporary studies on extreme calorie and macronutrient restriction are short term, focused on only a few metabolic parameters (insulin and glucose dynamics and weight loss, most often) and/or focused on men, and I’ve found very little attention paid to leptin dynamics, thyroid health and menstrual function in the literature.  The best use for highly restrictive diets are in the treatment of the illnesses they were developed to treat, and under the supervision of a qualified medical professional. For generally healthy people, a more modest, if slower, approach is probably the most prudent.

What do you do, though, if you’re already experiencing symptoms of endocrine adaptation to starvation? First of all, you may have an eating disorder, and even if you don’t you will still likely deal with issues associated with eating disorder recovery as you work your way through this stuff. Finding a medical professional with ED experience would probably be very beneficial, if for no other reason than that they can give you an idea of what to expect as your body recovers. Ask your doctor for a referral to an endocrinologist if possible. Eat! You should be eating at least as many calories as your body burns each day. If you have a history of undereating, you may need to keep track of your calorie intake to ensure it is adequate to support your energy needs. Carbs are helpful in raising leptin levels, so don’t restrict them unless you have a medical reason to and are being monitored by a medical professional. Prioritize sleep. Ask for help. You are not alone.

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Check out these other bloggers’ thoughts on this subject:

Krista Scott Dixon wrote an awesome post on hormones, homeostasis and carbohydrate restriction specifically in women. She touches on fasting as well.

Stafani Ruper’s discussion of carbs for health and fertility.

Danny Roddy gives a Peat‘s Eye View of female hormone regulation and provides some dietary recommendations for optimization. Of note, carbohydrates are on the menu.

Lyle McDonald’s series on leptin.

Gweneth Olwyn’s discussion of restrictive eating, leptin dynamics and infertility.

Related Posts:
Moderation is Evidence Based
Adrenal Fatigue as a Cover for Starvation
HCG, Intermittent Fasting and Ketosis
The Thing About Science

HCG, Intermittent Fasting and Ketosis: the Unholy Trinity of Metabolic Downregulation

Today, for a change, I’m not going to hit you with a bunch of studies. I’m just going to tell you what I’ve learned through experience with my clients and readers. Then I give you a couple links to check out if you want to read some more sciency stuff.

My client base is made up largely of women who’ve already run the diet gauntlet. By the time they get to me, most of these women have essentially been on one diet or another for years, or even decades. They’ve done it all. They’re experts at losing weight. Trouble is, the weight always comes back. With each successive diet, they ultimately find themselves fatter and sicker. I don’t put my clients on diets: they’ve already been, to a one, on all the diets. I get my clients off diets. Get them eating a humane, sustainable amount of food, with a focus on supporting their activity and honoring their personal tastes and cultural traditions. The vast majority of my clients stabilize fairly quickly and begin making forward progress, once they wrap their minds around eating to support their metabolic health.

There are a few clients, though, who have a much harder time stabilizing. Their weight won’t budge, or it fluctuates wildly. They don’t seem to be able to build muscle mass as effectively. They begin to store more fat around their belly than they have in the past. They experience edema. They deal with anxiety and insomnia and other symptoms of starvation, even when their calorie intake is adequate. It is as if their bodies refuse to emerge from the starvation response (see my Adrenal Fatigue post for more info on the starvation response). This goes on for months, even when calories and macronutrients are all adequate and consistent. I’ve had several clients who’ve experienced this, and every single one of them had a history of one or more of the three diet philosophies that I’ve taken to calling the ‘Metabolic Downregulators’. Those three diet philosophies are: HCG, Intermittent Fasting, and Ketosis.

All three of the Metabolic Downregulators appear to provoke the starvation response by design. The first symptom of the starvation response is rapid weight loss. Subsequent symptoms are endocrine adaptations that slow the body’s metabolic processes and insure against famine by shoring up fat reserves, stopping reproductive function and reducing metabolically expensive lean mass. IF and ketosis seem to be able to do this even in the absence of a caloric deficit. HCG, of course, simply relies on extreme calorie deprivation. That initial rapid weight loss is what the dieter fixates on, and when the weight loss stalls out they wonder what they are ‘doing wrong’, and double down on the diet in an effort to get the weight dropping again. This only compounds the metabolic downregulation, and the dieter ends up exhibiting all the symptoms of starvation AND excess fat stores.

Like I said, I’m not going to throw studies at you today (I’ll let Alan Aragon, Anthony Colpo, Stephanie Ruper and others do that). I’m simply sharing the observations I’ve made amongst my clients and readers.

My clients who’ve succeeded in downregulating their metabolic function need much more time to repair and stabilize than others who’ve followed less extreme diet philosophies. 6 months is not uncommon. Some women need a year or more. The longer a person’s body has been in the starvation response, the longer it’s going to take to recover. This is a frustrating reality. The temptation to return to extreme dieting can be great. I encourage those of you who are experiencing this to remember that the diets ultimately failed, and it is exactly those diets that brought you to where you are today. There is a better way. Consistently and dependably giving your body the nutrition and energy it needs to be healthy and active will allow it to emerge from the starvation response and heal from the damage the diets have done. But it takes time. Be patient! The long-term benefits are worth it.

If you’ve gone through this, please share your experiences in the comments so that people just beginning the healing process know they are not alone. There is a vast support network out there for those ready to start on the path out of the restriction maze. Please reach out, from wherever you are, to support each other and to find the help you need.

I will add to this list as I find additional resources.

http://www.alanaragon.com/an-objective-look-at-intermittent-fasting.html

http://www.paleoforwomen.com/shattering-the-myth-of-fasting-for-women-a-review-of-female-specific-responses-to-fasting-in-the-literature/

http://anthonycolpo.com/why-intermittent-fasting-isnt-all-its-cracked-up-to-be/

My Pissed Off Low-Carb Rant

 

I’m not a scientist, I’m a lowly little Personal Trainer and Massage Therapist. I don’t perform studies (other than my N of 1 ones), I don’t write research papers, I don’t have a degree in anything health related.

What I do do is read a lot. Blogs (I’ve got a few of them listed in my blogroll), news articles, and most importantly, science. I try to find and read as many sides of an issue as possible.

And one thing I have, that a lot of people don’t, is an ability to think critically.

There’s a Diet War going on out there. One faction would have you believe that primitive man spent most of his time lolling about the savannah, working on his tan, only getting up off his ass long enough to throw a spear at a passing buffalo, then sitting back down to gorge himself and get back to the serious business of lazing about. Sounds pretty idyllic. Sign me up! Oh yeah, and that buffalo was made out of bacon.

Building on this belief system, they argue that modern humans are therefore primed for a life of blogging and bacon eating. It’s the true path to optimal health! See, our bodies are made to sit and eat fat, so when we eat carbohydrates, everything goes haywire. Insulin resistance, diabetes, obesity, cancer, DEATH.

‘Course, there’s all that pesky scientific data that suggests that increasing physical activity improves metabolic function (don’t believe me? Google ‘exercise and insulin resistance’, or check out my pinterest board on the topic). How can that be, if the body’s natural state is lolling about the savannah? If our bodies are designed to sit, why would moving improve metabolic function?

Do you REALLY believe primitive man spent most of his time on his ass? I don’t, not for a minute. I believe primitive man spent most of his time on the move. I believe the human body’s natural state is one of almost constant motion. When we move, we metabolize carbohydrate just fine. In fact, science holds carbohydrate is the brain and muscles’ preferred fuel (yep, I’m aware of the studies that suggest otherwise. Guess what? So far, they’re outliers). ‘Course, if we’re not moving, carbs can cause problems. But is eliminating carbs the answer? Only if you believe our bodies are designed to sit all day. If you believe that our bodies are designed to move, then eliminating carbs is a band-aid. A band-aid that might allow you to sit on your ass a few more years before disease sets in, but that ultimately doesn’t address the CAUSE of the disease: exercise deficiency. That’s right folks, I’m calling it like I see it: Metabolic Dysfunction is a disease of exercise deficiency, not of carb intolerance.

“But modern lifestyles make adequate exercise nearly impossible!” they claim. Bullshit. I have kids, a job, a household to manage, and a social life, and I am able to include adequate exercise into my daily routine. I also manage to maintain a blog! Yes, you too can blog AND exercise.

“But only young people and endurance athletes can eat carbs safely!” they counter. Bullshit, again. I’m 40. I exercise 30 minutes a day on average.

“But…but…some of us are so damaged by obesity and the Standard American Diet that we simply can’t ever eat carbs again!”. Bullshit, times 3. I was obese for 3 decades. At 35, I had a whole laundry list of metabolic issues: PCOS, high blood pressure, blood sugar regulation control problems, low HDL, and obesity (not to mention depression, panic attacks, migraines, hair loss, cyctic breasts and acne and much, much more). I reversed it ALL while eating carbs.

Ask yourself: which is more likely the natural state of the human body:
a. sitting and eating only one or two macronutrients, to the exclusion of thousands of edible energy sources
b. moving and eating whatever is easiest to find (which, where I live, would be mostly plants, with some rodents, insects and perhaps an occasional bit of larger game thrown in to supplement)

I choose b, and live accordingly (minus the rodents and insects). And you’ve seen my pictures. I suspect I look a lot more like the mythical Grok(ette) than most basement dwelling, bacon eating bloggers.