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Female hormones are a symphony of complexity that is affected by various factors including our gut microbiome, diet, toxicity and stress.
Although a monthly visit from “aunt flo” may not be something we look forward to, irregular periods and the absence of a period during reproductive years (amenorrhea) is a cardinal sign to the body that one of these areas are imbalanced. Women who have missed at least three menstrual cycles in a row have amenorrhea.
What is the Cause of Amenorrhea?
A lost period is an indication to dig deeper as it is often a sign from the body that it doesn’t feel safe.
This could be the result of a recent drastic weight change, nutrient deficiency, your body being overburdened by endocrine disruptors, or it may be dealing with chronic stress and is operating in the sympathetic fight-or-flight response with inadequate parasympathetic regulatory balance.
As a functional medicine practitioner, I seek the root causes of imbalance within the body addressing the gut, liver, and stress axis known as the hypothalamic pituitary adrenal (HPA-axis) trying to swing the individual back to a balanced parasympathetic state.
With the right approach, women can get their period back, including those with PCOS and hypothalamic amenorrhea. A high-fat, low-carb, re-feeding dietary approach combined with stress management and a diet that supports the natural detoxification of the body is a great way to start and get the body back into hormone balance.
How Does Insulin Resistance Affect Sex Hormones and Fertility?
Under normal circumstances the hormone insulin helps keep blood sugar levels stable. However, when insulin resistance occurs, glucose accumulates in the blood and can eventually lead to pre-diabetes and type 2 diabetes. To be insulin resistant means that your body can't properly respond to the insulin it makes. Over time, this leads to chronically high blood sugar levels.
Insulin resistance and chronically high blood sugar levels drive hormone imbalance. This is also why metformin, a drug commonly used for the treatment of type 2 diabetes, is so commonly used for the treatment of infertility.
Elevated insulin levels reduce sex-hormone-binding-globulin (SHBG) which means that our sex hormones may be suppressed, especially in severely overweight individuals suffering from hyperinsulinemia ( 1).
Elevated insulin levels reduce sex-hormone-binding-globulin (SHBG) and impair fertility. Low levels of SHBG are a marker of insulin resistance, and consequently, a predictor of type 2 diabetes.
Keto as an Anti-Inflammatory Tool and Insulin Regulator
When following a low carbohydrate diet in the state of nutritional ketosis, blood sugar levels are regulated at lower levels which will also lead to lower insulin levels.
Intermittent fasting paired with a keto diet, especially in overweight individuals, may further aid bringing insulin levels down and supporting hormone signalling in the body.
However, beware that for underweight individuals or those who have lost their menstrual cycle after losing a significant amount of body weight, measures must be taken to ensure sufficient food intake so that the body feels safe and nourished. When you follow a keto diet and want to maintain or gain weight, you simply need to eat enough fat and calories. Any fasting practices for underweight people are not recommended.
In my practice, I use the the ketogenic diet to support fertility. When the body produces ketones, inflammation and oxidative stress are reduced which often helps improve both female fertility (egg health) and male fertility (sperm quality). ( 2)
The Role of Hypothalamus in Fertility
Ketosis has a direct impact on our central stress response system, also known as the hypothalamic pituitary adrenal (HPA) axis system, as ketone bodies cross the blood-brain barrier and influence expression of neurotransmitters. They do that by converting the excitatory glutamate into an inhibitory compound GABA which mellows out a stress fight-or-flight response in the body ( 3).
The hypothalamus plays a significant role in fertility as it produces two main hormones: gonadotropin releasing hormone (GnRH) which signals the production of other hormones in the pituitary FSH (follicular stimulating hormone), and LH (luteinizing hormone) required for an egg to mature, and for ovulation.
Nutritional ketosis also impacts hormones that regulate the HPA axis balance. On a ketogenic diet, a satiety hormone leptin is able to signal the brain and resume its dual role to lower hunger and increase metabolic rate. Leptin provides a 'safety signal' to the body’s regulatory system, by docking to the hypothalamus and telling the body to support regulatory signals of the parasympathetic state vs. reactive signals in the sympathetic state. Optimizing leptin can support appetite regulation as well as metabolic and hormone balance.
When the body produces ketones, inflammation and oxidative stress are reduced which is beneficial for both female and male fertility.
Hormetic Effects of Keto
The ketogenic diet can act as a mild stressor which can be beneficial, just like exercise, intermittent fasting, or even sauna. However, remember that too much of a good thing can also be harmful.
As an example, imagine you are lifting a weight for 20 reps in a couple of sets. You work the muscle to fatigue, then shift to another exercise, and eventually rest and recover to support healthy muscle growth. However, if you had to lift that weight for hours and hours, the level of tear and atrophy would be so intense that the body would suffer rather than gain any benefits from the exercise. Simply put, know your limits and make sure you are still getting the benefits you seek.
When Weight Loss Can Be an Issue
A potential pitfall that can occur with nutritional ketosis is under-eating due to the natural satiety effect of low-carb diets. Such appetite suppressing effect is beneficial for those who need to lose body fat but it is not a desired effect for those who lack ample body fat reserves, and need to either maintain or gain weight.
I have personally and clinically seen women who go keto, feel amazing, and then try to take on too much. As a result, they're not eating enough, over-exercising and/or not sleeping enough and their leptin levels can dip too low. This way the body may go into an under-fed, unsafe mode during which sex hormones are suppressed as the body prioritizes survival in a stressed state over reproductive health ( 4).
High levels of cortisol suppress sex hormone production in the body as it feels unsafe to carry a child. In a stressed state the body prioritizes survival over reproductive health.
Manage Your Stress Levels to Help Your Body Feel Safe
When in chronic fight-or-flight mode from physical, emotional, or mental stress, and more stress drives up our androgenic hormones.
This can lead to excess levels of dehydroepiandrosterone (DHEA) and cortisol which suppress sex hormone production in the body as essentially the body feels unsafe to carry a child and does not prioritize ovulation ( 5).
Beyond diet intervention, consider managing your stress levels. Shifting priorities to what is truly important, and working to allow a healthy mental perspective of 'making peace with the now' may aid in shifting the body to a more balanced parasympathetic state.
If you are going through a divorce or have a demanding position at work, maybe you don't have control over those factors. Focus on other factors that you do have control over, such as switching from a spinning class or a cross-fit workout — a type of exercise that further increase cortisol and enhance stress response — to calming type of physical activity such as yoga or walking while taking time for rest, meditate and sleep. You may also want to consider supplementation with adaptogen herbs such as abhwagandha or calming herbs such as chamomile to reduce stress and anxiety.
The Role of Keto in Getting Your Period Back
A whole food based approach to nutritional ketosis that includes leafy greens, cruciferous vegetables, wild-caught fish, pasture-raised proteins, and an abundance of fat from olives, avocado, coconut, nuts, seeds, and quality animal products can provide a rich source of bioavailable B-vitamins, hormone regulating indole-3-carbinols (I3C), omega-3 fatty acids, antioxidants, and saturated fats as building blocks of hormone production and cell membrane support.
A healthy ketogenic diet helps reduce inflammation, gut stress, and hormone imbalance, while promoting optimized antioxidant status. A whole foods based keto diet provides the nutrients needed for the production of healthy eggs and protection of membranes to support healthy implantation.
A well formulated ketogenic diet can also aid fat loss, improve insulin sensitivity, aid in the reduction of excess estrogen and support liver health. The ketogenic diet is more than just a fat loss tool and can in fact be used for a healthy weight gain, provided you get enough fat and calories.
A whole foods based ketogenic diet provides the nutrients needed for optimal health, hormone balance and to support fertility.
7 Practical Tips for Getting Your Period Back
Here are the steps you can take to get your hormone health back.
1. Go Low-Carb
Reduce the amount of carbohydrates you're eating to balance your blood sugar levels and reduce insulin to support hormone signalling in the body.
2. Eat More
Make sure you are not in a chronic caloric deficit and consume enough fat as a building block for hormone production. Additionally, to ensure sufficient caloric intake, you may need to give up intermittent fasting too.
3. Include Healthy Omega 3 Fats
Opt for wild-caught fish and consider supplementing with omega-3 fatty acids. A 2013 randomized controlled trial found that omega-3 supplementation at just 3 grams a day helped reduce androgen levels and regulate menstrual cycles ( 6).
4. Eat Foods High in B Vitamins
To support fertility, include liver and leafy greens for B Vitamins, including folic acid (Vitamin B9). B Vitamins are often depleted in stressed individuals and those with history use of hormonal contraception as it can drive Vitamin B deficiency and can negatively impact ovulation ( 7).
5. Consider Supplementing with Inositol
Research suggests that Myo-inositol, or Vitamin B8, improves insulin sensitivity, reduces androgens, and can even restore ovarian activity in women with PCOS ( 8).
6. Choose the Right Type of Exercise
Certain types of exercise such as high-intensity exercise (HIIE or HIIT) and prolonged cardio raise the stress hormone cortisol. If you need to get your period back, switch to other types of exercise such as yoga, walking or moderate amounts of resistance training.
7. Your Body Needs to Feel Safe
Make sure you get enough sleep — try to get 7-9 hours of sleep every day. Managing stress is very individual and you'll need to find ways that work for you. Try meditation, acupuncture, or schedule a massage.
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