Ask the REI: How should we approach getting pregnant with HA?

Feb 17, 2024 | Let's Hear From The Experts

Ask the REI: How should we approach getting pregnant with HA?

Dr. Goldstein is the founding physician of Beverly Hills Fertility.  She is one of the most trusted names in fertility and is highly recommended by her patients for her communication, responsiveness, and attention to detail. Dr. Goldstein obtained her MD from the Mount Sinai School of Medicine in New York City and is a double board-certified OB-GYN and Reproductive Endocrinologist.

In an industry that is continually becoming less personalized, Dr. Goldstein is proof that you can provide world-class fertility care and empower hopeful parents to choose a fertility journey that aligns with their goals before anything else.  She weaves her way through the often overwhelming world of fertility care with intuition and empathy, to make sure her patients have a clear understanding of their diagnosis and treatment options. Dr. Goldstein lives in Santa Monica with her two children and her husband. When she is not taking care of patients, she enjoys rowing, kayaking, yoga, traveling, and hiking in the Santa Monica Mountains.

In this episode:

  • Understanding the physiology of Hypothalamic Amenorrhea
  • Distinguishing between HA and PCOS 
  • Diagnosing HA when your labs are “normal” 
  • How set point comes into play with regards to fertility 
  • Should you do IVF if your period is still missing?
  • Why some women lose their period with HA and others do not 
  • Why some Obgyns aren’t up to speed on how to properly diagnose HA 
  • The questions your REI should be asking upon your initial fertility assessment 

Connect with Lindsey Lusson: Instagram: @‌food.freedom.fertility
Twitter: @LindseyLusson
Tiktok: @food.freedom.fertility


Dr. Goldstein  00:00

So just remembering that the normal range BMI was not your normal range BMI. So if she wants to get pregnant, the most important thing is period recovery for sure. Because actually, if she gets her period back and she starts cycling regularly, she has an 85% chance of being normally fertile, just like anybody else. 

Lindsey Lusson  00:15

Right, right. I say this all the time, but it’s so comforting to hear this from an expert in the field as well. 

Lindsey Lusson  00:21

Welcome to the Period Recovery and Fertility Podcast. Here we discussed the challenging, rewarding and life changing process of recovering your period and finding freedom with food and exercise. Whether you’re hoping to regain your cycle to get your health back on track, or you’re ready to become a momma, this podcast is for you. While the recovery process isn’t always rainbows and butterflies, it’s my hope to bring you both information and inspiration during your own recovery journey. I’m your host, registered dietitian and fellow HA woman Lindsey Lusson. 

Lindsey Lusson  00:53

Okay, everybody. Thanks so much for joining us again on the Period Recovery and Fertility Podcast. This is the first time I have brought on a reproductive endocrinologist. I am so excited to welcome Dr. Goldstein.

Dr. Goldstein is the founding physician of Beverly Hills fertility. She is one of the most trusted names in fertility. She’s highly recommended by her patients for her communication responsiveness and attention to detail. Dr. Goldstein obtained her MD from Mount Sinai School of Medicine in New York City. She is double board certified OBGYN and reproductive endocrinologist.

In an industry that is continually becoming less personalized, Dr. Goldstein is proof that you can provide world class fertility care. Empowering hopeful parents to choose a fertility journey that aligns with their goals before anything else. She weaves her way through the often overwhelming world of fertility with intuition and empathy. She makes sure that her patients have a clearer understanding of their diagnosis and treatment options. Dr. Goldstein lives in Santa Monica with her two children and husband when she’s not taking care of her patients. She enjoys rowing, kayaking, yoga, traveling and hiking the Santa Monica Mountains. Welcome, Dr. Goldstein. Thank you for being here. 

Dr. Goldstein  02:05

Hi, thank you so much for having me, Lindsey.

Lindsey Lusson  02:07

Yes, absolutely. Well, I’ve, I feel like we’ve been connecting a bit over social media for a while now. And it’s just so cool to finally connect with somebody in this space. Because I feel like sometimes it feels like doctors just don’t get it. Or maybe they’re not on our team. And in reading your bio, and following you on social media, I know that that’s not your approach at all. So I’d love to just have you talk a little bit more to listeners about medically how HA is treated. Maybe debunk some myths and things and we’ll kind of go from there. But maybe let’s just start with that. Obviously, you’ve been through tons of school education, trainings, fellowships, all the things. Did you always know you wanted to work in fertility? Or how did you find yourself kind of in this space?

Dr. Goldstein  02:53

So, thank you so much for asking the path. We all have such an important and unique path to get to where we are going to be. This field to me feels like such a gift and such a the exact right place for me to be. I can’t imagine doing anything else. But it wasn’t always that way. And no, I didn’t know that this was where I was going to wind up. So fertility physicians are, we are first and foremost OBGYN.

We do medical school. We do four years of OBGYN training. Deliver hundreds upon hundreds of babies, take care of general gynecologic care, gynecologic cancer, and everything that we need to know to the OBGYN. Then there’s a very high price of admission to be a fertility doctor because there’s a bottleneck where there’s only 42 to 45 positions every year in the whole country for the special training programs that we have to go through to be fertility doctors. We do another three years of training.

A large chunk of the training that we do is actually in performing and interpreting research. We are a very academic field, just like any specialty field, where we have to really be very critical readers and critical analyzers of all of the primary medical literature that comes out of our fields so that we know; and as such, we’re very interested, we always want to do everything by the book, evidence based. I really don’t do, I always tell people, I don’t do BS things like I only do what is supported by scientific evidence, but we are also very early adopters of new technologies and new practices that have good scientific evidence behind them. 

Dr. Goldstein  04:28

So we strike this balance of being very interested and open to an ever evolving, arsenal of treatments and technologies that we can use for our treatments for our patients. So I’ve always been interested in genetics and molecular biology and sort of the root cause of things. And I always wanted to pursue being the kind of doctor who would get to the bottom of things with my patients.

And so I actually thought I was going to be a clinical geneticist. Clinical geneticists, which clinical genetics is a very cool branch of medicine, where each patient is unique. They all have something rare going on with them. The really beautiful thing about that field is connecting with the humanity of the patient and their family. Even while they’re going through something very isolating because they have a very rare condition. But most medical geneticists are either pediatricians or internal medicine physicians as their primary field and they go into genetics. 

Dr. Goldstein  05:23

And what happened in medical school was that I just loved OBGYN. I just like jumping out of bed at four o’clock in the morning. Like could not wait to go to my OBGYN rotation. And OB is a very, very hard field. I mean, all of you women out there, like, please go give your OB a hug. Because they’re never home. They never see their family, like they sacrifice their entire lives for you, for their patients. And I loved it.

But I also there was a certain sub population of the OBGYN population that I really connected with even more. That was the fertility population and sort of endocrinogical disorders and people with irregular periods and disorders of puberty and disorders of menopause. All of the things that we deal with as reproductive endocrinologist. And so it just became this really natural fit, because there’s also a lot of genetics and molecular biology.  It’s just the perfect marriage of everything in one field. And it’s also like, I’m addicted to it. I mean, there’s this dopamine hit, like, every day, it’s like, somebody had a good treatment outcome. Somebody’s pregnant, they bring you their baby to see, it keeps you going.

Lindsey Lusson  06:32

Yes, well, that’s amazing. And that’s the kind of doctor you want, right? The one who’s in love with her job, obsessed with the science, always looking for new and upcoming things. And you own your own practice. Is that correct, in Beverly in Beverly Hills?

Dr. Goldstein  06:45

So I don’t own it. The practice was built by private equity money. And they built this beautiful facility. And they went looking for the right doctor to run it. So that all was sort of this perfect confluence of factors where I had been building my reputation and my experience in private practice in another center in LA. I was ready to run my own show. And so I didn’t build it. It’s not my money, but I do everything medical there. And it is really cool.

Lindsey Lusson  07:16

Yeah. Okay. Awesome. Curious. Probably biggest question on a lot of our listeners mind is how common is HA? I don’t even know if you can put a statistic or percentage on it, but also just maybe thinking about where you’re located in LA, do you see HA a lot? Or is it a small percentage? Tell us a little bit about kind of your experience with patients with this condition.

Dr. Goldstein  07:40

You know, it is definitely common enough that it’s always first, it’s always at the front of our minds. It’s always in our differential diagnosis. When we see people with irregular periods or irregular absent periods. It’s always something that we’re looking for. And you’re right, in Los Angeles there have been studies. I remember when I was in training, one of my co fellows was like doing a study where they actually were reporting on IVF outcomes in underweight women. Truly like legit, they had to have a BMI and underweight category.

And in order to have 100 women to have IVF cycle outcome whose BMI was actually underweight. Like you’re, you’re not going to know where else in the country is going to have those very many people going through IVF that are underweight with that. And so you have to wonder, what was the actual underlying etiology for their infertility with somebody BMI is 17.  But it’s not something that I see that often. I probably only make a true diagnosis of HA, once or twice a month at most. Yeah, it’s just it’s truly not that common. Common enough that we see it, but it was common enough that I see it only once or twice a month. Then imagine another doctor is not seeing it so rarely that they’re not comfortable with it, basically.

Lindsey Lusson  08:54

Yeah, yeah. No, thanks for that. And statistically, it is on the rarer side. Although I think that there’s some cases that don’t present completely textbook, right. So, I always kind of share that in my practice, 95% of the people I work with are normal BMI some people aren’t even mid BMI. Some people are kind of even in the over kind of higher BMI. So do you think that’s a barrier in diagnosing and your practice?

Dr. Goldstein  09:25

Absolutely. People with HA do not fit one profile, not in how they look to you nor how their laboratory values look. I think the biggest reason why fertility doctors included but also especially general OBGYN, are going to miss diagnosis of HA is because the classic hormone pattern is actually the rarer thing to see. Let’s just talk about what is it. HA is hypothalamic amenorrhea, actually even more accurately, FHA or functional hypothalamic amenorrhea.

So the reason why you call it functional is that there’s not actually anything anatomically wrong with your ovaries or your brain, there’s nothing sort of chemically wrong with their ability to do what they need to do. It’s a functional problem, which means that the communication between the brain and the ovaries is not working or  functioning properly. The brain and ovaries are not talking to each other the way that they should. There’s usually a very close cross communication between the two organs. And so what happens and just to nerd out a little bit, do you know about the genetics of FHA? So there are a spectrum of 30 to 40 recognized genes that are in the pathway of the communication between the brain and ovaries.

And what’s super interesting is that these are the same genes that are involved and there are also certain individuals with more severe genetic abnormalities where they never actually didn’t go through puberty, they have primary amenorrhea, their brain and their ovaries never talked to each other properly. Even though their brain their ovaries are, again, anatomically normal. They don’t they never communicate properly, even like don’t even go through puberty and have the same genes involved. So there are more severe mutations that cause the primary amenorrhea and less severe mutations in the same genes that get people functional hypothalamic amenorrhea. 

Lindsey Lusson  11:26

I read one of those research studies over the summer, and my mind was blown, because my grandmother, she’s in her 80s now. And she was like, “I never knew when I was pregnant, because I never knew when I was getting my period”. I was like, that’s interesting. And then I started thinking about a little bit more, and my cousin, so another one of her grandchildren had primary amenorrhea and I ended up with FHA. So I was like, well, dang, that makes so much sense. And a lot of the people that I work with, too, they’re like, I think mom had this . Actually, more often than not, I hear, “Well, PCOS runs in my family”. And sometimes that can get misdiagnosed and thrown in the mix. It’s so interesting, thanks for sharing.

Dr. Goldstein  12:13

And right, and then what happens is, if you carry one or more of the milder mutations and one of these genes, that doesn’t mean that you are set up to have amenorrhea, what it means is it sets you up to have a lower threshold for losing your period. And so that, if you were, God forbid, in a famine or a war, you would be, you would lose your period before your next door neighbor. It only takes this much stress for you to lose your period, whereas your next door neighbor needs this less stress to lose her period. And so it’s a lower threshold where you stop cycling. And I

Lindsey Lusson  12:46

I think you’ve answered one of the biggest frustrations that people that end up with HA, right, because so many people are like, “Oh, but she’s thinner than me, she works out more than me, why do I have to end up with this?” And yeah, a lot of it is genetics. So thanks for sharing them.

Dr. Goldstein  13:01

Yeah, so it’s predisposition. But it also shows you why you can get your period back, because all you got to do is raise yourself above that threshold. So like, whatever your particular threshold is, where below a certain weight or below a certain nutritional status, you’re gonna lose your period, all you do is get yourself back above that threshold. The general OBGYN especially are taught that there’s some classic hormonal pattern for HA, which is that you can actually detect in the blood, demonstrably low. LH and FSH, which are their gonadotropin of hormones from the brain that talk to the ovaries, which then results in a demonstrably low estrogen level, which is a hormone that’s made by the ovaries. I would say, three quarters of the HA that I’ve ever seen in my life have not had that classic pattern. 

Dr. Goldstein  13:47

So if somebody comes into me, and tells me that she hasn’t had a period in a year, and I check her hormone levels, there is a very high chance, I mean, first of all, I’m gonna look at her whole picture, I’m going to have HA in my differential because of things that she tells me about her weight and her exercise and her diet. But also there are certain things that we’ll get into if he really wants you to differentiate this from PCOS.

So like if she has a certain appearance to her ovaries, like a normal AMH value instead of a high AMH value, although there’s totally overlap in these two things, for sure. But if she looks like HA, and she doesn’t look like PCOS, and I want to make that diagnosis very, very often her own, her gonadotropin levels are going to be “normal”. And her estradiol level is going to be even like low normal, but still normal. 

Dr. Goldstein  14:40

And when I say normal, I mean in the range on a laboratory, like when your doctor gets back a laboratory report, there’s a range of normal values. Anybody who’s not savvy in interpreting these values, all they’re going to do is look at the brackets and say this is a technically normal value. Therefore there’s nothing wrong with you, right? Let me just give you a range of values, okay, so like a normal FSH and LH is in four to seven range. And a normal estradiol is anywhere from 20 to 200. Okay, depending on where you are in your menstrual cycle.

Now the classic LH, the classic FHA pattern, which is what people are looking for is going to be, frankly, low LH and FSH like below 2.0, and an estradiol very low, like below 10. But if all you do is look for that pattern, I think you’re gonna miss like 75% of FHA, because many, many, many, and many of you listening may have been told you have LH and FSH in a four to six range and estradiol in the 20 to 40 range. And I like to do some sort of low normal values that all your doctor is doing is looking at a bracket and telling you “Oh, you’re fine”, when that’s not the way that these laboratory values were meant to be interpreted. You have to look at the picture and know what you’re looking at. 

Lindsey Lusson  16:10

How many times have we gotten calls from the nurse that you’re from your OB saying, “your labs are fine”, like, “goodbye”. 

Dr. Goldstein  16:20

What we say is that they’re inappropriately normal. So both of these, all of these hormones, they’re supposed to pulsate and fluctuate and change, every day they change multiple times. And so a static assessment of what those values are doesn’t tell you anything, because the whole clinical picture is that I know that this person is not cycling. So like, if she’s not cycling, it means that these hormone levels are humming along at a static level, and they’re not actually doing the jobs that they should be doing. And so it’s really a situation where their levels are inappropriately normal, but they’re not cycling.

Lindsey Lusson  16:54

And so from a treatment perspective, somebody comes in with HA, what are her options? What do you educate on? Like, how do you kind of counsel and guide these patients.

Dr. Goldstein  17:04

So it depends on if she wants to get pregnant or she doesn’t want to get pregnant. So just like PCOS, you have to divide your life into these two timeframes. One is what do you do for maintenance of this condition when you’re not trying to get pregnant?

What do you do when you are trying to get pregnant? If she’s not trying to get pregnant, then the main concern is that living your life with low estradiol levels is not okay for your bones, your heart, or your skin or your sex drive, now you need a normal estrogen level to function like a woman. But also we know that going for years and years and years without cycling is going to put you at higher risk for osteoporosis and also, heart disease even early heart attacks. And so what you need in your life as a source of estrogen.

The 100% best way to get estrogen back in your life is to resume your cycle. So everything that you’re doing with you is trying, you gotta get back your own internal endogenous source of estrogen. That’s what’s going to save your heart and your bones. Now, if it’s a bad situation where it’s been years and years, you already have osteopenia, on your DEXA scan, things like that, certainly, that would be helpful to start to give a patient like that an estrogen patch or an estrogen pill.

Birth control pills work fine, too. But it’s slightly better to use a physiologic estrogen replacement, like a patch or a pill. And it’s actually just estradiol and not a birth control pill. And it’s complicated If the cycle of progesterone all this stuff, certainly answer these questions later. But like, the best best thing is to get your own internal estrogen levels back. Yeah. And then you have to be aware that when your period comes back, you may be super fertile. And if you don’t want to be pregnant.

Lindsey Lusson  18:38

I heard a couple of other physicians do the transdermal estrogen and cyclical progesterone with thoughts of that making the period come back, jumpstarting the cycle. Have you observed that and your practice ever?

Dr. Goldstein  18:51

I mean, that will get your period back, but that’s a false period.

Lindsey Lusson  18:54

Yeah, I guess what I’m getting at it. I’ve heard some people, some school of thought saying that, we do this for six months, and then you should cycle on your own.

Dr. Goldstein  19:03

I would not expect that to work. If she’s not also taking the steps that she needs to make to get her period back because I think that maybe it’s possible that for somebody who doesn’t, who isn’t ready to gain weight or change their nutrition, I mean, giving her the cyclic estrogen or progesterone is better than nothing, but it’s not going to help jumpstart anything if she’s not changing her nutritional status.

Lindsey Lusson  19:26

Thank you for that. Because I do think that sometimes kind of something that gets thrown around in the treatment of  HA, and I’ve seen it used as a bridge, especially in like eating disorder recovery, right, because we do want to do what we can to kind of prevent or slow decline. But ultimately getting to a place if possible, where somebody can cycle on their own is great. Do you ever come across patients that you feel like we’ll just never get their period back? Like, I guess maybe let’s just start with like sometimes I hear from physicians, actually, I was told this, “some women just never get their period back”. You might have, cuz I also struggled with an eating disorder in my late teens, early 20s, that there could be like, kind of permanent damage to the hypothalamus. Any truth to that?

Dr. Goldstein  20:10

I mean, I think, of course, there’s going to be really, really, there’s going to be some people who are on the more severe side of these genetic mutations and who are still in this situation of still with eating disorder and disordered exercise. I really don’t think that, it doesn’t ring true to me that there can be permanent damage. Because again, this is not something that’s damaging your hypothalamus. It’s not functioning properly, but there’s nothing wrong with it.

Lindsey Lusson  20:40

Right. More of a suppression than like a physical damage. Yeah. Okay. Well, let’s talk through the pregnancy options now. So she’s HA, she’s, we’ll call her Jane. She is FHA. She’s ready to get pregnant yesterday. She is so ready to form her family. What are her options?

Dr. Goldstein  20:59

Yeah. So trying to get her period back. So number one is if she can do nutritional recovery, and gain even just a little bit of weight. Even if her weight is normal, she probably needs to gain a little bit of weight. Actually, I’ve never read No Period, Now What. Many of my patients have and I know that what’s in there is very, very legit. I assume it says getting a little bit of weight, even if your weight is normal, right?

Lindsey Lusson  21:24

Yeah, it does. And one thing about the research there is, and I know that this gets scary for a lot of people, but it’s almost like gaining more than just a little bit of weight. So like some of the research in the book talks about for women who are below a BMI of 20, gaining up to around a BMI of 22. So, you do the math, and it could be anywhere from like, 10 to 25 pounds for a patient. And with the typical profile, somebody is typically very, I’m speaking candidly, in my experience prideful about their bodies, and that’s really scary for them. And so, yeah, that it’s definitely a recommendation in the book.

Dr. Goldstein  22:04

I think it just speaks to the understanding that your body’s setpoint, even if you can say “well, but my BMI is normal, it’s 19.5”.  And it’s like, but your setpoint must be higher. But your body, your threshold for losing your period must be something above 19.5, where your body needs to be higher than that. So just remembering that the normal range BMI is not your normal range BMI. So if she wants to get pregnant, the most important thing is period recovery, for sure. Because actually, if she gets her period back, and she starts actually cycling regularly, she has an 85% chance of being normally fertile, just like anybody else.


Right? Right. I say this all the time, but it’s so confirming to hear this from an expert in the field as well. What if she’s like, I don’t want to recover my period? I feel like I hear sometimes of fertility clinics being like, “you can’t get your period back or that’ll take forever. Let’s just do IVF”. Is that not an approach that’s taken in your clinic by any other physicians?

Dr. Goldstein  23:07

First of all, I haven’t seen it take that long. I mean, I’ve seen it take only like three to six months, potentially. Is that is that in your experience as well? 

Lindsey Lusson  23:16

Yeah. I mean everyone’s a little bit different, right. Like I see people, especially if we’re cycle tracking together, I’m teaching them how to confirm and identify ovulation. So sometimes people will get pregnant even before they get their period. But yeah, I mean, barring that being their only fertility issue, we do see pregnancy relatively quickly.

Dr. Goldstein  23:35

Yeah. So that’s what I would say. And then I would have these serious conversations where I say, look like why your body is telling you something, it’s telling you that you don’t have the proper nutritional status to even support your own homeostasis. Why should we get you pregnant and put this even bigger stressor on your nutritional status, where you’re going to have a pregnancy, leaching calories and calcium from you that you’re not even potentially even taking in enough for yourself? And I don’t think I would flat out, put my foot down and say no, but I would come very, very close, I would strongly, strongly, strongly, strongly recommend that we not proceed with fertility treatment for this person until she has made a good faith effort to get her period back.

Lindsey Lusson  24:21

Do you ever get pushback from patients when you’re having those great conversations?

Dr. Goldstein  24:27

No. For the most part, people are very receptive to it.  I don’t think people want to go straight to IVF. You don’t want to do IVF for no reason.

Lindsey Lusson  24:37

I mean, across the board. What about In other practices though, do you think that some people want to cycle through an IVF cycle because it is potentially more profitable for the practice?

Dr. Goldstein  24:51

Sure. I mean, I try not to work in those places. Of course they exist,


Right. So gold standard, obviously it’s getting your cycle back and then you’re in agreement that natural pregnancy is possible. What about the person who gets their cycle back and is still dealing with some ovulatory dysfunction, some luteal phase defect, what do you do in those situation? 

Dr. Goldstein  25:15

Well, so that’s a situation where you have to remember that there’s an evolution of medical treatments that we can try for ovulation induction. The textbook answer is that somebody with HA is not going to respond to the less aggressive oral medications that we use for ovulation induction.

So textbook lectures on clomid are not supposed to work in situations of FHA. I will say that I definitely have seen more often than not, in a situation like what you’re talking about. So what’s interesting, I actually have a lot of patients that are sort of a mixed FHA, PCOS picture, which is like so complicated, like, I’m sure you deal with a lot of that too.

And so in those people, as long as I feel if they sort of tell me that they’re, I do usually talk to them about period recovery stuff, but they’re less likely to kind of really get back a real normal cycle, they will often respond to Clomid or letrozole, just like anybody else. But true FHA, you have to use injectable gonadotropins, even for ovulation induction, even if you’re not doing IVF, even if you’re just doing ovulation induction to try to have her try on her own or with IUI. Well, that is complicated and expensive.


Okay, I was gonna ask, what’s the likelihood of success with that? Because I actually visit with a number of people who go through multiple cycles of that. And granted like, I probably have a skewed perception, right? Because they’re coming to me because those things don’t work. But you know, are there things you use in your practice? Do you find them to be helpful? 

Dr. Goldstein  26:44

I have used them more frequently in the past. I used to work at Kaiser where people, if somebody had fertility coverage at Kaiser, then they had coverage for six IUI cycles. And Kaiser would pay for very expensive medication regimens, the patient wouldn’t pay anything. And of course, if it’s all paid for, she’s going to want to do it, even if it’s not the best medical decision for her that we could use to do it a lot more.

Those cycles are, I mean, I would say there’s probably a good 15 to 20% chance of pregnancy per attempt, similar to like on the high side for any IUI attempt or something as unexplained infertility, it’s like 12 to 15% per cycle. If she has FHA, it’s probably like 15 to 20%. on the high side, probably why, but still low. It’s not bad 20% per cycle, but it’s complicated and expensive, and has an incredibly high risk of multiples.

Lindsey Lusson  27:32

Okay, where do you start bringing IVF in for an HA patient if she really wants to go for it or if there’s other fertility stuff, or like, where where do you see being beneficial?

Lindsey Lusson  27:45

Well, certainly, if she has tubal factor, or male factor and needs IVF for those reasons, or if she has gotten her period back, and you’ve done and she’s tried on her own for four to six months and or done sort of less complicated attempt to add ovulation induction and IUI for another two to three months, she’s gonna move on to IVF just like anybody.

I’ll say, in my experience, I don’t, I can’t even think of ever going to IVF and somebody who truly has FHA, who has not made an attempt to get back for a period who wasn’t made no progress to get back I’ve just, I’ve just not done it. Certainly I do have a four or six times a year, patients who have other clear indications for needing fertility treatments.

And I think there’s a small component of HA but it’s not the main thing. I get the feeling that those patients that I’m dealing with are not from your content anyway, I feel like you’re dealing with very, like healthy functional people without anything else wrong with them, but they’ve like, sort of exercise their period away and that’s not typically, there is always a spectrum of the hypothalamic function and everybody that I see. And so I have people with a component of it but it’s not because it’s not the only reason.

Lindsey Lusson  29:00

Dr. Goldstein, we seem pretty aligned. You are totally recognizing the importance of lifestyle changes and nutritional component for something like FHA. Why do you think other reproductive endocrinologist, other OBGYN maybe don’t recognize those things?

Dr. Goldstein  29:19

And I think like I said, unfortunately the problem with what’s going on with the general OBGYN is that OBGYN residency is so difficult. And office, the hospitals are so busy with just babies lying at your head all night long. You just lose four years of your life to just babies all night long all the time. And you’re kind of numb, you get numb to an understanding of  these more complicated, nuanced diagnostic conundrums like a patient with it. 

Somebody who walks into your crazy busy general OBGYN clinic, where you’re quadruple booked and you’re exhausted because you’re up all night delivering a baby like they don’t have the brainpower thinking about it because they’re so overworked. And the other thing is that  they’re so busy even out in practice after residency, that they’re out in practice, and there are babies flying out their heads all the time.

They’re just less inclined to realize how devastated this one woman sitting in front of them with infertility for whatever the cause is, whatever the reason for infertility, they’re not they’re like, not attuned to it, because they’re so used to everybody else being so fertile. And so  that’s what’s going on in the general OBGYN world. They’re just so exhausted and burnt out, like I said, give them a hug.  I think that it’s a different problem, everybody has kind of decided that IVF is such a good treatment. And it’s such good technology, like, why wouldn’t we just bypass everything with it, that I hear this out of the mouths of everybody all the times.

Lindsey Lusson  30:48

But it sounds like not everybody agrees with that. That there are still some REIs that are open to seeing whether or not IVF is really necessary before pushing someone into a cycle. 

Lindsey Lusson  31:01

To maybe help some of our listeners out too, with getting properly diagnosed with HA, because this is something that I really observe really more like, in hindsight, is, I hear that people will go to their doctor’s and not be totally forthcoming with maybe how much they are struggling with food, maybe how much they really are exercising. Can you share, like how that can put a kink in someone potentially getting properly diagnosed, but maybe somebody’s not being totally forthcoming with what’s going on with them? 

Dr. Goldstein  31:32

 I think that’s gonna come out in the diagnostic workup. So like, remember, I said, if she tells me she’s not cycling, and I get her labs, and there ar this sort of pattern where either the number either the levels are, frankly, low, or they’re in this low normal range, but they’re not appropriately cycling. That’s when I’m going to start asking more probing questions about her exercising and her diet. I’ll see it often comes out even during the initial consultation, even before I have lab values. Like it’s just a hunch that we learn, and we start to ask the right questions about.

Lindsey Lusson  32:06

Yeah, and that’s fantastic. Do you think that maybe you’re spending more time with your patients than in maybe some other fertility clinics? Because I just feel like this is an area that gets missed a lot or not, or maybe not probed deep enough?

Dr. Goldstein  32:20

Yeah. I mean, I don’t know. It’s hard to say, because I don’t know how other people are doing it. From the minute that I went out into practice on my own. Even when I worked at Kaiser, I’ve always been 100% for each  new patient comes to see me and I would never just gloss over stuff like that.

Lindsey Lusson  32:34

Yeah. You mentioned coming across some of these patients that start with HA and then start to have kind of PCOS like symptoms. Can you talk a little bit more to that? Because I know there’s a ton of listeners who are in that boat right now.

Dr. Goldstein  32:47

It’s a complicated one. And I will say we suspect it a lot more often than we actually diagnose it. So PCOS is basically, like we suspect it, it’s on our radar and then the person clearly goes in one direction or the other. So PCOS r is the most common cause of irregular periods. PCOS people can be overweight and struggle with hair growth, or they can be perfectly normal weight and everything else is fine. But they still fit a PCOS pattern for their labs and everything. And that is also a functional problem.

That’s a different kind of functional pattern where the brain and the ovaries don’t speak to each other properly. But it just kind of the pattern of everything of all the labs and everything just looks a little bit different. And so I say that I suspect a combination of the two. So one of the biggest clues is the ovarian reserve. So ovarian reserve is kind of how many eggs you have resting in your ovaries when we look at you with ultrasound and when we do a lab test called an AMH. And somebody with PCOS is going to have very high ovarian reserve like they’re going to have just all the little tiny follicles in the ovaries and also much higher than average AMH value.


I mean even numbers like four and five can be PCOS. But certainly people that we see with ages of 8, 10, 12, 20, 50. Those are PCOS. The interesting thing about HA and this is like such a subtle thing is that HA patients, their ovarian reserve is going to look lower than it actually is. And then once they get their period back, they’re usually going to have a normal ovarian reserve, but not a high like PCOS ovarian reserve. So it’s like super subtle. But what happens is she’s going to be told that she has a lower than average AMH and that her egg numbers are low. But that’s part of the functional issue.

Lindsey Lusson  34:38

There’s been somebody this week. I revisited because she had just gone through an egg retrieval because she was told she was running out of eggs, right? 

Dr. Goldstein  34:47

And itmay actually not be correct at all. So what’s happening is because the brains communication with the ovary is not correct, there’s a suppression of the actual apparent ovarian reserve, even though again, the ovaries are normal, and so once you get the period back, your egg numbers are actually going to rebound. But they’re typically going to be like, average, not high. Like, if that makes sense.

Lindsey Lusson  35:11

Okay, that makes total sense. And that’s that’s super, super helpful because I do think AMH is one of those mysterious ones that a lot of people don’t understand. So thanks for for clarifying that. And we’ll also what I’m hearing you say is like, it’s pretty rare in your experience, to have both ha and PCOS going on? 

Dr. Goldstein  35:30

Right. So I’ll say what’s interesting is the times when I’ve suspected it is when somebody has come to me and they’re very thin. And like looking at them, you would think I bet this person has HA, and then the labs just come back looking like clear cut PCOS and there’s just no need especially if she’s forthcoming and says, I really like I just have a thin body type and I think I don’t exercise that much and I think I eat everything. I really like she she’s really forthcoming about it and her labs looks like clear cut PCOS. It’s just PCOS.

Lindsey Lusson  36:05

Yeah. And, I’d say one gray area that I kind of start to see is sometimes when people start the recovery process, as hormones can start balancing out and people just happen to get labs down at the right time, that’s when people will start to see like the high LH to FSH ratio, and I’m like, “well, let’s back up and like, look at your whole, like, 10 year history”.

So that’s really reassuring to hear that you’re taking that much detail and looking at things like that with your patients and everything. Dr. Goldstein, anything else you just wanted to share with listeners who are maybe, even though I’d say more people I work with are thinking about fertility than not maybe. Because I get this a lot to maybe talk through some of the health repercussions, you touched on bone, you touched on heart. Why do we need periods, like why get your period back if you don’t want to have kids now or ever?

Dr. Goldstein  37:05

Your body is in a menopausal state 20 or 30 years too early. And the reason why women have lower rates of heart disease than men is because of estrogen. Estrogen is protective for your heart. If you start depriving your heart of estrogen too early, you are going to have a much higher rate of early heart disease. And that is the number one killer of women. Osteoporosis will render you having mobility. You’re such an active person who loves to exercise well, now, you’re gonna break your hip when you’re 52. It’s like, it’s really a problem.

I don’t want any of this to sound blaming or shaming at all and I think that this is such a special audience and such a special group of women that you’re talking to, and that everybody is so lucky to have found this content. I think one of the biggest things to understand is that this is a genetic predisposition.

It’s a genetic predisposition to limit to losing your period, it may even be a genetic predisposition to your particular personality type. This need to be in control of how you look and how you present and all of the food and all the exercise, like that’s a personality type that probably goes along with this. And it’s probably fairly genetic. And so it’s all about understanding who you are, and where this comes from, and meeting yourself where you are, and to be the best, healthiest version of yourself.

Lindsey Lusson  38:26

Right, right, trying to take some pressure off your plate, some things go taking the edge off. And I’ve heard this from so many clients too. That in getting their cycles back, people also start to notice their moods are a lot more balanced, right? 

Dr. Goldstein  38:41

Probably this sort of constant state, it’s not starvation. Because you may be eating enough, but your bodily processes are needing a little bit more. And everything’s just gonna function a lot better if you get back to that setpoint. 

Lindsey Lusson  38:57

Yeah. Thanks so much for your time and sharing everything that you’ve observed in your practice and how you work with people. Do you happen to work with patients virtually at all? Are you strictly brick and mortar in home?


There’s a telehealth company that I’ve been working for since before I got this crazy, busy job. I give second opinions through just through that platform. But no, it’s everything has gotten so busy here. But you know what people people travel. People travel to see me. Because I think that there’s something very different about how I approach fertility care. And I don’t think it’s going to be satisfying for either of us to sort of try to interject in what your doctor is doing. I’m just sort of hoping that I can spread messages that can help people. I’m always happy to talk.

Lindsey Lusson  39:45

Amazing. Well, we have listeners in the LA area. What is the name of your practice again?

Dr. Goldstein  39:53

It’s Beverly Hills fertility.


All right. Thanks so much, Dr. Goldstein. And again, we just appreciate all of your wisdom and everything you’ve shared with us today.

Dr. Goldstein  40:01

This is really great and thank you.


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I’m a fertility nutritionist and registered dietitian who specializes in hypothalamic amenorrhea. My passion is helping women trying to conceive find freedom with food and exercise, so they can recover their period, and get pregnant naturally.

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Jan 19, 2022

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