A seventeen year old pediatric patient accompanied by her mother presented for naturopthic treatment for a chief concern of “missing periods.” Her last period had occurred five months ago. Before then her period was progressively reducing in frequency and becoming less regular. Her mother was seeking a second opinion to her pediatrician’s recommendation to start oral contraceptive pills. These would be used to induce her period in an effort to avoid sequelae of amenorrhea such as bone-loss, cardiovascular disease and increased risk for endometrial cancer.1
Secondary amenorrhea, defined as cessation of menses for greater than three months, affects an estimated 3-5% of adult women, though we do not know its prevalence in adolescents. Secondary amenorrhea can indicate a deficiency of hormones such as progesterone and estrogen produced by the ovaries. These hormones promote healthy development of sex characteristics during puberty to promote fertility. Additionally, estrogen plays a key role in bone acquisition. The teenage years are especially a critical time for bone mass acquisition, with menarche closely linked to the peak age for bone mass accrual.2 Without treatment, adolescents with menstrual irregularities may be miss a key developmental period for maximal bone ossification.3
Our patient reported eating vegan bi-weekly and for a longer period during Easter. On further questioning we found she had modified her diet restricting gluten and lactose and lost thirty pounds over the last ten months. Her BMI was 20.95, which is within the normal range.
At her first appointment, she was prescribed seed cycling. Seed cycling is a dietary intervention that integrates different seeds at different times in the menstrual cycle. Women who are not menstruating are asked to incorporate different seeds based on the cycle of the moon, with the new moon associated with Day 1 of menses (Figure 1)4.
During the follicular phase Day 1 to 14, or until ovulation, she was advised to consume 1 tablespoon each of ground flax seeds and pumpkin seeds daily. During the luteal phase Day 15 to 28, or until menses, she was advised to incorporate 1 tablespoon each of freshly ground raw sunflower and sesame seeds daily. These seeds can be eaten in smoothies, salads or soups to ease their digestion. Starting with one teaspoon of Ground flax seed (Linum usitatissimum), is advised before increasing intake to one tablespoon in an effort to minimize bloating.
While evidence on seed cycling as an intervention is limited, some of the individual seeds involved are well supported. Flax seeds are considered an optimal source of lignans. Lignans such as secoisolariciresinol, matairecinol and pinoresinol can be converted by intestinal bacteria into enterolactone and enterodiol. These lignans directly affect hormonal balance and are found to decrease risk of breast and prostate cancer.6 Flax seeds are a rich source of omega-3 fatty acid alpha-linoleic acid. Omega-3 fatty acids have been found to support follicle structure and function for hormone production, including increasing progesterone secretion.7
Pumpkin seeds are a rich source of zinc. Seven tablespoons (100g) of whole roasted, unshelled pumpkin seeds contain about 10 milligrams of zinc.8 Zinc has been found to increase follicle stimulating hormone (FSH).9 FSH in turn supports the follicular phase and ovulation, triggering the ovaries to produce progesterone.
During the luteal phase, women are asked to consume sesame seeds and sunflower seeds. Sesame seeds are a rich source of nutrients such as copper and manganese. They also contain sesamin and sesamolin, which are lignans that are converted by gut bacteria into enterolactone, similar to flaxseeds. In post-menopausal women sesame seed powder has been found to increase urinary 2-hydroxyestrone, which is protective of breast cancer risk.10
Finally, sunflower seeds are a rich source of vitamin E. Vitamin E has anti-inflammatory effects, found to decrease the severity and frequency of hot flashes in women.11 Pre-menses, this antioxidant may play a role in reducing inflammation that studies have suggested is behind period pain.12 Sunflower seeds are also a source of selenium, a trace mineral incorporated into glutathione peroxidase for detoxification by the liver.
Our patient had her period again eight days after her first appointment and starting seed cycling. Seed cycling in this case represented a creative way to increase total caloric and healthy fat intake enough to support her menstrual cycle.
Secondary amenorrhea associated with weight loss appears to be caused by lack of release of gonadotropin releasing hormone, with the lack of a pituitary response under extreme conditions. In our patient’s case of suspected functional hypothalamic amenorrhea, seeds are a particularly rich source of healthy fats. Leptin, a hormone made by adipose cells, has been implicated as the link between menstrual irregularity and fat-intake.13
Functional hypothalamic amenorrhea (FHA) is found in over 30% of cases of secondary amenorrhea.14 FHA occurs as an adaptive mechanism to chronic stress, which may occur from emotional or physical causes such as exercise or food restriction.
The consequences of untreated secondary amenorrhea are only beginning to be understood. FHA is associated with neuroendocrine abnormalities across the thyroid, growth hormone and adrenal axes. One study found that coronary heart disease was prevalent in 69% of women with FHA, compared to 29% of those without the condition.15, 16 Along with heart disease, complications of secondary amenorrhea caused by FHA include endometrial hyperplasia and osteoporosis which could lead to increased risk of fractures.
At her check-in five months after her first appointment, our patient had reduced some of her previous dietary restrictions, including adding a small amount of gluten back in her diet. She reported a 30 day menstrual cycle.
Seed cycling is an old yet novel approach to naturally restoring a regular menstrual cycle. Although the mechanism of action is unclear, seed cycling appears to correct potential nutritional deficiencies, rebalance the HPA axis, reduce inflammation, and provide healthy essential fatty acids.
For directions on how to seed cycle, click here