diff --git a/soh/soh/Enhancements/mods.cpp b/soh/soh/Enhancements/mods.cpp
index f12b12174..72f1bc599 100644
--- a/soh/soh/Enhancements/mods.cpp
+++ b/soh/soh/Enhancements/mods.cpp
@@ -434,7 +434,7 @@ void UpdatePermanentHeartLossState() {
     if (!CVarGetInteger(CVAR_ENHANCEMENT("PermanentHeartLoss"), 0) && hasAffectedHealth) {
         uint8_t heartContainers = gSaveContext.sohStats.heartContainers; // each worth 16 health
         uint8_t heartPieces = gSaveContext.sohStats.heartPieces; // each worth 4 health, but only in groups of 4
-        uint8_t startingHealth = 16 * 3;
+        uint8_t startingHealth = 16 * (IS_RANDO ? (OTRGlobals::Instance->gRandomizer->GetRandoSettingValue(RSK_STARTING_HEARTS) + 1) : 3);
 
 
         uint8_t newCapacity = startingHealth + (heartContainers * 16) + ((heartPieces - (heartPieces % 4)) * 4);
diff --git a/soh/soh/Enhancements/randomizer/savefile.cpp b/soh/soh/Enhancements/randomizer/savefile.cpp
index ffab46e49..e8998b4a4 100644
--- a/soh/soh/Enhancements/randomizer/savefile.cpp
+++ b/soh/soh/Enhancements/randomizer/savefile.cpp
@@ -140,6 +140,11 @@ void SetStartingItems() {
         gSaveContext.inventory.gsTokens = Randomizer_GetSettingValue(RSK_STARTING_SKULLTULA_TOKEN);
     }
 
+    if ((Randomizer_GetSettingValue(RSK_STARTING_HEARTS) + 1) != 3) {
+        gSaveContext.healthCapacity = (Randomizer_GetSettingValue(RSK_STARTING_HEARTS) + 1) * 16;
+        gSaveContext.health = gSaveContext.healthCapacity;
+    }
+
     if (Randomizer_GetSettingValue(RSK_STARTING_OCARINA)) {
         INV_CONTENT(ITEM_OCARINA_FAIRY) = ITEM_OCARINA_FAIRY;
     }
diff --git a/soh/soh/Enhancements/randomizer/settings.cpp b/soh/soh/Enhancements/randomizer/settings.cpp
index 11a42aefb..48011f423 100644
--- a/soh/soh/Enhancements/randomizer/settings.cpp
+++ b/soh/soh/Enhancements/randomizer/settings.cpp
@@ -202,7 +202,7 @@ void Settings::CreateOptions() {
     mOptions[RSK_STARTING_NOCTURNE_OF_SHADOW] = Option::Bool("Start with Nocturne of Shadow", CVAR_RANDOMIZER_SETTING("StartingNocturneOfShadow"), "", IMFLAG_NONE);
     mOptions[RSK_STARTING_PRELUDE_OF_LIGHT] = Option::Bool("Start with Prelude of Light", CVAR_RANDOMIZER_SETTING("StartingPreludeOfLight"));
     mOptions[RSK_STARTING_SKULLTULA_TOKEN] = Option::U8("Gold Skulltula Tokens", {NumOpts(0, 100)}, OptionCategory::Setting, CVAR_RANDOMIZER_SETTING("StartingSkulltulaToken"), "", WidgetType::Slider);
-    mOptions[RSK_STARTING_HEARTS] = Option::U8("Hearts", {NumOpts(1, 20)}, OptionCategory::Setting, "", "", WidgetType::Slider, 2);
+    mOptions[RSK_STARTING_HEARTS] = Option::U8("Hearts", {NumOpts(1, 20)}, OptionCategory::Setting, "gRandomizeStartingHearts", "", WidgetType::Slider, 2);
     // TODO: Remainder of Starting Items
     mOptions[RSK_LOGIC_RULES] = Option::U8("Logic", {"Glitchless", "Glitched", "No Logic", "Vanilla"}, OptionCategory::Setting, CVAR_RANDOMIZER_SETTING("LogicRules"), mOptionDescriptions[RSK_LOGIC_RULES], WidgetType::Combobox, RO_LOGIC_GLITCHLESS);
     mOptions[RSK_ALL_LOCATIONS_REACHABLE] = Option::Bool("All Locations Reachable", {"Off", "On"}, OptionCategory::Setting, CVAR_RANDOMIZER_SETTING("AllLocationsReachable"), mOptionDescriptions[RSK_ALL_LOCATIONS_REACHABLE], WidgetType::Checkbox, RO_GENERIC_ON);
@@ -773,6 +773,7 @@ void Settings::CreateOptions() {
         &mOptions[RSK_STARTING_OCARINA],
         &mOptions[RSK_STARTING_CONSUMABLES],
         &mOptions[RSK_STARTING_SKULLTULA_TOKEN],
+        &mOptions[RSK_STARTING_HEARTS],
     }, false, WidgetContainerType::COLUMN);
     mOptionGroups[RSG_STARTING_NORMAL_SONGS_IMGUI] = OptionGroup::SubGroup("Normal Songs", {
         &mOptions[RSK_STARTING_ZELDAS_LULLABY],
@@ -933,6 +934,7 @@ void Settings::CreateOptions() {
         &mOptions[RSK_STARTING_CONSUMABLES],
         &mOptions[RSK_FULL_WALLETS],
         &mOptions[RSK_STARTING_SKULLTULA_TOKEN],
+        &mOptions[RSK_STARTING_HEARTS],
     }, false);
     mOptionGroups[RSG_STARTING_INVENTORY] = OptionGroup("Starting Inventory", {
         &mOptionGroups[RSG_STARTING_ITEMS],
@@ -1196,6 +1198,7 @@ void Settings::CreateOptions() {
         { "Start with Consumables", RSK_STARTING_CONSUMABLES },
         { "Full Wallets", RSK_FULL_WALLETS },
         { "Gold Skulltula Tokens", RSK_STARTING_SKULLTULA_TOKEN },
+        { "Hearts", RSK_STARTING_HEARTS },
         { "Timesaver Settings:Cuccos to return", RSK_CUCCO_COUNT },
         { "Timesaver Settings:Big Poe Target Count", RSK_BIG_POE_COUNT },
         { "Timesaver Settings:Skip Child Stealth", RSK_SKIP_CHILD_STEALTH },