Acetyl-L-Carnitine and Restoring Missing Periods

Continuing my series of posts on supplements and recovery of mising periods… overview here, and post on Vitex here 🙂 I am going to review acetyl-l-carnitine next as it is a supplement for which there is evidence for effectiveness in restoring missing menstrual periods from controlled clinical studies. Thanks to Addie for helping with the research!

Here’s a table of contents for this post, as it ended up being super long!!

Alright, let’s get started. First, acetyl-L-carnitine, also known as L-acetylcarnitine, ALC, or ALCAR, is a derivative of the amino acid L-carnitine (aka levocarnitine). L-carnitine acts as a recipient of an acetyl group in a reaction that releases CoA for use in the Krebs cycle that generates energy (ATP) in the mitochondria. ALC is naturally synthesized in our bodies on an ongoing basis, and crosses the blood/brain barrier, therefore potentially affecting brain hormones, chemistry, or brain function. Studies have been performed examining the effectiveness of ALC in a number of indications, ranging from diabetic neuropathy to Alzheimer’s disease.

Chemical structure of Acetyl-L-Carnitine:

By Ed (Edgar181) - Own work, Public Domain, https://commons.wikimedia.org/w/index.php?curid=31705679

Continue reading

Missing period recovery story!

Just about every day there is a new post in one of my facebook groups about someone getting their first post-hypothalamic amenorrhea period, or their positive pregnancy test. It is so inspirational and truly helps those who are still working to recover to stay the course. I wish that everyone struggling with missing periods, thinking about maybe doing something about it but perhaps too scared, afraid of “losing everything they’ve worked so hard for” could read each of these stories and see how much there really is to gain. (We did include a lot of recovery stories in our book/ebook 🙂 ) I’m going to start sharing some here, in hopes that others will be motivated to start or continue their own journey toward true health.

Gemma wrote:

“I have always been a fit and active person ever since I was young. And my weight had never really fluctuated. I went on BCP when I was about 16 years old until I was 28. I came off the pill because my partner and I wanted to try for a baby.

Before making the decision to try for a baby I had a job for about five years that had become very stressful, 10 hour days with minimal rest, and I was commuting to and from work on my bike, which came to about 9 miles a day. Weight-wise I had always been a healthy weight for my height, but from cycling everyday my BMI had gone down a couple points and it had been there ever since. I never questioned it because I was never fussed on my body shape, big or small, but looking back these were all signs that I chose to ignore. Weight loss, stress, and for the amount of activity I was doing I was not eating enough.

I don’t know for sure that this is when I lost my period because I was on BCP but after reading Nicola Rinaldi’s book I think that could have been my significant HA moment.

When I came off the pill I went to the doctors after 3 months because I wasn’t having a period. I was told that it was normal, coming off the pill can take a while for your body to adjust, come back in a year. So, a year later I went back, the doctor tried to put me back on the pill so I could have a ‘period’. I refused, I don’t know why but I knew that my lack of period was a symptom of something and I needed to find the cause.

The past 5 years have been very hard for me, both emotionally and physically, with a lot of medical poking and prodding, blood taking and a lot of mental exhaustion, confusion, anger. The doctors decided that It was just a case of unexplained infertility and the only thing that might help would be IVF.

Strangely enough my next GP appointment is next week, this was going to be my opportunity to discuss fertility treatments.

I really had lost all hope, I just wanted my period back, I struggled with my friends, those who do know about my condition try really hard to understand it but they don’t really get it, and I would be an awful person to expect them to but It is just something that unless it is happening to you it is a very difficult concept to comprehend.

I felt so alone and so lost but then one night, completely by accident i came across Nicola’s book No Period. Now What?. I read the book from cover to cover in about two days, everything in it was so true to me and I just knew that this is what I had. It was such a leap of faith, I never doubted the process for a second but I was scared of It. Scared because this conditions forces you to face your self head on and admit things to yourself that you have maybe been denying. Recovery is giving me such a feeling of freedom, freedom from exercise, freedom from anxiety which was a huge thing when I was doing too much, not eating enough or resting enough.

My husband thought I had gone temporarily crazy when I told him about this adventure I was about to embark on, stopping all the things that I loved like mountain climbing, surfing, cycling and eating 2500-3000 calories a day but he has and continues to support me, he has seen me re-emerge from myself like a flower. I didn’t know how much of a shell of myself I had become but having this condition and finding the tools that I need to rebuild myself has helped me come back to life.

I have gained 17 lbs so far, I started recovery on the 25th November 2016 and every pound is a pound that I am so proud of and so grateful for. At first, it could’ve been 6 weeks, I hardly put on any weight which made me realise just how much damage I had caused to myself. At this point I decided I was literally just going to walk to and from work and anything beyond that, that was un-necessary activity I would just have to stop. So, since January I have been parked on my bum, not even doing yoga but still walking to and from work. Then about 2 weeks ago I injured my neck, all my muscles had seized up and the pain was radiating down my shoulders and back, I literally couldn’t move for a week and I think that was the final kick start my body needed, just complete bed rest.

I in no way think I am recovered, I am still at the very beginning and I fear that this gift I have been given could be taken away from me at any moment but time will tell, regardless of the outcome I am recovering, my body is reacting to rest and nourishment and I never thought my body would ever feel strong enough or trust me enough that it felt it could try to bring another life into this world. I think my body is a miracle.

We are all incredible, we show incredible strength by facing our fears head on and not running from them but I wouldn’t be on the path to recovery if I didn’t have you all supporting me, I hope I give back to you what you give to me.”

<3

Nico

Does Vitex Help Restore Missing Periods?

(This is the first post in a series on supplements and period recovery – see the overview here. The very short version is that I did a survey of women in hypothalamic amenorrhea recovery facebook groups and 53 women had tried 65 different supplements in order to try and recover periods. We are going to examine each of them to see what the scientific evidence shows.)

VITEX

The most common herb/supplement taken in hopes of helping recover missing periods was Vitex, taken by over a third of those who responded to my survey (21/53). This is a shortened name for Vitex Agnus Castus also known as Chasteberry, which is something I learned as I started looking into this. So most women reported taking “vitex’, but some said “agnus castus” or “chasteberry” – as far as I can tell they are synonyms.

Vitex-agnus-castus-foliage

RESEARCH METHODS

I did a search of the medical literature using the following queries in pubmed to find research relevant to understanding whether vitex can help restore a missing period.

Vitex fertility
Vitex amenorrhea
Vitex oligomenorrhea
Vitex luteal phase
Vitex follicular phase
Vitex progesterone
Vitex estrogen
Vitex osteoporosis

RESULTS

The searches came up with between 5-25 results, many overlapping between searches. I read through abstracts where available (a few articles were in languages I don’t speak, or had no abstract available) and the full article if the abstract seemed relevant and I wanted to learn more.

My conclusion is that Vitex Agnus Castus does NOT lead to restoration of cycles in someone experiencing hypothalamic amenorrhea (unless that amenorrhea is due to elevated levels of prolactin), and may in fact be hindering the return of a missing period.

Continue reading

Supplements to Recover Missing Periods?

I recently asked in my Facebook support group what supplements women had used while trying to recover from hypothalamic amenorrhea / no period as I wanted to look further into the science behind each of them. I was astounded at the range of answers – 53 women used one or more of 65 different supplements!

Can pills help recover missing periods?

By Root66 (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

How do I restore missing periods?

Unfortunately, many women are prescribed supplements instead of what we all know works – eating more, exercising less (particularly less high intensity exercise), and reducing stress. A common refrain was captured well by one poster:

Ellen: Oooh, I’ve tried so many supplements in hopes of sidestepping real lifestyle change! I’ve dabbled with vitex, maca, soy, estroven, bulletproof diet recipes, acupuncture…while some (acupuncture) really benefited me in other aspects like stress level, none served as proxies for eating bravely and resting bravely- which I am finally giving a go.

It is really important to take heed of what Ellen says – there is no way around making lifestyle changes. If you have no period due to HA, while you might (possibly – success is not guaranteed!) be able to get pregnant using injectable gonadotropins or IVF, those are not going to restore your system to balance or bring back that missing period / cycle. In the words of another wise woman: Continue reading

Positives of Recovering from Hypothalamic Amenorrhea

I asked women in my new facebook support group to tell me about one thing (or more) positive about recovery or working toward recovery, which they did not expect. Some responses are shared below…

Lindsay: a sense of freedom and ease and ability to go with the flow that I had been missing since I was a teenager and that I never thought would come back.

Oh, another one: when my husband says, “Doesn’t a burger sound good tonight?” not having to make things difficult and try to convince him to go somewhere healthy and insist that I don’t really like burgers … and just get to enjoy the freaking burger together! With a side of fries!

One more, because there are so many: when I first get home after being on a long flight, not having to go on a run before I even unpack my bags and instead just collapsing on the couch and ordering takeout.

Florence: Less anxiety, babies, ice cream, support from all of my fellow HA ladies into motherhood, boobs and poops, not waking up hungry at night, my hair growing back, feeling like a normally functioning woman, saving my bones, sleeping better, spending more time with my family and friends, holidays without a single workout, not going round with my tupperwares, eating socially, finally using my time for something i love & aiming to save the world, discovering a more fun, more balanced person inside of me.

Nicole: Not having to worry about when to eat, what to eat, and listening my body tell me what it wants. My eating used to revolve around an IBS and paleo diet as well as my workout schedule – no more of that taking up space in my head.

Oh, and my laughter is so much deeper now. Happiness feels amazing, like its own high.

Louisa: Realised that restricting myself and stressing around food/exercise was 100% the reasons behind my gut issues. Since eating everything I’ve actually been pretty ok!

Also, Sleeping in, not having to schedule my week around my workouts, desserts, a pretty much healed digestive system, freedom around food, just food in general, boobs, oh and you ladies!
Also as I’m not yet recovered just knowing there’s more that will improve is all the motivation I need to keep going 💪🏻 x

Sarah: Crying. Like full body weeping. You know that saying, “have a good cry?” I haven’t been able to do this for months and it’s felt strange. In the past week (just went all in), I’ve wept and I feel I’ve been cracked open in a healthy way.

Mary: Resurrection of my libido!

Corey: Realizing how high strung I was, and how my anger was on a hair trigger!! I was ALWAYS planning out the food I was going to eat, or rehashing the food I had just eaten. I still focus on food a lot, but now it’s looking forward to all the great stuff I get to eat, and enjoying it! I also didn’t expect all of the stories and personal growth shared in NPNW to apply to me as closely as it did…man, did I try to fight it! “But that’s not ME…. I’M not like that….” 😐

Liz:  I no longer feel out of control around food. I don’t feel disgusting anymore for feeding my body what it needs or weighing what it wants to (for the most part, there are some bad days). I had a list of “bad” foods I thought were poison to me (because if I had ever binged on them they went on this list of supposed poison trigger foods) much longer than the list of foods that I deemed pure and wouldn’t cause binging (protein veggies select oils). I had to go to the gym every day sort of like paying for an ok day. If I didn’t get to it for some reason I felt like it was an automatic terrible day. I’m definitely not in the best place but so much better and I’m so grateful. I usually am grateful to nourish my body. I try to eat mostly foods that I believe are nutritious for my body and feel grateful for that. If I am hungry or crave something I don’t usually think it’s an urge to binge but maybe that… I’m hungry and my body is telling me. I no longer eat salad for every single meal… I no longer feel like many of the foods I thought were poison are (some I do still struggle with… it takes time and is a journey to completely free myself and don’t know if I’ll ever get there… but the list is def a lot smaller)… I can eat all u can eat sushi sometimes usually no guilt. Chocolate sometimes ❤️… I’m happy to enjoy a treat once in a while and see now that I can have one or two when I want and not have a compulsion to stay up and binge on 20 like I feared)… I can walk some mornings (hope to get back to running sometime bc I enjoy it) and others rest if I don’t feel like it… and it’s not the end of the world and I can function and have an ok day without exercise. So there are a lot. I have a way to go and there are def some weird thoughts about food still but I’m in a much better place and someday if I’m a mom I feel I’ll pass on much better attitudes that I would have.

Oh another very random that i was thinking of recently during a discussion with someone… i used to have major bladder issues for most of the time i had HA. I thought i might have interstitial cystitis as I frequently had infections, and even when I didn’t i often felt burning and sharp pain sensations… very strange another thing no one could quite figure out 🙁 It mysteriously went away around when I recovered from HA. I have never had any pain or a bladder infection since. I can’t help but wonder if it was related to my super low estrogen levels…

Erika: Bladder issues is a symptom of low estrogen. 😊 I had them, too. Mine was more frequency (now if I go in the middle of the night it’s 1X where used to be as much as 4Xs). Also if I had to go, I had to go. Extreme urgency. Some of mine could have also been kidney function just from low body weight, too.

This is just a sampling of the comments. Are you ready to dive into YOUR recovery and discover how your life will change?

<3

Nico

Missing period and hair loss?

Jenny recently joined my facebook support group (now closed to new members, but a new group has just started, so come join us!) and posted about her experience with hypothalamic amenorrhea…

Hey! I’m new here. I just cracked open No Period Now What this morning and got to Chapter 3. I wanted to share a little bit of my story, since I’ve been inspired by reading a lot of yours.

I am a lifelong runner and I’ve been dealing with HA for the better part of the last 10 years. I ran competitively in high school then went on to run at the D1 level, where it was widely accepted to not have a period for months (or years), and I was actually told that this was a normal and acceptable thing.

I’ve been navigating the recovery on my own the last 5 months after finally going to see an endocrinologist to get to bottom of my issues.

The reason I finally decided to go in and get help was not that I’m ready to have a child. I’m 23 years old, and about a year ago, I started losing my hair.

It doesn’t come out in chunks and I don’t find strands on my pillow in the morning. It’s been a slow process of overall thinning, with large thinning areas on the top of my head (the front of my scalp). I never expected to deal with hair loss/receding hair line, especially not at the age of 22.

At first I was panicked, but it was also not noticeable enough for anyone to really see it or acknowledge that I wasn’t crazy. But now, my hair is noticeably gone in areas on top of my head. Here are a couple more photos.

When I went to the endocrinologist last winter, we found that my reproductive hormones were extremely low. We also did a bone density scan to see if my bones had improved since college.

I assumed that they would because I hadn’t been running as hard (but I was “triathlon training” and would exercise 3-4 hours a day with a lot of intensity).

My bone density actually worsened since college, putting me in the osteopenia zone. My doctor urged me to gain weight and lessen my exercise. She thinks that in solving my hormone issues, I will solve my amenorrhea and my hair loss. I’m hoping this is true.

I guess my hair loss is somewhat of a blessing because it has forced me into action. I want to improve my bone density now so I can run later in life, as well as address my issues with gaining weight.

So at the beginning of 2017, I tried to change things. I stopped doing cardio and starting weight lifting instead. I started eating way more calories.

But the stress of trying to navigate this change on my own, in addition to rapid weight gain, was so much that I was only able to sleep about 5 hours per night – not great.

I’m a type A sort of person that has to do things perfectly, and I also genetically have low estrogen. Women in my family (if they exercise or not) always have trouble with maintaining a normal cycle, so I assume that my cycle is pretty sensitive to things like over-exercising and under-eating.

It’s only been until the last few weeks when another runner, Tina Muir shared her amenorrhea story and talked about this book that I’m learning what it takes to really recover. Which for me, will include stopping my exercise for now and drastically reducing my stress. (Being 23 is stressful, believe it or not!)

So I’m going doing my best to go “all in” for recovery of my period, my bones, my hair, and my health.

Has anyone else dealt with hair loss or thinning at the top of your head as a symptom of your HA? Any thoughts on addressing this issue aside from my overall recovery?

And now, a few comments from other members of the group:

Erika: Welcome! And Yes. My hair came out in clumps. Looked really similar to what yours looks like. I was misdiagnosed with PCOS at first, but told to bring BMI up to a healthy weight (started in low 17). I think my hair loss mostly slowed or stopped by then. In pictures from that time I have visible new growth around my face. Once I got correctly diagnosed and went all in, my hair growth had been pretty good. It’s not quite back to its full lion status, but it’s getting there. Tried to take a pic, but I just look super creepy in all of them!! My weight also came on quick, but then leveled out. I think it’s really great that you’re doing something at 23!! Here is a before pic. I thought it was mostly around the cowlick, but just sort of looks thin all the way around.

I’d only gained 10 lbs and you can see all the new growth around my face here:

Here’s a better view of my hair. So it’s pretty wavy today and looks bigger just because of that… but you can eat least get a good shot of how the baby hairs filled in on the left side.

Lindsay: Hi Jenny, your story is SO similar to mine. I was a serious runner starting from the end of high school all the way until I recovered from HA last year (at age 30). This issue is SO common among runners and it’s really terrible how normal and acceptable it is perceived for female runners to not get their periods. There is an utter lack of understanding, even among doctors, of how big of a health issue this is, and it needs to change.

My hair came out too. And my skin was dry & dull. I feel like when you have HA, there are some big things in your body that aren’t functioning properly (like your fertility and your bone health!) but also countless small things. Your mood, your energy, your digestion, your “glow.”

I’m really glad that you’re taking action for recovery. I will share that for me, I needed to give up ALL exercise, even weight lifting, in order to recover. This was hard, but remember that during recovery you are trying to add enough body fat and rest so that your body feels like it is safe to ovulate again. Weightlifting is counterproductive towards that goal. The faster you recover, the faster you will be able to return to normal activity!

Oh I forgot to say one thing! At my last haircut, my hairdresser’s jaw dropped open and she said “What in the world have you been doing, your hair looks so much thicker and healthier!” And I was like, “well, I stopped running.”
Natalie: So i am not recovered yet but have gone from bmi 15 in June last year to around 19 currently. Last year a big bit of hair literally snapped off. I have curly hair and atm its the thickest it has been in years 🙂 xxx

Here I am at a BMI of 15

BMI of 19 thick hair 🙂 xxx not particularly long but I’ve found my hair type, i.e., curly, tends to grow outwards not long hehe xxx

Oh and this was the bit that snapped to basically about 1-2 inches that has now grown 🙂

So basically there is hope! I am probably one of a few on here who have been very, very unwell. I still hold out hope for periods to return but little bits like hair growing thicker keep me going because my body IS capable of repairing damage just like yours will be too hun 😍😍😍 Oh and those glasses in the original pic? Yep I haven’t needed them at all in months because my eyesight has improved. Sorry for the waffle and hope it helps 🙂 xxx
Nadia: Great job on taking the steps to recover from HA. I also had A LOT of hair loss from HA. I also had subclinical hypothyroidism but it was directly related to HA. Recovery improved my hair immensely. It takes a long time to grow back, but it does come back.
Clarice: Yes that exactly what my hairline looked like… I would definitely suggest lowering exercise and upping your food as much as you can…. Maybe start looking into the fact you may be holding on to some other emotions around food and exercise… Working with someone can be helpful in the transition! Also maybe check thyroid levels…
Florence: See these weird bangs? This is the hair i was denying myself to have by never eating enough! Pretty much same location as yours right? It took a while but as soon as you’ll start fueling properly, it WILL grow back!
Anna: I have those weird bangs too and never even thought about that being one of the many positive side effects of recovery!!! I used to always have these weird short little hairs on my left side that would never grow. And I just assumed those are non-growing hairs lol But a few months ago I noticed they’re getting longer…
Nicole: Here’s some hair growth after reaching a BMI of 22!!! See those hairs sticking up? I have a few sections of those through my head, granted I didn’t have bald spots, but seems like more follicles (hair and other 😉 are waking up.
 
Shanta: Yes. I kept my hair short because it was so thin. Even so I was getting bald patches.
Thank you for reaching out. This is a very hard process to do on your own. If you can find a counselor or group for eating disorder recovery it may help. Honestly though for me this group was the most effective help.

The journey from type A to type play, the journey from control to love, is often rocky. But it is, ultimately, exactly that: a journey to love, and the end result is as good as that sounds and better then any love story you will ever watch/ read. What is more you deserve that amount of love and joy, you always have, and the world will be a little more right every step you take towards it.Many women here come from an eating disorder background, and we all have each others back.You can do this.
Jenny responds:Thank you so much for sharing. I’ve struggled to reach out to get help but this seems like a great place to do it. It’s reassuring to find others that have dealt with the mental struggle of hair loss. I appreciate the support.
So as you can see, hair loss is not uncommon with HA – but like so much of the other damage done to our bodies through underfueling, overexercising, stress – whatever your personal combination may be – the effects are reversible.
<3
Nico

Can you ovulate but not get a period?

I have heard in quite a few places now that it is possible to be ovulating regularly but not getting a period, or women think they are ovulating but not getting that monthly bleed.

Women who are experiencing amenorrhea will most likely ovulate before they get their first post-amenorrhea period. (A few get an anovulatory period; bleeding without ovulation beforehand). If one happens to have intercourse around the time of this ovulation, it is absolutely possible to get pregnant, therefore getting pregnant without ever getting a period. And that’s where the idea of ovulation without a period arises.

But, monthly ovulation without getting a period is only feasible under very limited circumstances:

  1. On the Mirena IUD. The hormone doses are low enough that they do not affect the reproductive system in general; locally the hormones prevent buildup of the uterine lining and thus many women on the Mirena IUD will ovulate but not get a period. (Note that the manufacturer states the Mirena should only be used in women who have been pregnant.)
  2. A physical abnormality that prevents bleeding, such as Asherman’s syndrome or a reproductive system defect that does not allow for discharge of the uterine lining.
  3. As stated above, if pregnancy occurs on the first post-amenorrhea ovulation.

Barring that…. The mechanism does not seem plausible.

In a normal menstrual cycle, the egg-containing follicle starts growing at the beginning of the cycle and the uterine lining is thin. As egg/follicle growth and maturation continues, estradiol is secreted. The estradiol leads to an increase in the thickness of the uterine lining. The lining thickens as the dominant follicle is selected and proceeds to maturation. When the egg/follicle is mature, the increased estradiol leads to a sharp peak in luteinizing hormone (LH) that causes ovulation.

I do not believe that it is possible to have this LH surge without sufficient estradiol (and therefore a thick lining to shed).

And while it may be true in a small minority of cases that the lining does not respond to estradiol and get thicker (this IS the case with the Mirena IUD), in a normal menstrual cycle the lining will thicken. My suspicion is that if a woman’s lining did not respond to estradiol by thickening, that would always have been the case and she would never have gotten a period – primary amenorrhea.

After ovulation, progesterone is secreted by the cells that surrounded the now-released egg, maintaining the thickness of the lining and causing other changes that prepare the lining to accept an embryo. If no pregnancy occurs, progesterone drops and the lining is shed.

If progesterone levels are lower than normal, the lining is shed earlier.

What do you think? If you believe you’re ovulating but not getting a period, have you confirmed an increase in LH by ovulation predictor kits, or confirmed ovulation through temperature charting?

If you are getting changes in cervical mucus each month that seem to indicate ovulation, but no bleed, it is possible that your body is trying to ovulate but not quite succeeding.  If that’s the case… Look into whether you might have hypothalamic amenorrhea (HA). (Asherman’s syndrome should also be ruled out.)

Nico

Menstrual Cycle Hormones

Whenever someone asks me about levels of menstrual cycle-related hormones during their cycle and the answer isn’t obvious I go to the figure below from Wikimedia (this article). What I love about it is that it shows the average (bold blue line) and then the biological variability around that average (dark blue shaded area)… and then also how much this can vary between cycles and between women.The figure is based on a study performed in 2006 that measured hormone levels in 20 ‘normally cycling women’ not on birth control pills. The data were reanalyzed in 2014 and these figures created.

One example of when I might refer to these figures is if someone tells me that they’ve just had blood drawn, they don’t know what cycle day they’re on (e.g. have not yet had their first post-HA or first postpartum period), and LH was measured at 17 and estradiol at 215 pg/mL. I can check these figures and see that that most likely corresponds to just before ovulation. If LH is 17 and e2 is 85 pg/mL that might mean that ovulation has just occurred. If LH is 17 and estradiol is 30 pg/mL then I might suggest inducing a bleed and testing a hormone panel to determine if PCOS might be in play.

I think what is unique and particularly helpful in these figures is the inclusion of variability so one has an idea of the typical range for these hormones. Let me know if you have any questions!

Nico

 

 

Do you really ovulate “late”?

Some women, as they recover from hypothalamic amenorrhea, will be worried that they are ovulating “late” in their cycle, maybe Cycle Day 21, 22… but then they get their period around the normal time, maybe CD 28-30.

In some cases, and this was true for me, the issue is the short luteal phase (remember, that’s the time between ovulation and when your period arrives) leading to a seemingly long follicular phase (time between period and ovulation).

When I tracked my ovulations and periods carefully I noticed that my ovulations were routinely 28-30 days apart, as expected. So it wasn’t that the ovulation was messed up, it was more that my period wasn’t aligning with the ovulation as in a normal cycle. A similar phenomenon was observed in a research study where women with short luteal phases were observed to have longer follicular phases (this was not the main focus of the study, but my observation from data reported in Table 2).

My theory is that to some degree, our period and then subsequent ovulation are actually hormonally separate events. The period comes because of a drop in progesterone, that is unrelated to the decrease in estrogen that primes the small increase in FSH to start the new follicle growing. So in a woman with a short luteal phase, the drop in progesterone occurs early, leading to an early period – but that does NOT drive the start of follicular growth, which waits for a few days and then begins, on its regular 28 day cycle.

I know this is confusing, so check out these diagrams. Here’s a normal cycle…the small increase in FSH at the beginning leads to growth of the egg-containing follicle. In the middle of the cycle, around CD12-13, LH spikes leading to ovulation around CD14. After ovulation, the follicular structure collapses into the “corpus luteum” which starts secreting progesterone by around CD16. When progesterone levels fall approximately 12 days later, the period starts, FSH increases, and the whole cycle begins again – with ovulation around CD14 and period around CD28.

Here’s my view of what is happening when one has a short luteal phase. Let’s imagine that the first period in this diagram was induced by Provera and then Clomid is used to start the follicular growth. So the follicular phase proceeds just as above – a small increase in FSH leads to growth of the egg-containing follicle, LH spikes around CD12-13, and ovulation happens on CD14. This is where things aren’t working quite right – the corpus luteum forms, but isn’t making enough progesterone. So the increase in progesterone is lower, and for a shorter amount of time. This leads to an early period – in this diagram, about a week early, for a 6 to 7 day luteal phase.

This leads to what I’m terming the “apparent cycle day” in the figure – menses have started, so ostensibly it’s CD1 again. However. The OTHER hormones involved in the cycle are not at CD1 levels yet. They are still at CD22, 23, 24 levels. The estrogen needs to drop further to instigate the increase in FSH to start the follicular growth… and THOSE hormones are not affected by the lack of proesterone. They continue along their merry way as if it’s CD 22-28, not caring that you’re bleeding already and *think* it’s CD1. So then you get to CD14 and think that ovulation should be happening… but it doesn’t. So you get frustrated (trust me, I know!!) But in reality, your other hormones are on their normal 28-30 day cycle, when when you get to where CD14 would have been if your period had come on time at CD28, that’s when you ovulate. Does that make sense? If not, feel free to drop a question in the comments!

To further illustrate this, here’s a table with my cycle data (this was after my second son was born in September 2008… my first postpartum ovulation was 7/29/2009 while I was still breastfeeding morning and night. I got my period just five days later on 8/3/09, for a four day luteal phase. This cycle isn’t a great example as the cycle is long as is common in initial postpartum or recovery cycles. However the next one (cycle #2) is a perfect example. After only a six-day luteal phase, I got my peiod on 9/15/09 – had it been a normal length LP (e.g., CD14 ovulation, CD28 period start), my period would have come on 9/21/09 instead. I then ovulated on 10/6/09, which based on when my period actually started was apparently CD22… but had my period come when it “should have”… the ovulation would have been CD15.

One anomalous cycle happens on cycle 10 – I had gotten pregnant the cycle before, but unfortunately had a miscarriage that was resolved after two D&Cs. After that I started to use progesterone suppositories to support my luteal phase, which leads to close to normal LPs and pretty close to CD14 ovulation. I did NOT use progesterone on cycles 15 or 16… leading to shorter luteal phase and apparent later ovulation!

You can see from this data set that there’s a fair bit of variability between cycles – compare the days between ovulation and you see that mostly they’re around ~28-30 days, but there are a few that are shorter, and a few that ar longer. I know that some women are like clockwork, but that is certainly not true for me!!

I hope this helps explain why a short luteal phase and longer apparently follicular phase are associated – again, feel free to ask any questions you may have – or please share if this has been your experience as well – or not!

xox Nico

P.S. Check out Chapter 19 in No Period. Now What? for a LOT more information on luteal phases, why they might be short, and what you can do about it!!

How long will my cycles be?

Have you just had your first period party? The utter thrill when you are working to recover from hypothalamic amenorrhea (HA) and you see blood in your underwear is indescribable. I got my first bleed when I was on vacation. It had been really tough because my sister was announcing to our family in South Africa that she was pregnant; we were supposed to be pregnant together but I hadn’t even gotten a period yet, and here she was – Kate and 2/9 as my Uncle put it. I went upstairs to the bathroom and there was my first glorious period. I felt like a million bucks, I had *done* it!!!!  I could finally start trying to get pregnant myself!

After that celebration, though, comes another wait. This one is so tantalizing; you got a period, you hope that if you just to keep up what you’ve been doing you will  ovulate again and get another… or if you’re trying to get pregnant, you’ll get that oh so magical positive test instead. But for many women newly recovered from HA, cycle day 14 (when ovulation happens in a “normal” menstrual cycle) comes and goes, with nary a fertile sign. This can feel incredibly defeating (I know – in my case I randomly had an ultrasound scheduled on CD13 of my next cycle and we saw a nice juicy 13mm follicle which had my heart soaring, until I went back two days later and it hadn’t grown, and my doctor told me we’d need to do injections…).

But it is extremely common in women with HA for it to take a few cycles for the length to normalize, and this is one reason we say in No Period. Now What? to wait at least three cycle before making any changes in terms of eating, exercise, or stress.

I think that it is helpful to know exactly how common longer cycles are, and how long it typically takes for them to normalize, so I graphed the cycle length data I had from the surveys I did for NPNW. I took the data from each person who had at least one natural cycle, and ended up creating four graphs, split by number of cycles to get pregnant (most of the women who took the survey were trying to get pregnant).

Occasionally a woman will get pregnant on her very first ovulation–before getting her first period–in which case I do not have cycle length data (this happened in about 5% of women who ovulated naturally prior to any treatment). Other than that, in the data from my survey respondents, it took between one additional cycle to up to 12 to get pregnant the first time (in the women who provided cycle length data), so I split the graphs into one cycle to get pregnant (so these are women who had one period then got pregnant on their next ovulation), between 2-4 additional cycles, 5-7 cycles, and 8-12 cycles.

Here’s the first one – those women who took only one additional cycle to get pregnant. You can see that the cycle day of ovulation ranged from CD13 to CD63. (These were natural cycles as my requirement for using data for these graphs was that there was at least one natural cycle; there were certainly people who got pregnant on their first oral med, inject, or IVF cycle, but I will leave that for another day.)

The next graph shows those for whom pregnancy took 2-4 cycles… oh, but first here’s the figure from the book that shows the cumulative pregnancy rate by cycle so you have an idea of how long it is likely to take (if you desire pregnancy at the moment). Not everyone supplied cycle length data, so the numbers on these cycle length graphs don’t give a good sense of how long it took on average. Of my survey respondents, 56% achieved pregnancy within the first three cycles, and 84% within the first six. This is very similar to other studies of similar nature.

Back to those who took 2-4 additional cycles after their first period to get pregnant. This graph is a little more complicated, but if you just look at the first versus second cycle you can see a significant decrease in time to ovulation for those who had long initial cycles. The one case where cycle length increased, the woman in question decided to increase her exercise amount. You can see why we suggest not doing that right away, her cycle length increased from 45 to 60 days. This graph also includes some information about cycle lengths for those who used either oral medications (i.e. Femara or Clomid), or injectables. Some started with treatment but then after failed cycles got pregnant naturally (like the one woman who had ovulation on CD12 with injects, red triangle, on her first cycle, also used injects for cycles 2 and 3, but then got pregnant naturally cycle #4). Others had a natural cycle but then moved to treatment, like the woman whose first post-period ovulation was on CD70, reduced to CD24 with Clomid (and pregnant, filled blue square). Another example of this is the woman whose first post-period ovulation was at CD45, increased exercise and up to CD60, decreased exercise again and ovulated CD45, then used Clomid, ovulated CD18 and was pregnant.

The next graph shows those for whom pregnancy took between 5-7 additional cycles after their first period. Again you can see the commonality of a marked decrease in cycle length for those who had long initial cycles, and also a trend toward shorter cycles when oral meds were used. In this group were seven women who initially used Femara or Clomid to ovulate, but then after failed cycles stopped taking the meds and cycled naturally. Note that the filled red triangle indicates a pregnancy achieved on an injectable cycle (adding the legends to the graphs was taking me too much time).

Finally, those for whom it took between 8-12 cycles to achieve pregnancy. In this case the bump down to “CD 0” indicates no ovulation on that particular cycle. Here you see somewhat of an anomaly, with one woman whose first post-period ovulation was on CD63, which didn’t decrease until she started on oral meds, and another whose subsequent cycles were longer than her initial one. However, as you can see from the other graphs, this pattern is definitely not the norm. In either of these cases I probably would recommend oral meds (assuming that eating and exercise were not more restrictive). And again, filled red triangle indicates pregnancy achieved through injectables, black triangle shows a miscarriage on an injectable cycle.

I know that this is a lot of information, kudos if you’ve made it this far 🙂 I am happy to answer questions, please leave a comment if there’s anything unclear or another way you’d like me to analyze the data.

<3 Nico