Do you really ovulate “late”?

Some women, as they recover from hypothalamic amenorrhea (missing periods), 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 (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!!

Femara or Clomid for Ovulation Induction?

Summary: If you are not ovulating naturally even after working on recovery, and want to use medication to induce ovulation for pregnancy, Femara (letrozole) is preferable to Clomid (clomiphene)*.

letrozol3d

 

 

Letrozole, By MindZiper – Own work, CC0, https://commons.wikimedia.org/w/index.php?curid=15991603

 

In No Period. Now What? (NPNW), our book on hypothalamic amenorrhea recovery, Chapter 21 covers the oral medications that can be used to encourage ovulation. We discuss how soy isoflavones, Femara, Clomid, and tamoxifen reduce estrogen levels to encourage an increase in follicle-stimulating hormone (FSH) that in turn leads to growth and maturation of eggs. These medications can be used when pregnancy is desired, but also to “jump-start” menstrual cycles*. It is really important to note that these meds are unlikely to work without progress having made toward recovery in the form of increased eating, reduced exercise, and reduced psychological stress – all of which you can read about in earlier sections in our book.

clomifene_ball-and-stick

 

 

Clomiphene, by MarinaVladivostok (Own work) [CC0], via Wikimedia Commons

 

 

We also cover research comparing pregnancy rates, likelihood of a multiple-gestation pregnancy, uterine lining thickness, and other metrics between Femara (letrozole) and Clomid (clomiphene citrate) to help women decide which choice is optimal for them. (Tamoxifen is an alternate that is rarely used, so there is not a large body of research to reference, although in many ways it is preferable to Clomid based on fewer effects on the uterine lining.) We also discuss dosing recommendations, what to do if the first cycle doesn’t work, and much more. 🙂

Our conclusion in NPNW is that if one is trying to get pregnant, Continue reading

Reader Questions

I thought that now that my kids were back in school I’d have all kinds of time to post here – but somehow between being PTA president, starting a PTO at my youngest’s preschool, getting involved in local politics, reading a bunch of books and starting to lift weights again (because I was feeling weak NOT for body sculpting purposes), and yes, getting a little mired in the national election coverage too… not so much. But hopefully this will start a new routine!

I asked in my facebook group for questions people would like answered. If you have anything else you’d like me to address, pop it in the comments and I will do so on another post!

1. What do you think about soy and other estrogen increasing foods?

Many people think that the issue when one has HA is low estrogen. This is not the case. The issue is that your hypothalamus is not sending the signals to your reproductive system. Once your hypothalamus turns back on again, your estrogen will rise appropriately. So as far as foods go – I advocate moderation on all fronts. It’s fine to eat some soy but I see no need to specifically increase the amount you’re currently eating. If you’re eating a “lot,” I’d advocate cutting down and substituting with other protein and fat sources simply in the interests of eating as many different types of foods as possible.

2. Does color and length of your period indicate anything?

This one actually comes up a lot! Many women are afraid that their period is “too light” when they start cycling again. My ‘normal’ post pregnancy has been one heavy day (which I define as filling a regular tampon every 2-4 hours), a medium day (filling a tampon every 6 hours or so), two light days (a tampon every ~12 hours) and then a day or two of spotting. Something around that seems to be reasonably common. Some women obviously have much heavier periods, some have significantly lighter periods – but anecdotally I haven’t noticed a correlation with ease of getting pregnant. Also, interestingly, it seems that not all the lining is shed as “blood” but some can actually be resorbed into the uterus. So I think that really what is important is what is normal for you. If your periods after recovery are much lighter than before, that may indicate a need to relax a little further on the exercise, eat a bit more, or see what you can do about relaxing (all of which we cover in our book :)). If they’re much heavier, you may want to check in with your doctor, just in case there is another issue at play like endometriosis. If they’re normal for you, however heavy or long that may be – chances are excellent that everything is fine. If you are trying to conceive and not getting pregnant, you can discuss with your doctor, but barring that – go with the flow. (yes, pun intended ;))

3. How long will it take to recover?

In a previous post I discussed whether time to recovery was associated with length of time without a period, and the answer in that case seems to be no. The median time to recover is about six months – some shorter, some longer. In general, the more quickly you are able to go “all in” the more quickly you will recover your cycles. I wish there was a formula I could plug your information into that would spit out an answer – but unfortunately life doesn’t work like that. Your particular recovery formula will depend on what your BMI was/is and how quickly you’re able to increase that to a ‘fertile’ BMI of 22+, how much exercise you did and what you’re doing now, what your food intake looks like (hint: the more variety the better, assuming sufficient energy), and what your daily stress and anxiety levels are (and unfortunately this is a vicious circle because stressing out over how long it will take to recover can make it take longer!).

4. I can’t go all in. I don’t trust the process.

From my experience what really helps here is seeing other women recover. (Read the success stories in our book and join my facebook group!) When you find someone just like you and read about what they did to restore cycles or get pregnant, it makes it that much easier to believe that it can and will happen for you. Keep reading the successes, keep listening to the other amazing resources that are out there (I cannot recommend Meret Boxler’s podcasts enough, she will introduce you to everyone you need to know in this arena), do as much as you can to work toward recovery (fake it ’til you make it) and one day it will click for you too. I have seen it countless times. It will come.

5. How do you track food while in recovery and know you’re eating enough?

This is a tough one because really, tracking is a big part of the problem. So it’s hard to see it as part of the solution too – but I know that when you’re starting on this path from a place where you are tracking it is hard to let that go. What I did initially was to increase the amount of calories I was allowing myself each day (“allowing”…that’s a whole different topic) and I continued meticulously tracking as I had been. I’m a numbers person so that was hard for me to let go. But there came a time when I’d skip a day… and that quickly grew to two and three and then to not tracking at all anymore. At that point I had a good sense of how much I needed to eat each day and I was much better at listening to my hunger signals. If you’re not tracking now I wouldn’t suggest starting unless *maybe* you log your food intake for a day just to see where you’re at. Really the best way to know you’re eating enough is two-fold: 1) if you’re under a fertile BMI to make sure you are gaining, and 2) notice your fertile signs (chapter 16) and obviously return of your period. And yes you often have to go beyond what feels comfortable for you, both in the amount you’re eating and in how much weight you gain… but I *promise* you, the return of your cycles and your fertility is worth that discomfort. Again – seek out success stories and read about how little women care about what their body looks like when they see that first sign of red, or get their positive pregnancy test.

6. If a period was lost with no exercise, will adding exercise while eating more calories, fat, carbs delay recovery?

Abso-freaking-lutely yes. I was over in a different facebook group today and a women commented on how she had just started a new exercise routine, going five days a week instead of the one she had been doing, and how her ovulation was six days late (and still nowhere to be seen). Especially if your body isn’t accustomed to it, the increased cortisol from exercise can do a number on your hypothalamus. Walking and yoga, *light intensity* are probably okay but I would add even those slowly. Also, I noticed a big effect of exercise on my own cycles (p. 162 in our book) even while gaining weight.

I hope you found this helpful, and if there’s anything else you’d like to know, drop a comment!

How long will it take to recover???

One of the unique aspects to our book on recovering from hypothalamic amenorrhea is the data we include from our survey of over 300 women who have experienced missing periods. I also love having the data set because when people ask me questions that I didn’t address in the book I can go and get the answer pretty quickly.

A question that was recently asked was Is there a difference in time to recovery depending on how long one’s period has been missing? The range of time for which periods were missing for the women who took our survey was from three months to over twenty years!

However, I found that there was hardly any difference in time to recover based on length without a period. Note that the start of working on recovery was defined as the time at which eating more / weight gain commenced. The data are shown below (note that the scale is logarithmic, not linear):

MonthsWithoutCycleVsTimeToRecovery

Each point represents one woman, with the amount of time she was without a cycle on the Continue reading

Getting the word out!

Helping women with hypothalamic amenorrhea / female athlete triad / missing periods to recover–regain their cycles and realize how much needless energy has been spent on food, exercise, and appearance–has been my passion for the last ten years. For many years I helped women on the HA forum at FertileThoughts.com, but since 2012 my posting there slowed down as I worked on the book.

Now that the book is done… it’s really time to get the word out. We’ve gotten so many positive reviews and comments on our work, like what Amanda said recently,

I want to take a moment to thank you from the bottom of my heart. I’m almost done your book and can see that you’ve poured years and years of your life, heart and soul into that book and raising awareness around HA. I can’t tell you how much I’ve learned and how motivated I’ve become to continue to work on my health and hormonal integrity and to incorporate BALANCE into my life. Not to mention that this book will spearhead an increased awareness of HA and hopefully a new understanding of the importance of maintaining female health……THANK YOU!!!

Meret Boxler, whom I met on a hypothalamic amenorrhea support group on Facebook, has been working on being compassionate with herself, redefining her view of what healthy is and looks like, and focusing on the positives in her life. As a former radio DJ creating a podcast series seemed a natural next step – and she wanted to interview ME!  So I am super excited to share that interview with you. Take a listen, and if you enjoy, please subscribe to her feed, give her lots of likes, and reviews would be fantastic.

LU 003: Nicola Rinaldi – No period. Now what? Health issues from overexercise and too little food.


Subscribe on iTunes (Apple), or on Stitcher (Android)

Shortly thereafter, having gained some confidence from the interview with Meret (on top of which it was a really enjoyable conversation), I was directed to a video on YouTube that contained misinformation about HA and its causes. So I immediately thought that doing my own video would be another fantastic way to get the word out about our hypothalamic amenorrhea recovery book along with basic information about HA that it’s important for people to understand. That video is below – and again, if you could like and comment that would be stellar – the more likes, the more people will be able to find it and educate themselves about missing periods and the effects on our health.

Thanks so much!!! xox Nico