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

Embracing the New You

I just went to see the movie Embrace with my new friend and fellow HA warrior Kate. It was lovely meeting her in person and we spent a lot of time over dinner before the show bemoaning how our society has encouraged us toward the predicament of treating our bodies so harshly in an attempt to be healthy – and also how much more common hypothalamic amenorrhea is these days with the latest trends in “clean” eating and strength and endurance training for women.

embrace_showing

Anyway, the movie was utterly fantastic and I cannot recommend it enough. Whatever your personal situation is, I can pretty much guarantee that Embrace will speak to you. I love the idea that is becoming more and more commonplace: that we should love ourselves and others for what we accomplish and *think* instead of what we look like (and heck, let’s do our best to pass this idea on to the next generation!). I know, not really a newsflash anymore, but at the same time it’s an idea that is easy to give lipservice to without truly believing. Embrace took me even further than I was down the path of believing. Find a way to see this movie! #ihaveembraced

Along the lines of switching your outlook, a woman recently posted in a facebook support group of which I am a member (join mine here) about how she was struggling with feeling frumpy and not hot when she went into a fashionable store to try on some new clothes. The responses were amazing, insightful, and inspiring, which is why you should join too if you’re working on recovery. Who doesn’t need an army of HA warriors at their back?

Lindsay said, “I’m so sorry you’re having a rough day. I understand; I had MANY of them. The next time you go shopping and you don’t like how something looks when you try it on, try to shift your mindset from “This fabulous shirt doesn’t fit my body” to “My fabulous body doesn’t fit this shirt“. There is nothing wrong with your body; it’s the shirt that doesn’t work. Take it off, and try on a different style. Do you remember the show What Not to Wear? I like to think of that show every time I go shopping, because Stacy and Clinton could always make ANY person look fabulous, no matter how big/small/short/tall. It’s just a matter of finding clothing that really flatters you. Body love and acceptance takes time… you’re just getting started here, and the changes are fresh and new. Over time, you’ll get used to your new self, and you will grow to love it as much as you did your old self. Maybe even more. Remind yourself daily that you are a multi-dimensional person… you are not just a body. And truly, the other aspects of your being – your personality, your sense of humor, your wit, your charm – are what people are most drawn to. Don’t let any perceived ‘imperfections’ of your physical body spoil the rest of that.”

Yes, yes, YES!

<3

Activating your hypothalamus

Women who have missing periods often question why their cycles aren’t returning when they get to a weight at which they formerly cycled, or at the same exercise level they were at when previously cycling.

The reason is that it takes more of an energy surplus / exercise decrease to get the hypothalamus to turn back on than it does to keep going once it has restarted. It reminds me a lot of the activation energy required to start a chemical reaction.

Chemical reaction activation_energy

The amount of energy required to get the reaction to run is greater than the difference in the energy of the reactants (starting material) and products (ending material) because the chemicals involved need to meet in the correct orientation and with enough energy for the reaction to take place. Continue reading

What to do if you’re a competitive athlete with a missing period?

Our hypothalamic amenorrhea / female athlete triad recovery book No Period. Now What? describes the causes of HA, many of the short- and long-term effects, and offers a Recovery Plan that has worked for hundreds of women. We also offer support throughout in the form of our own experiences, anecdotes from other women in similar situations, and advice we have gleaned over our years working with women to restore menstrual cycles.

There are two major components to recovery, both of which are covered in great detail in our book, but simply put, they are to eat more and cut out high intensity exercise.

Easy, right? Except, really, not at all. It is incredibly difficult for most of us to relinquish the food myths that we have been taught over the years, to let go of the rules that we have placed on ourselves, and particularly, to gain weight. For many it’s even more difficult to stop our cardiovascular exercise, whether it be running, biking, classes, or being a ‘gym rat.’ That’s why we spend more than a hundred pages on the rationale for the recommendations, ideas to implement them, and support for all the mental work that needs to happen.

While it’s hard enough for a recreational athlete to cut out high intensity exercise, for a competitive athlete this might truly be impossible. If you’re in high school and hoping for a college scholarship, or already in college being provided funds to attend, or a professional athlete – you might not be able to just quit for a few months. There is so much riding on your ability to perform.

relay Pole_vaulter Division’s_own_earns_Camp_Pendleton_Female_Athlete_of_the_Year,_runner_up_in_Marine_Corps_award_140313-M-PC317-003 Women 60 m final during Doha 2010 World Indoor Championships, by Erik van Leeuwen

(Photo credits, L to R: Erik van Leeuwen, Atitaya Kongkaew, Sgt. Timothy Lenzo (https://www.dvidshub.net/image/1189561), Erik van Leeuwen http://www.erki.nl/pics/main.php?g2_itemId=33469, all via Wikimedia Commons)

And yet.

Continue reading

Setting the tone for your day

Mindset is probably more than half the battle when working to recover your period. Changing your attitude to what you eat, your exercise, and your body takes daily effort, and support from others is huge in sticking with your changes.

Particularly if you’re used to getting up and exercising first thing in the morning, when you decide you’re not going to do that anymore it’s really hard to fill that time with another activity without pining for your workout.

A fellow HA recovery warrior shared a post from tinybuddha.com in support those who have recently decided to go “all in”; cutting out all exercise in hopes that will be the last push needed to recover periods.


The article is well worth a read. But as a highlight, when you wake up in the morning instead of thinking about topics that make you feel stressed or anxious (like choosing not to exercise or running through a totally packed itinerary for the day) rather choose a positive question or two to mull over. Some ideas:

  • What do I have to look forward to today?
  • What’s absolutely perfect about my life?
  • How can I make today absolutely awesome?
  • What’s the best thing that could happen today?

“You get peace of mind not by thinking about it or imagining it, but by quietening and relaxing the restless mind.” ~Remez Sasson

This goes along with our suggestion in the No Period. Now What? book of placing affirmations – positive statements that help ground you and reframe negative thoughts – around your house.

What other ideas do you have for ways to keep reinforcing a positive attitude through the challenge of recovery? (and after too!) What’s been most helpful for you on your journey?