We Know More About Menstrual Cycles and Ovulation – But We're Not Teaching ItHOWEVER, w
e now know far more about menstrual cycles and ovulation than we are teaching pre-teen and young women+ or, for that matter, our
future doctors! An example: I was wrongly taught that every regular
menstrual cycle is normally ovulatory.
But we now know that every predictable, about-month-apart (usually called “regular”) menstrual cycle is NOT normally ovulatory. Instead, one-year data in 53 healthy, normal-weight, non-smoking and initially normally cycling and ovulatory woman+ showed that, although cycles remained regular, the luteal phase is not “fixed at 14 days” as dogma would have us believe1. Instead, over a third of cycles either have too short a luteal length for optimal fertility2 or to prevent bone loss3 4. Just so you know, that 1-year observational result in a convenience sample of highly screened, healthy women+, is very similar to what was shown by cycle-timed serum progesterone levels in a single, normal-length cycle in a population-based group of over 3,000 women in Norway5. Ovulatory disturbances, within normal-length, predictable cycles, are real.
Silent Ovulatory Disturbances (SOD): What Every Teen and Young Woman+ Should Know
Teen and young women+ need to know that their cycles may be perfectly regular but that they can also experience Silent Ovulatory Disturbances (SOD). These short luteal phases and anovulatory, yet normal-length cycles, may occur if they are upset, not sleeping well, or feeling anxious or blue. The same changes can occur with exercise training (as an athlete does) or with any reason for not eating enough to meet our energy needs6. Other reasons can be anything from problematic interactions with a parent, workmate or a potential or existing partner. Or they may be because a person is being abused or for many reasons may feel that they have no control and can only gain some sense of running their own lives by consciously choosing what they will eat (called cognitive dietary restraint)7. Although body weight stays steady and usually is normal, with this changed eating attitude comes both higher stress hormones and bone loss7.
We have been discussing the subtle changes within our menstrual cycles. However, if we are hit with many kinds of stresses at once, or we are close enough (within ~10 years) to our first period (menarche) that normal ovulation has not yet been securely established, with stress or abuse we may have long or skipped periods (oligomenorrhea) or not have any flow for 3-6 months (amenorrhea).
Cycle or Ovulatory Disturbances Are Adaptive and Reversible
The above would be horrifyingly dire messages if we could not also teach that these changes are adaptive, PROTECTIVE, and reversible8. “Hypothalamic reproductive suppression” (meaning any cycle or ovulation disturbances not caused by a disease) are neither permanent nor inevitably negative. That the normal stresses of daily life can cause SOD, would be a hard message to teach medical students if we didn’t further teach them that there are safe, natural and evidence-based treatments.
SOD and even stress-related oligomenorrhea and amenorrhea can recover without any intervention at all. That’s what happened to my amenorrhea during my first year of university in a strange city, being locked into a dormitory at night and having to get A grades to keep my scholarships. I told no one. My period returned when I went home to Alaska in the summer to work.
Paying attention and attending to what is bothering us, plus learning to deal with these issues, are usually associated with total and complete recovery. Sometimes recovery just requires a supportive listener, but other times we need the help of counsellors or some training in cognitive behavioural therapy that effectively treats even hypothalamic amenorrhea9.
If increased self-awareness and self-worth, associated with developing the maturation to make creative and positive changes in response to psycho-social stressors, are not sufficient for recovery, or if we are in difficult situations from which we are unable and insufficiently supported to find solutions, there is an effective medical therapy. It is “luteal phase replacement” with prescribed progesterone identical to what our bodies would normally make.
Progesterone Therapy: An Evidence-Based Treatment for Ovulatory Disturbances
Cyclic progesterone therapy (300 mg of progesterone at bedtime cycle days 14-27 for normal-length cycles, or every two weeks in amenorrhea or oligomenorrhea) will not only prevent bone loss but increase bone density10. That was the result of a 1-year randomized trial in 61 normal-weight, non-training community women+ with amenorrhea/ oligomenorrhea, or regular cycles short luteal phases/anovulation in which we randomized all four kinds of changes into four different therapy groups of progesterone, calcium, both, or one or both placebos10. This therapy used medroxyprogesterone, a synthetic progesterone-like hormone that works on bone through the progesterone osteoblast receptor10 (since we did not yet have progesterone as an oral medication). At the end of that trial, almost half of the participant women+ had normal-length, normally ovulatory cycles, no matter to which therapy or placebo they were randomized.
Also, clinical evidence says that, if SOD is associated with infertility, then cyclic progesterone (same dose and duration as above) can safely be used. Progesterone must, however, only be started after a positive urine LH surge test (called “ovulation test”) or after disappearance of midcycle stretchy egg-white-like mucus. With this simple treatment, I can’t count how many women+ with SOD and subfertility have been able to become pregnant and carry healthy, normal-weight babies to delivery by treatment with cyclic progesterone therapy!
Why This Matters: Changing How We Teach, Treat, and Talk About Menstrual Health
How do we currently treat irregular or missing cycles, acne, menstrual cramps or heavy flow? We prescribe the combined hormonal contraception (CHC, aka “the Pill”). What does CHC do for woman+ with amenorrhea? A retrospective study of a clinical amenorrhea treatment programme showed that those who took CHC were both slower and less likely to recover than were those who were treated with menopausal-type therapy or who refused treatment 11. We also know that adolescent CHC use (before age 20) is associated with bone loss 12. Why? Because the high dose estrogen in CHC paralyzes bone so that bone formation, which is necessary during the teens, cannot happen. A meta-analysis of multiple controlled prospective observational studies showed that CHC-using teens did not gain to peak bone mass12 putting them at increased risk for later-life osteoporosis.
Whether it is about ovulatory disturbances in regular cycles, the negative effects of CHC treatment for amenorrhea or CHC use in adolescence, the time has come for us to teach and empower women+ with evidence-based information. Only by a commitment to teach science and evidence-based information can we transform women+’s reproductive health knowledge. We must also treat based on science rather than on dogma.
