Regardless, it is at times like this that observing your cervix and other secondary fertility signs can help you determine whether your fever had no impact, or did indeed affect your cycle by either delaying ovulation or preventing it altogether. Of course, if you are using FAM for birth control, you need to be exceedingly careful in ambiguous situations like this.
Ovarian Cysts
This is one of the most common causes of temporary anovulation and irregular cycles. If they cause you to not ovulate, they are usually due to a cyst in the first part of the cycle. If they cause you to have irregular cycles, they may occur in the second phase of the cycle. Either way, they are usually not serious. They’re covered more extensively in the next chapter.
Travel
Traveling is notorious for affecting cycles. There’s nothing quite like wearing a pair of crisp white walking shorts while strolling down the Champs-Elysées in Paris when . . . uh-oh, surprise, surprise. Although many women are blessed with cycles that continue like clockwork while vacationing, many others are faced with the challenge of trying to figure out if or when they will get their periods.
As delightful as vacation may be for you, your body still interprets it as a type of stress. Many women find that their cycles become extremely long due to delayed ovulations. Others actually stop ovulating and getting periods altogether. Once again, charting your cycle can be very helpful in determining what is happening in your body. Keep in mind, though, that traveling is a time when it’s especially helpful to chart all three signs in order to understand any ambiguities that result from the disruption in your life. In particular, always be on the lookout for factors that may affect your temps.
Years ago, my college roommate seemed to redefine the limits of travel-related anovulation. Cathy spent her junior year in England. She had a period just before she arrived in London, then didn’t menstruate for the ten months she lived there. But sure enough, the month she returned home, she got her period again.
Exercise
Strenuous exercise has the potential to delay or even prevent ovulation completely. You may be tempted to use this as an excuse not to exercise—nice try! It seems to affect mostly those who are competitive athletes with a very low ratio of body fat to total body weight. The women most affected are athletes such as runners, swimmers, gymnasts, and ballet dancers. But what is somewhat inconclusive about studies of these athletes is that they seem to have been unable to separate out the effects of fat ratio from physical and emotional stress, diet, and even changes in thyroid metabolism. All of these can affect a woman’s cycle.
Weight Gain or Loss
In order for the average woman to maintain normal ovulatory cycles, she should have a BMI (body mass index) between 20 and 24, or at least 22% body fat. You can easily check a chart online to determine your BMI.
Extremely thin women, particularly those with anorexia, often stop having periods altogether. Since they don’t have enough body fat, they don’t produce the hormones necessary to ovulate. In addition, women who lose 10 to 15% of their total body weight (or about one-third of their body fat) may also cease having periods. And as mentioned above, female athletes often stop menstruating because of the combination of lean body fat and stress caused by competition.
Among my clients was a French couple who had been trying to get pregnant for five years. They asked to meet with me privately rather than take a group seminar because he was a doctor and felt the class might be too elementary for them. When they arrived at my office, I sensed a potential fertility problem immediately.
The woman was tall and extremely thin. I asked her whether she would consider gaining a little weight to alter her cycles, but she said she was adamantly opposed to consuming any fat in her diet. Yet they both claimed they were totally perplexed as to why she wasn’t getting pregnant, since she took such good care of herself. But when I asked her to describe her cycles to me, she said there weren’t any to describe—she hadn’t had a period in five years!
I was stunned. Here were two educated people, one of them a physician, yet they couldn’t understand why she wasn’t getting pregnant even though she wasn’t menstruating. I questioned why they thought she was fertile if she hadn’t had a period in all those years. Their answer amazed me. Years prior, when they were trying to avoid pregnancy, her physician asked her what form of contraception she used. She said they didn’t use birth control because she wasn’t menstruating. Her physician at the time insisted that she protect herself anyway, since, as he rightly pointed out, she could still ovulate at any time. Based on that one comment, that she could ovulate at any time, she interpreted that to mean she was indeed fertile.
I was able to explain to them that the odds of pregnancy must be seen differently, depending on the goals of the couple. From a contraceptive perspective, her doctor was right—it’s imperative that women protect themselves because ovulation always occurs before menstruation. But if a woman is trying to get pregnant and is not menstruating, then she is clearly not ovulating. Their experience taught me how easy it is to confuse the risk of an unplanned pregnancy with the slight possibility of one that is wanted. Unfortunately, I never did learn what happened to them because they returned to France shortly after we met, but I assume that they at least dealt with her anovulatory condition.
On the other end of the spectrum are women who tend to be overweight. They too may stop ovulating. At this point, you may be thinking, “Wait a second. She just said that it could be problematic if the woman is too thin, and now she’s saying it could be a problem if she’s too heavy.” Such is the nature of women’s bodies! Excess fat tissue can cause too much estrogen, disrupting the hormonal feedback system that signals the egg follicles to mature.
Stress
One of the most likely causes of occasional long cycles is stress, both physiological and psychological. If stress affects a cycle at all, it tends to delay ovulation, not accelerate it. As you know, the timing of ovulation will determine the length of the cycle—the later it occurs, the longer the cycle will be. Sometimes, if stress is severe, it can actually prevent ovulation from occurring at all, as seen here.
MEDICAL CAUSES OF ANOVULATION OR IRREGULAR CYCLES
In addition to the various temporary factors listed above, a variety of potentially serious medical conditions may cause women to stop ovulating indefinitely. Many of these conditions can be treated, but all will require consultation with a physician who will need to determine the cause of your anovulation or irregular cycles.
Whether or not you’re trying to get pregnant, I would encourage you to be examined sooner rather than later. Highly irregular cycles can reflect a medical condition requiring treatment, not only because of its overall impact on your health, but also because of its implications for your fertility. If you’re trying to avoid pregnancy, a medical condition can make the Fertility Awareness Method more challenging to use effectively. And if you’re trying to get pregnant, it can prevent you from doing so. In any case, your doctor should examine you for a number of conditions, especially those discussed below.
Hypothyroidism
The health of the thyroid gland is intimately connected to a woman’s cycle, and therefore, one of the first things to consider when dealing with anovulatory cycles is that of a low-functioning thyroid, the bow-shaped gland at the base of your neck. Because this condition can so directly lead to hormonal imbalances, it’s more thoroughly discussed in Chapter 9.
Polycystic Ovarian Syndrome (PCOS)
Even if you’ve never heard of this condition, there’s a good chance you know someone with it, or you, yourself, have it. PCOS is one of the most common causes of anovulation and irregular cycles, affecting up to about 10% of all women. It’s a serious hormonal disorder that impacts almost every organ of the body. For this reason, I’ve written more extensively about it in the following chapter. But the takeaway message here is that if you have very irregular cycles, or ones longer than 35 days, or you don’t seem to ovulate at all, you
should be diagnosed by a physician (preferably a reproductive endocrinologist), who can start treating you as soon as possible.
Endometriosis
Women with this condition have tissue from their uterine lining that implants in sites other than the uterus, and this may cause numerous symptoms. As with PCOS, it is a fairly common condition. It may cause irregular cycles, but not to the extent that PCOS does. Again, because it’s so prevalent, I’ve included an extensive discussion of it in the next chapter.
Excessive Prolactin (Hyperprolactinemia)
Prolactin is often referred to as the breastfeeding hormone, because it’s what circulates in nursing women, and it’s often partly responsible for suppressing ovulation in women who are fully breastfeeding. But occasionally, a woman who is not nursing (or hasn’t even given birth) will have an excessively high level of the hormone in her body, preventing ovulation altogether. It may be due to a benign pituitary tumor. Regardless, it’s a condition that is fairly easy to treat.
Primary Ovarian Insufficiency (POI)
You may still occasionally hear this condition referred to as Premature Ovarian Failure (POF) or Premature Menopause. While it’s true that the ovaries may stop functioning normally before the age of 40, and sometimes as early as the teen years, the former term is misleading. Indeed, sometimes the ovaries don’t necessarily shut down completely, so women may continue to menstruate intermittently even though their cycles will undoubtedly be irregular and eventually cease altogether.
However, it’s also the case that POI symptoms caused by the lessened production of estrogen may mimic those of perimenopause, such as irregular cycles, hot flashes, or vaginal dryness. In addition, women may notice that intercourse can become painful from thinning vaginal walls.
There are two main concerns for women with this condition:
1.POI is an endocrine disorder that has serious health consequences that need to be addressed. Women with POI don’t produce enough estrogen, so they should consider taking estrogen-progestin therapy until at least age 51, in order to help prevent osteoporosis and possible heart disease.
2.Women with POI are unlikely to be able to still get pregnant. But the good news is that they could probably still carry a baby to term through donor eggs, as discussed here.
PUTTING ANOVULATION IN PERSPECTIVE
As you have seen, there are many reasons why women don’t necessarily ovulate every cycle. Some involve particular phases in a woman’s life, such as adolescence, pregnancy, breastfeeding, or premenopause. Others are due to more transitory factors such as coming off the pill or other hormones, as well as stress, illness, exercise, body weight, and travel.
And finally, some are caused by more serious medical conditions. The important point is that anovulatory cycles need to be understood in the right context. At times, they are completely normal and even predictable. But if you think you have a serious medical issue, your charting will help you and your doctor to accurately diagnose it.
In fact, anovulation and irregular cycles are often one of the easier fertility issues to treat, since they are frequently caused by a hormonal imbalance that can be rectified by natural remedies. Chapter 9 specifically addresses ways you can try to treat these issues yourself. Regardless, though, you may want to first see a physician to rule out anything serious.
FERTILITY AWARENESS AND ANOVULATION
Remember that while you are obviously not fertile when an egg isn’t released, ironically, you need to view every day as if you were still in your preovulatory phase. So if you plan to use Fertility Awareness for contraception during periods of anovulation, you should be aware that the rules are somewhat more involved than the normal ones you will be learning in Chapter 11. Depending on your own particular anovulatory pattern, this may or may not be difficult. In any case, I suggest that you finish reading the normal rules first, and then, if you have determined that you are in an anovulatory phase of your life, you should carefully read Appendix J.
CHAPTER 8
Three Prevalent Conditions All Women Should Be Aware Of: Ovarian Cysts, Endometriosis, and PCOS
My hunch is that many of you will be so eager to get to the nuts and bolts of natural birth control or pregnancy achievement that you may prefer to skip this chapter. That’s fine. But just know these conditions are so prevalent that there’s a decent chance that you yourself will eventually discover through charting that you have at least one of them.
I imagine you’ll have a few “Aha” moments while reading about these disorders, and my hope is that by charting you’ll feel more equipped to take the first steps necessary to deal with them. Even if you’re not personally affected by any of these, you’ll now be able to educate your friends and family on the various symptoms that so many have likely already experienced.
The first condition, ovarian cysts, is the most common, and rarely poses serious health problems. However, if you realize you have one, you will want to learn what to do if they become painful or a nuisance.
The second, endometriosis, affects about 10% of women, and as you will learn, is an often strange and invasive condition that each woman experiences in her own way. Some may never be impacted by it or not even be aware that they have it until they try to get pregnant, while others may experience almost debilitating pain that will be easier to diagnose if they are charting.
The third, Polycystic Ovarian Syndrome (PCOS), is another condition that affects about 10% of women. However, unlike the first two, it’s very important to get on top of this one as soon as you realize you have it, because it’s associated with major long-term health risks.
OVARIAN CYSTS
Most women will experience at least one ovarian cyst in their life, and usually, they are no big deal. In fact, unless you were charting your cycles, you would not necessarily be aware that anything was even amiss.
There are several types, the most common being functional cysts, which are called that because they develop as a result of the normal function of the menstrual cycle. But instead of following a typical path, they continue to grow beyond normal. Some of these functional cysts may cause anovulatory, irregular, or just plain confusing cycles. Unfortunately, there is no consensus among physicians as to how to define or treat them. Still, the following should be a helpful overview.
In brief, ovarian cysts are enlarged fluid-filled sacs on the ovary, typically categorized by when they occur in relation to ovulation. In most cases, these cysts persist longer than normal, but are completely benign and will usually resolve on their own. But if they cause pain due to swelling, twisting, rupturing, or bleeding of the cyst itself, further treatment may be required.
All ovarian cysts can be removed with surgery, but it should only be considered as a last resort, since it can compromise fertility by causing adhesions. So if you plan on getting pregnant one day, you’ll want to be assertive by asking whether you could wait for them to resolve on their own, or if there is another option. (Click here about a type of surgery that decreases the risk of scarring anytime surgery is performed on the ovary.) In any case, it will be easier to understand the three types of functional cysts if you first review the normal sequence of events surrounding ovulation below.
Functional Ovarian Cysts
As mentioned above, these types of cysts are, by definition, a result of the normal functioning of the menstrual cycle gone somewhat amiss, and thus not surprisingly, their cause is hormonal. They may occur just once, or recur often.
Follicular Cyst
With this type, the follicle surrounding the egg continues to grow as you approach ovulation, but instead of rupturing to release the egg, as it normally would, it enlarges into a cyst that encases the egg inside, preventing ovulation.
How it could affect your chart
You may continue to produce fertile-quality, wet or slippery cervical fluid for weeks on end, but you would never experience a thermal shift indicating ovulation had taken place. Eventually, you would probably have breakthrough bleeding (as oppos
ed to a true period), thus ending in an anovulatory cycle. You would still treat that bleeding as Day 1 of a new cycle.
How it can be treated
Follicular cysts will usually resolve on their own, typically by Day 5 of the next “period” (again, it’s not technically a period because ovulation did not take place prior to the bleeding). However, if it’s causing you chronic pelvic pain, the most efficient and successful treatment is a progesterone injection. This will break the estrogen dominance, and you will usually start menstrual-like bleeding within 3 to 5 days. Birth control pills are also often prescribed, but they don’t address the underlying cause! And of course, you already know the potential problem with ovarian surgery.
Chloe’s chart. Follicular Cyst. Chloe seems to have a normal cycle up until what appears to be her Peak Day on Day 15. But then, instead of having a thermal shift a day or two later to confirm that ovulation has taken place, the rise in temps never occurs. In addition, she continues to produce what appears to be fertile-quality cervical fluid through to Day 38. She finally gets a “period,” which is technically anovulatory bleeding. Note that there was no reason to do a pregnancy test, since she clearly did not ovulate that cycle.
Luteinized Unruptured Follicle (LUF)
With this type of cyst, the maturing egg prepares to be released, and the follicle in which it is encased goes through the sequences of a normal ovulation, including the formation of a corpus luteum that produces progesterone. However, again, the egg remains stuck in the follicle, so ovulation does not actually occur.
Taking Charge of Your Fertility Page 13