How it could affect your chart
It would seem as if you ovulated and maybe even conceived, because you would experience a normal buildup of fertile-quality cervical fluid with a Peak Day, followed by a deceptive thermal shift, with temps remaining high for about 12 to 16 days. And occasionally, the temps could remain high even longer due to the continued release of progesterone.
This condition can be particularly confusing, since you might mistakenly think you’re pregnant, given the misleading nature of your charts and the fact that your period may be delayed. An HCG pregnancy blood test will clarify the situation by about the 20th day into what you would erroneously view as your “postovulatory luteal phase.”
How it can be treated
As with follicular cysts, luteinized unruptured follicles will usually resolve on their own by Day 5 of the next “period.” However, if they too cause pain, they can be treated with a progesterone injection that will usually relieve any discomfort within an hour. And as with follicular cysts, birth control pills are often prescribed, but again, they don’t address the underlying cause. Finally, the risk of surgical scarring is still an issue.
For those trying to conceive, you should click here for more on the Luteinized Unruptured Follicle Syndrome.
Hanna’s chart. Luteinized Unruptured Follicle. Hanna seems to have an absolutely normal pregnancy chart, since she had the classic buildup of cervical fluid, culminating in a Peak Day on Day 15 followed by a thermal shift on Day 16 and then 20 days of high temps after. But on the 18th and 20th days of her luteal phase, she took a pregnancy test which was negative both times. Then she got her “period” on Day 36.
Corpus Luteum Cyst
With this type, the egg is released during normal ovulation, and a corpus luteum develops, as usual. However, instead of degenerating within 12 to 16 days, the opening where the egg was released is sealed off and filled with excess fluid or blood, thus causing it to grow into a cyst. Fertility drugs tend to raise your risk of getting one.
How it could affect your chart
It could appear as if you had possibly gotten pregnant, or you may indeed have gotten pregnant. This is because, again, you would experience a normal buildup of cervical fluid with a Peak Day, followed by a thermal shift with post-ovulatory temps remaining high, possibly beyond 16 days due to the continued release of progesterone. (As with LUF above, an HCG pregnancy test by the 20th day of the luteal phase should clarify whether you are pregnant.) The end result would be that your period might be delayed until the cyst disappears. But if you did indeed get pregnant, the cyst would usually resolve within the first three months of your pregnancy.
How it can be treated
No treatment is usually necessary since these innocuous cysts almost always resolve on their own within a few weeks to a few months.
Michi’s chart. Corpus Luteum Cyst. Michi seems to have a completely normal pregnancy chart, since she had the classic buildup of cervical fluid, culminating in a Peak Day on Day 14 followed by a thermal shift on Day 16 and at least 18 high temps after. But on the 18th, 21st, and 24th days of her luteal phase, she took a pregnancy test which was negative each time. Then she got her “period” on Day 40.
In reality, with this type of cyst, even though it appears to be a completely normal cycle, what actually happens is that the egg is released, but the resulting corpus luteum doesn’t disintegrate after 12–16 days, continuing to produce progesterone that raises the temperature and delays the onset of bleeding. Unlike LUF, though (discussed on the prior page), a woman could indeed be pregnant, and continue to have this harmless corpus luteum cyst into the first trimester of her pregnancy.
The Difference between Functional Cysts
Functional ovarian cysts result from an underlying hormonal disorder of the menstrual cycle, so they may recur if the hormonal dysfunction is not addressed. But most require no surgery, and usually resolve on their own.
Other Types of Ovarian Cysts
Dermoid cyst
If you’ve ever seen a picture of a dermoid cyst, you might think it’s someone’s idea of a bad joke. They’re somewhat common in women between 20 and 40 years old, but are usually benign and fairly innocuous. They are bizarre saclike growths which often contain structures such as hair, skin, and teeth (yes, teeth), since they form from cells that produce human eggs. They may actually grow anywhere in the body, though they are perhaps most common on the ovaries and are typically only discovered in a routine pelvic exam.
They often don’t cause any symptoms, but they can become extremely painful if they grow and cause ovarian torsion. They are rarely cancerous, and typically do not affect a woman’s fertility or cycle. But it’s considered good medical practice to remove them since they can continue to grow. They can be removed with either laparoscopy or conventional surgery.
Cystadenoma or Cystoma
These cysts develop from ovarian tissue and may be filled with a watery substance or viscous material. They are benign tumors that rarely turn malignant, but they can be painful because they may grow between 6 to 12 inches and cause ovarian torsion. They are usually diagnosed with simple imaging or X-rays.
They can impair ovulation by causing adhesions on the ovarian tissue. The watery types are usually aspirated, but the viscous types are usually removed through surgery. Of course, you know the drill about ovarian surgery.
Endometrioma or “Chocolate Cyst”
These cysts develop on the ovaries (and elsewhere) as a result of endometriosis, the cellular condition discussed next. They typically contain old blood which resembles a chocolate syrup–like substance, and often adhere to surrounding structures such as the ovary, fallopian tubes, and bowel. Symptoms are the same as those often associated with endometriosis (i.e., pelvic pain, painful periods, and painful sex).
If they rupture, the pain may be acute, and blood tests may reflect an elevated white blood cell count with a low-grade fever. They can also impact fertility by causing adhesions on the ovaries that prevent ovulation. As with all the others, they can be removed with surgery.
ENDOMETRIOSIS
This is one of the most curious gynecological conditions and is surprisingly prevalent. In this disorder, some of the uterine cells that normally shed during menstruation attach themselves elsewhere in the body, most often within the pelvic cavity. They usually grow in either small superficial patches, in thicker, penetrating nodules, or within cysts in the ovary. An easy way to think of it is that the uterine tissue inside the uterus is the endometrium and that same tissue outside of the uterus is endometriosis.
The most puzzling aspect of the condition is that the degree of pain it causes is completely unrelated to its severity. So it may produce absolutely no symptoms even though it has spread extensively, or cause debilitating pain with just a minor amount of spreading. It’s also unpredictable in that it may or may not spread further.
Causes of Endometriosis
There are many theories as to what causes it, with the most common being “retrograde menstruation” in which some endometrial cells flow backward through the fallopian tubes and out into the pelvic cavity, where they start to implant. But that theory alone is not enough to explain how it’s possible for endometrial cells to travel to distant sites, which is why researchers hypothesize that it can also be spread through blood or the lymphatic system. And finally, some believe that the endometrial cells can even be inadvertently transplanted through pelvic surgery.
Regardless, once these cells are implanted in other areas, they behave as if they still line the uterus, thickening during the cycle and shedding during menstruation. But since there isn’t an exit route, the immune system perceives the bleeding as a type of cut, and tries to heal it, forming scar tissue. Eventually, excess scar tissue can become adhesions that can cause a lot of pain and lead to compromised fertility, depending on where they adhere.
Symptoms of Endometriosis
The first three symptoms below are the classic signs, but even then, not
all women with the condition experience them.
•Intense menstrual cramps
•Pain during intercourse, especially with deep penetration
•Infertility
•Chronic pelvic pain, including lower back pain
•Heavy or irregular bleeding
•Premenstrual spotting
•Intestinal pain
•Painful urination or bowel movements during menstrual periods
•Diarrhea, constipation, bloating, nausea, dizziness, or headaches during menstrual periods
•Fatigue
•Low-grade fever
•Low resistance to infection
Diagnosing Endometriosis
If you notice that you have the following fertility signs in addition to some of the symptoms listed above, it may further confirm your need to be tested.
•short menstrual cycles (less than 27 days) with periods lasting longer than eight days
•barely any days of wet cervical fluid or even dry days throughout the cycle
•a luteal phase which may be a normal length of 12–16 days, but reflect low temps hovering near the coverline, signifying potentially lower than normal progesterone levels
The bottom line is that endometriosis can be very difficult to diagnose. Ultrasound is of limited value unless you happen to have ovarian endometriomas or “chocolate cysts,” as mentioned above. Even then, it would only pick up that endometriosis, and not any other throughout the pelvic cavity.
Scarlet’s chart. Endometriosis. Scarlet has been experiencing debilitating periods for the last year or so. In addition, every time she has sex, she feels a deep pain inside (as recorded in the bottom row), which has obviously affected her desire to have intercourse. Along with these issues, she often feels so tired that it’s hard to be productive. Finally, she has at least 3–4 days of premenstrual spotting every cycle. Any one of these symptoms would maybe not be indicative of anything serious, but taken as a group, they indicate that she most likely has endometriosis.
The only reliable and gold standard test is laparoscopy, with microscopic examination of the tissue as confirmation. But it’s crucial that the surgeon have a thorough understanding of the various appearances of endometriosis in order to perform “near-contact” laparoscopy, a specific technique that allows for a much more accurate diagnosis. This is because the microscopic endometrial cells can often only be seen at an even more magnified level than normal. Even then, some of the endometrial tissue can be so miniscule that it’s hard to detect, making it possible to overlook the condition altogether, or to underestimate its severity.
Finally, the diagnostic laparoscopy should ideally be performed in the pre-ovulatory phase of the cycle, when the chances of recurrence following laparoscopic treatment is less likely.
Treating Endometriosis
One of the most discouraging things about this disease is that remission is rarely permanent. It will usually return once therapy stops or often within months of surgery. Interestingly enough, pregnancy itself provides a respite from continuous cycles that promote endometriosis. Of course one of its cruel ironies is that, even though pregnancy is one of the few natural conditions that help the disease to regress, the condition itself often causes infertility.
Endometriosis, probably more than any other condition affecting fertility, needs to be treated on a very individual basis, since there are numerous variables to consider. How old are you? Do you have symptoms requiring pain relief? Do you want to have children? In general, the options are the following:
•Nonsteroidal antiinflammatory drugs
These are used to help reduce the pain. They work in part by stopping the release of prostaglandins, one of the main chemicals responsible for painful periods. Unfortunately, they only treat the pain, but do not shrink or prevent new cellular growth. Examples include ibuprofen (Advil and Motrin) or naproxen (Aleve, Anaprox, and Naprosyn).
•Hormonal birth control
This can reduce the bleeding that may cause the pain. Obviously, this would be inappropriate for those who desire pregnancy. Regardless, it’s only a temporary fix while on the hormones and does not cure the condition. And of course, hormonal birth control has its own set of risks and side effects.
•Gonadotropin releasing hormone agonists
These drugs work by, in essence, causing a temporary menopause. They’re also exceptionally good at reducing severe pain, but again, they cannot be used for women trying to get pregnant. In addition, the drugs have numerous side effects such as hot flashes, vaginal dryness, decreased libido, and insomnia, though taking a hormonal “add-back” of a very small amount of estrogen or synthetic progestin can help alleviate some of these symptoms.
While certainly less invasive than surgery, hormonal therapy only works in mild cases and has numerous side effects. Moreover, it is typically taken for at least 6 months in order to be most effective, although it rarely eliminates the underlying condition. Examples of hormone agonists include naferelin (Synarel), leuprolide (Lupron), goserelin (Zoladex), or danazol (Danocrine).
•Surgery
Laparoscopy is considered minimally invasive surgery and can often be used to drain fluid and remove small patches through laser or electrical current, but not all cases can be treated through the laparoscope. Both laparoscopy and more traditional surgery can remove adhesions, implants, or blood-filled cysts, regardless where they are in your body. But again, if you are planning on getting pregnant, you should be sure that your doctor is experienced and skilled in the type of surgery that lessens the risk of scarring. As mentioned earlier, it should ideally be performed in the preovulatory phase of the cycle.
Occasionally, more extensive surgery is necessary when already-present scar tissue is thick or involves delicate structures. And if you’ve had surgery and find that you still have pain, ask if your pelvic lymph nodes were treated for the condition, because if they weren’t, your pain may persist.
For more on endometriosis, click here of color insert.
POLYCYSTIC OVARIAN SYNDROME (PCOS)
This subject is probably more complex and challenging than any other in this book.
Briefly stated: PCOS is not for sissies.
This is the most common hormonal disorder among women of reproductive age and has the most far-reaching repercussions, including the possibility of major health risks later in life. So I want to give you the tools to identify whether you have it now, regardless of your future pregnancy goals. This will serve you well if that time comes, since you won’t have to start at Square One trying to figure out what is taking so long to conceive.
So what is PCOS? The short answer is that it’s a hormonal disorder primarily due to an overproduction of male hormones leading to the prevention of regular ovulation. Unfortunately, its causes, symptoms, and treatments are the topic of much confusion and disagreement within the medical community. Because of this, if you think you have this condition, you will need to do your homework in order to find the best medical advice for your particular situation.
The primary reason PCOS can be so confusing is that it’s a syndrome and not a disease. More specifically, it’s not one disorder, but a variety of possible conditions. However, it usually presents with one thing in common: an overabundance of immature follicles on the ovaries that rarely release an egg. As you’ll also see, its various symptoms are all reflective of a hormonal imbalance that can have important consequences for both your fertility and general health.
Overt Symptoms of PCOS
Women who have PCOS may have different observable characteristics (called phenotypes), so they may appear physically different, such as being thin or obese. They may also have different genetic makeup (called genotypes), which predisposes them differently to these various characteristics. Regardless, some of the classic signs that women typically have in varying degrees include:
•Long (over 35 days) or irregular cycles that rarely result in ovulation
•A pattern of limited cervical flui
d for long stretches of time
•Frequent patches of fertile-quality cervical fluid which may or may not ultimately lead to ovulation
•Excessive body or facial hair (hirsutism)
•Male pattern hair loss
•Acne
•Obesity (about 50% of women with PCOS)
•Infertility
Clinical Symptoms
•Enlarged, white ovaries that have what appear to be a string of pearls on the surface—numerous immature follicles that never reach ovulation (see picture of the color insert)
•Elevated androgen (testosterone) and LH levels
•A reversal of the LH: FSH ratio (LH in women with PCOS is produced in excess of FSH, which is the opposite of a normal ratio)
•Often abnormal ovulation when it does occur (for example, the abnormal development of the egg as well as the corpus luteum)
Long-Term Health Risks
The reason why PCOS is so troubling is that it has a whole host of long-term health risks, depending on your genotype. For example, women who are predisposed to obesity are at significant risk for insulin resistance and metabolic syndrome, as well as for developing high blood pressure, diabetes, and heart disease later in life. And yet others with different genotypes may not have any of those risks.
The following is a more comprehensive list of conditions for which women with PCOS may run an increased long-term risk:
•Insulin resistance (in at least half of women with PCOS)
•Metabolic syndrome
•High blood pressure (hypertension)
•Type 2 diabetes
•Heart disease
•Endometrial cancer
•Breast cancer
•Ovarian cancer
Causes of PCOS
The causes are still not fully understood, but it’s likely that a number of factors play a role. For starters, it appears to often be passed down genetically. In addition, excess insulin is often produced, which may in turn cause you to produce excess androgens (male hormones). This in turn can lead to the production of polycystic ovaries, in which your follicles remain undeveloped at the antral level, never maturing enough to release an egg. It is these follicles, stuck on the ovarian wall, that form the characteristic string of pearls.
Taking Charge of Your Fertility Page 14