Back to basics – Menstrual Cycle
Most women spend the majority of their early teens and 20’s trying to avoid pregnancy. But when they decide the time is right to start trying to conceive a baby most are frustrated that it does not happen straight away. Why shouldn’t it be that easy? Boyfriend, Marriage, Baby?
Society has changed with not only more and more women becoming dominant in the workplace, deciding a career before starting a family, we also have very busy social lives. Whilst we are all hectically running around we have simply lost sight of our bodies and what they are trying to tell us and actually what they are telling us is a huge amount. It is so important to learn to understand our own unique bodies.
If a woman hasn’t fallen pregnant within 12 months, maybe it is time to get back to some biological basics. Getting your client to understand their own menstrual cycle and recognising their own ovulation symptoms will help them become more in tune with their body’s and help you as a therapist to identify any possible reasons why they are not falling pregnant.
Let us take a look at the menstrual cycle in more detail:-
The menstrual cycle is broken down into four phases:-
- Menstruation
- Follicular phase
- Ovulation and
- The Luteal Phase
Menstruation
The menstrual phase is where a woman will have her monthly bleed, where the lining of the uterus sheds (known as the endometrium). This is commonly referred to as a period. Menstrual blood is removed by the body from the uterus through the cervix, vagina and out through the vaginal opening. This fluid may vary in colour from bright red to light pink or even brown. A period usually lasts about three to six days. To calculate menstrual cycle length, you count the number of days from day one of the period (CD 1) up to, and including, the day before the next period starts.
Between the ages of 25 and 35, most women’s cycles are regular, generally lasting 21 to 35 days and around ages 40 to 42, cycles tend to be the shorter.
The follicular phase
This follicular phase typically lasts ten to sixteen days leading up to ovulation. The two main hormones that dominate this phase are Follicle-stimulating hormone (FSH) which is produced by the pituitary gland and oestrogen which is produced by the ovaries.
During this phase, the hormone oestrogen causes the lining of the uterus to grow. This lining in response to increased oestrogen levels starts to develop and thicken to receive a fertilized egg should you become pregnant. Oestrogen levels rise dramatically during the days before ovulation and peaks about one day before ovulation. The increase of FSH throughout this phase, in turn, stimulates the growth of ovarian follicles. Each follicle contains an egg. Late in the follicular phase, only a single follicle will remain active.
Oestrogen also has the role of:-
- Keeping the basal body temperature (waking temperature after five hours of undisturbed sleep) low around 36.2 degrees Celsius.
- Increasing and changing the appearance of cervical mucus. As the follicular phase progresses you will see a distinctive change in the consistency of your mucus. The general pattern it will follow is dry-tacky-pastey-sticky-watery-clear- stretchy – abundant- egg white. Raw egg white appearance is the most fertile mucus, therefore, the most optimum time to fall pregnant and
- Changing the cervical position to soft, high, wet and open. A perfect environment to transport sperm to the egg.
As oestrogen peaks throughout this phase, it triggers a spike in yet another hormone – the luteinising hormone, or LH. Ovulation occurs as this increase in LH causes the follicle to rupture and release an egg. The last four days of the follicular phase, plus ovulation day, is the fertile window. This is when your client is most likely to become pregnant if they have intercourse without using any form of birth control. This is because sperm can live in a woman’s body for around four to five days if conditions are favourable.
When trying to conceive, it is so important to know when ovulation occurs and to ensure the Luteal Phase (the phase after ovulation) is long enough to sustain a pregnancy. The majority of clients I see in my clinic will always tell me they know exactly when they are ovulating and will always have intercourse around that time. However, most are shocked when they start tracking their cycle (using the Basal Body Temperature (BBT) method), that they are ovulating either later or earlier than first thought; they are completely missing their fertile window! It is quite a revelation and that typical ‘penny drop’ moment but in a positive way. ‘Oh, no wonder I haven’t conceived yet! I’m not having sex at the right time’.
Ask most doctors and they will tell you everyone has a 28-day cycle with ovulation occurring around Day 14. This is the optimum situation as it gives you the most opportunities over the course of the year to conceive. However, this does not occur in a large percentage of women, therefore by helping your clients understand their cycle and pinpointing ovulation is fundamental in increasing their chances of a successful conception.
Ovulation
Ovulation normally occurs around Day 14 of an optimum 28-day cycle. However, this can vary greatly from woman to woman.
As oestrogen peaks throughout the Follicular Phase, it triggers a spike in Luteinising Hormone or LH. Ovulation occurs as this increase in LH causes the dominant follicle to rupture and release an egg (ova) and the Corpus Luteum (which has been formed from the follicle), produces the hormone Progesterone which sustains a pregnancy, up until 12 weeks, when the placenta takes over. Remember, the last four days of the Follicular Phase, plus ovulation day, are your fertile window.
This is when you are most likely to become pregnant if you have intercourse without using any form of birth control. This is because sperm can live in a woman’s body for around four to five days if conditions are favourable.
The most accurate way to confirm ovulation has definitely occurred (other than having a blood test) is by tracking your cycle through the BBT method. This method gives no warning of imminent ovulation but confirms it has occurred through the sharp rise (biphasic temperature shift) of temperature after ovulation. It’s the hormone progesterone which is dominant in the Luteal Phase and has the effect of increasing the basal body temperature. Three consecutive high temperatures that are 0.2 degrees Celsius above the previous six lower temperatures confirm ovulation, and therefore this pinpoints exactly when ovulation occurred.
Many women seem to worry about whether or not they are ovulating and therefore use Ovulation Prediction Tests or OPT’s. OPT’s have become quite popular over the last few decades and can be quite useful in determining your fertile period. However, OPTs work by measuring the presence of Luteinizing Hormone (LH) in the urine. LH surges anywhere between 12 and 48 hours before ovulation, therefore they only predict a short fertile window; i.e. the day/days before you ovulate. It is recommended that they are used along with temperature tracking. I also find some clients will start worrying unnecessarily if the OPT shows no surge at all. Not detecting an LH surge may not mean you have not ovulated that particular month, it may be simply because your cycle is out of synch. Another air of caution if you do use OPT’s – they are not suitable if you have Polycystic Ovary Syndrome (PCOS) as these women have naturally higher levels of LH in their urine, therefore, the OPT may give several false-positive readings.
I would recommend the following:
- Test every day starting on the day you expect to be most fertile.
- If your client is unsure when they ovulate then start taking the tests when they start observing fertile (stretchy, egg white consistency) cervical mucus (we talk more about this in day 2) .
- If your client gets a positive result, there is no need to test again. First-morning urine is usually not the best for OPTs since your LH surge usually begins in the early morning when you are still sleeping and may not be apparent in your first-morning urine. Therefore, late morning or early afternoon is usually best.
- Test around the same time every day.
- Record OPT results as positive if the test line is as dark as or darker than the control line.
Luteal Phase
The Luteal Phase is the phase after ovulation. It is dominated by the hormone Progesterone which makes the womb lining thick and spongy in preparation for receiving a fertilized egg and provides the support to maintain a pregnancy.
Progesterone has the following physical effects on the body:
- Increases the BBT which confirms ovulation.
- Makes the cervix hard and dry.
- Makes the cervix secrete ‘mesh mucus’ which is thick, acidic and impenetrable.
- Makes the cervix position closed and low.
The Luteal Phase usually lasts between 12 and 16 days long. It is very important that the phase is at least 12 days long – if not, a pregnancy cannot be sustained. A Luteal Phase shorter than 10 days is classed as a ‘Luteal Phase Defect’ and is due to a progesterone deficiency. This defect can only be determined if you track your cycle using the BBT method. This is the scenario if you have a Luteal Phase of 8 days: the egg is released and travels down the fallopian tube. Before it has a chance to implant into the uterine wall, the endometrium has already started to shed in preparation for the next menstrual bleed. Therefore, even if fertilization had occurred, pregnancy would not occur due to failure to implant.