Week 1
Welcome to the Module 1 Week 1 of the Fertile Ground Holistic Fertility Program!
Module 1
Week 1
Module 1 - Weeks 1-4 will be focusing on how our hormones work, phases of our cycles, cycle syncing, tracking our cycle, nutrition for each phase of your cycle
Foundations of Hormonal Health
It’s important for us to have a strong understanding of how the menstrual cycle works and key ways in which ovulation is disrupted. Menstrual cycle awareness and understanding is the bedrock for creating vibrant health for ourselves.
Ovulation is a vital bodily function that anyone of childbearing age needs to experience regularly, pregnancy aspirations or not. Ovulation that occurs on a consistent basis is the driver for sufficient levels of estradiol (the body’s most potent form of estrogen) and progesterone, both of which are the two key female sex hormones. While these two hormones are mostly known for their role in the menstrual cycle and reproduction, they actually play significant roles in other bodily functions too. In a nutshell, the estrogen and progesterone that are generated as a result of the ovulatory process support:
This is just a snapshot of the ways in which ovulation is vital to our overall health throughout the menstrual life cycle, meaning from puberty until the end of perimenopause. Consistent ovulation should be a non-negotiable throughout our lives.
Traditional medicine has focused on periods as being the main event of the menstrual cycle, but they aren’t. They may get the most attention because of all the pain and suffering they cause, but it is actually ovulation that is the star of the show, not our periods. While regular menstrual cycles are considered a sign that everything is in working order, it is important to know that these cycles can be anovulatory, meaning that ovulation has not occurred and the ovaries are not properly functioning. This is misleading and it’s why ovulation must be recorded as part of tracking one’s menstrual cycle, because as I said earlier, regular ovulation is a barometer of your overall health status. If regular ovulation isn’t happening, this is a sign of underlying health conditions that must be investigated.
Ovulation disruption and menstrual problems can be caused by multiple external and internal factors, all of which play a role in the following endocrine-related conditions:
Let’s begin with the hypothalamic and pituitary.
I want you to think of the hypothalamus and pituitary glands (which are regions in your brain) collectively as “hormonal headquarters”, sending signals in the form of “instruction” hormones to each of the other glands in the body so they know what to do.
The hypothalamus releases a hormone called Gonadotropin Releasing Hormone (GnRH), in a pulsed fashion. GnRH is an instruction hormone that tells the pituitary to release Follicle Stimulating Hormone known as FSH and Luteinizing Hormone or LH.
The pituitary then sends these two “instruction” hormones to the ovaries where FSH instructs them to get follicles ready for ovulation and where LH finishes the job by triggering ovulation.
When ovulation happens, the follicle turns into a small vascular gland called the corpus luteum which produces progesterone. The progesterone slows down GnRH pulses, thus reducing LH and increasing FSH to get the next round of follicles ready for the next cycle.
Now, let’s move onto the pituitary gland.
One of the most common problems associated with the pituitary is high prolactin or hyperprolactinemia, the hormone that is supposed to be high during postpartum to facilitate milk production for breastfeeding.
High prolactin causes include stress (especially chronic high stress), thyroid disorders, estrogen dominance/excess estrogen, blood sugar instability, head trauma/traumatic brain injury (TBI) and even the use of certain antidepressants.
High prolactin inhibits GnRH production, which as I just described, will cause ovulation problems. Women with hyperprolactinemia most often experience menstrual irregularities like irregular cycles and amenorrhea, short luteal phases, lowered libido, dyspareunia (which is pain during or after intercourse), and galactorrhea (milk production).
Testing prolactin is an important step in determining causes for irregular or sporadic ovulation. What’s concerning is that elevated prolactin levels are associated with a number of autoimmune diseases like rheumatoid arthritis, Hashimoto’s thyroiditis, Sjogren’s Syndrome, multiple sclerosis and lupus. Essentially, prolactin plays a role in modulating the immune response and has an immunostimulatory effect. Through various mechanisms that are a little too complicated to describe here, hyperprolactinemia can be a promoter of autoimmunity. So the goal is to address the causes.
Next up are the adrenals.
Adrenals basically influence everything in the body! It’s important to know that an overproduction of stress hormones influences every stage of the ovulation process, from the hypothalamus to the ovaries themselves.
General ongoing life stress wreaks havoc on our ability to ovulate consistently.
Now let’s chat about the thyroid.
Thyroid disorders cause all manner of menstrual disorders, like heavy periods, long periods, short menstrual cycles, irregular cycles or infrequent periods, spotting, short or scanty periods, and amenorrhea (missing periods).
Thyroid hormones support pituitary hormone production, they influence ovarian function (they support growth of ovarian follicles and ovarian hormone production) and they support healthy levels of GnRH and SHBG (sex hormone binding globulin), both of which will disrupt ovulation if imbalanced. Thyroid plays a critical role in menstruation.
And finally, let’s talk ovarian problems.
One of the conditions I’ve seen rising amongst my clients is something called primary ovarian insufficiency (POI) also known as premature ovarian failure (POF). Put simply, this is premature menopause or when one’s ovaries stop working properly before the age of 40. There are multiple causes, including genetic, autoimmune and medical treatment-induced (e.g. chemotherapy or radiation).
What’s essential to know is that POI can happen at any time during the menstrual life cycle, so it must be considered when assessing someone with extremely long menstrual cycles, anovulatory cycles, and amenorrhea. Women have been put on the birth control pill at such a young age and when they come off they’re diagnosed with this condition. So it’s hard to determine the cause of it because their cycle has been effectively shut down for a long period of time.
Moving on, we have Polycystic Ovary Syndrome. It affects over one hundred million women worldwide, making it the most common endocrine disorder in women of reproductive age and the leading cause of ovulatory infertility.
It is not just about ovarian cysts as we have been led to believe, but rather PCOS is a complex inflammatory endocrine disorder that has a systemwide effect, impacting the hypothalamus and pituitary, the thyroid, adrenals and ovaries.
This condition is traditionally treated with hormonal contraceptives, which is hugely detrimental to the person with PCOS because the OCPs only mask the underlying causes.
As you can see, there are dozens of conditions or pathologies that can disturb ovulation. This is why we need to prioritize ovulatory cycles making sure ovulation is occurring.
The most important points to take away are:
As you can see, charting our cycles can give us valuable information about our menstrual health and why our menstrual health can be a guideline to overall health and wellness.
Ovulation is a vital bodily function that anyone of childbearing age needs to experience regularly, pregnancy aspirations or not. Ovulation that occurs on a consistent basis is the driver for sufficient levels of estradiol (the body’s most potent form of estrogen) and progesterone, both of which are the two key female sex hormones. While these two hormones are mostly known for their role in the menstrual cycle and reproduction, they actually play significant roles in other bodily functions too. In a nutshell, the estrogen and progesterone that are generated as a result of the ovulatory process support:
- Brain health and cognitive function (estrogen and progesterone are your brain’s friends, which is partially why hormonal birth control is tied to major mood disorders)
- Sleep regulation (oftentimes women in menopause or in low estrogen states can’t sleep well), and progesterone also supports quality sleep
- Bone density (same as above – women in low estrogen and progesterone states like menopause, amenorrhea after being on the pill or premature ovarian failure are at serious risk for bone-related problems)
- Heart health (heart disease is tied to low estrogen states)
- Breast and uterine health - progesterone protects both from cancer
- Vaginal health - estrogen supports vaginal microbiome diversity, vaginal tissue health and lubrication via cervicovaginal fluid, all of which creates a healthy defense against pathogens and infections
- Skin and hair - estrogen plays a crucial role in skin thickness, firmness, elasticity and hydration as well as hair follicle health. You might notice your skin looks better in the leadup to ovulation, and this is likely why. Both estrogen and progesterone control melanin production, so when they are in balance, skin stays even toned. Progesterone actually reduces melanin production, thus reducing the chance of melasma and other skin pigmentation-related disorders.
This is just a snapshot of the ways in which ovulation is vital to our overall health throughout the menstrual life cycle, meaning from puberty until the end of perimenopause. Consistent ovulation should be a non-negotiable throughout our lives.
Traditional medicine has focused on periods as being the main event of the menstrual cycle, but they aren’t. They may get the most attention because of all the pain and suffering they cause, but it is actually ovulation that is the star of the show, not our periods. While regular menstrual cycles are considered a sign that everything is in working order, it is important to know that these cycles can be anovulatory, meaning that ovulation has not occurred and the ovaries are not properly functioning. This is misleading and it’s why ovulation must be recorded as part of tracking one’s menstrual cycle, because as I said earlier, regular ovulation is a barometer of your overall health status. If regular ovulation isn’t happening, this is a sign of underlying health conditions that must be investigated.
Ovulation disruption and menstrual problems can be caused by multiple external and internal factors, all of which play a role in the following endocrine-related conditions:
- Hypothalamic and pituitary problems
- Adrenal problems
- Thyroid problems, and
- Ovarian problems
Let’s begin with the hypothalamic and pituitary.
I want you to think of the hypothalamus and pituitary glands (which are regions in your brain) collectively as “hormonal headquarters”, sending signals in the form of “instruction” hormones to each of the other glands in the body so they know what to do.
The hypothalamus releases a hormone called Gonadotropin Releasing Hormone (GnRH), in a pulsed fashion. GnRH is an instruction hormone that tells the pituitary to release Follicle Stimulating Hormone known as FSH and Luteinizing Hormone or LH.
The pituitary then sends these two “instruction” hormones to the ovaries where FSH instructs them to get follicles ready for ovulation and where LH finishes the job by triggering ovulation.
When ovulation happens, the follicle turns into a small vascular gland called the corpus luteum which produces progesterone. The progesterone slows down GnRH pulses, thus reducing LH and increasing FSH to get the next round of follicles ready for the next cycle.
Now, let’s move onto the pituitary gland.
One of the most common problems associated with the pituitary is high prolactin or hyperprolactinemia, the hormone that is supposed to be high during postpartum to facilitate milk production for breastfeeding.
High prolactin causes include stress (especially chronic high stress), thyroid disorders, estrogen dominance/excess estrogen, blood sugar instability, head trauma/traumatic brain injury (TBI) and even the use of certain antidepressants.
High prolactin inhibits GnRH production, which as I just described, will cause ovulation problems. Women with hyperprolactinemia most often experience menstrual irregularities like irregular cycles and amenorrhea, short luteal phases, lowered libido, dyspareunia (which is pain during or after intercourse), and galactorrhea (milk production).
Testing prolactin is an important step in determining causes for irregular or sporadic ovulation. What’s concerning is that elevated prolactin levels are associated with a number of autoimmune diseases like rheumatoid arthritis, Hashimoto’s thyroiditis, Sjogren’s Syndrome, multiple sclerosis and lupus. Essentially, prolactin plays a role in modulating the immune response and has an immunostimulatory effect. Through various mechanisms that are a little too complicated to describe here, hyperprolactinemia can be a promoter of autoimmunity. So the goal is to address the causes.
Next up are the adrenals.
Adrenals basically influence everything in the body! It’s important to know that an overproduction of stress hormones influences every stage of the ovulation process, from the hypothalamus to the ovaries themselves.
General ongoing life stress wreaks havoc on our ability to ovulate consistently.
Now let’s chat about the thyroid.
Thyroid disorders cause all manner of menstrual disorders, like heavy periods, long periods, short menstrual cycles, irregular cycles or infrequent periods, spotting, short or scanty periods, and amenorrhea (missing periods).
Thyroid hormones support pituitary hormone production, they influence ovarian function (they support growth of ovarian follicles and ovarian hormone production) and they support healthy levels of GnRH and SHBG (sex hormone binding globulin), both of which will disrupt ovulation if imbalanced. Thyroid plays a critical role in menstruation.
And finally, let’s talk ovarian problems.
One of the conditions I’ve seen rising amongst my clients is something called primary ovarian insufficiency (POI) also known as premature ovarian failure (POF). Put simply, this is premature menopause or when one’s ovaries stop working properly before the age of 40. There are multiple causes, including genetic, autoimmune and medical treatment-induced (e.g. chemotherapy or radiation).
What’s essential to know is that POI can happen at any time during the menstrual life cycle, so it must be considered when assessing someone with extremely long menstrual cycles, anovulatory cycles, and amenorrhea. Women have been put on the birth control pill at such a young age and when they come off they’re diagnosed with this condition. So it’s hard to determine the cause of it because their cycle has been effectively shut down for a long period of time.
Moving on, we have Polycystic Ovary Syndrome. It affects over one hundred million women worldwide, making it the most common endocrine disorder in women of reproductive age and the leading cause of ovulatory infertility.
It is not just about ovarian cysts as we have been led to believe, but rather PCOS is a complex inflammatory endocrine disorder that has a systemwide effect, impacting the hypothalamus and pituitary, the thyroid, adrenals and ovaries.
This condition is traditionally treated with hormonal contraceptives, which is hugely detrimental to the person with PCOS because the OCPs only mask the underlying causes.
As you can see, there are dozens of conditions or pathologies that can disturb ovulation. This is why we need to prioritize ovulatory cycles making sure ovulation is occurring.
The most important points to take away are:
- Ovulation is a crucial part of female health
- Sex hormones are responsible for a whole lot more than just reproduction
- GnrH is the firestarter hormone - it kicks off the ovulatory process, and
- Ovulation can be disrupted by a number of factors
As you can see, charting our cycles can give us valuable information about our menstrual health and why our menstrual health can be a guideline to overall health and wellness.
Four Phases of the Menstrual Cycle and the Hormone Fluctuations That Drive the Phases
The Four Phases of Your Menstrual Cycle
Female bodies are cyclical by nature, producing varying quantities of sex hormones at different points in our monthly menstrual cycle—namely, estrogen, progesterone, and testosterone.
Other hormones, such as follicle-stimulating hormone (FSH), luteinizing hormone (LH), anti-Müllerian hormone (AMH), prolactin , oxytocin , and cortisol, as well as neurotransmitters such as serotonin, epinephrine, and dopamine, also fluctuate during this cycle.
These hormones are all directly and indirectly responsible for four distinct phases of the menstrual cycle. Yes, our bodies are constantly ebbing and flowing, and each phase of the monthly cycle brings about significant physical and emotional changes.
For women and menstruators who are getting their period roughly every 25 to 35 days, this occurs on an almost weekly basis. Yes, that is correct, we are basically different people every week of our cycles. But contrary to what society says, this is not a bad thing! For those with longer cycles, the follicular phase will be longer and for those with shorter cycles, the follicular and/or the luteal phases could be shorter.
Mastering our internal rhythms is the key to feeling more connected to our bodies and generally, the first step to solving a lot of the physical and emotional complaints associated with our cycles. This knowledge will help prepare you for your own natural ebbs and flows and will provide important clues about whether your hormones are functioning the way they are supposed to in the various phases.
Phase 1: The Bleeding Phase (Menstruation)
Let’s start with phase 1, the bleeding phase, also known as menstruation. Day 1 of your menstrual cycle is the first day of bleeding. On average, the bleeding phase lasts about 3 to 7 days. Right before your period, progesterone levels plunge, causing the breakdown and shedding of the uterine lining. As menstruation gets underway, estrogen and progesterone are at the lowest they will be in the entire cycle, with progesterone staying low until ovulation occurs.
The cervix, the cylindrical-shaped tissue that connects the vagina and uterus, changes position throughout the cycle. In this first phase, it is firm to the touch, sort of like the tip of your nose; in a low position; and slightly open to allow menstrual blood to pass through.
The bleeding phase also marks the first half of the follicular phase - I call it the menstruation part of the follicular phase. At this point, the region of the brain known as the hypothalamus has already been secreting gonadotropin-releasing hormone (GnRH) since a few days before the end of your last cycle. Remember from the last lecture, GnRH instructs the pituitary gland (the “master endocrine gland”) to release follicle-stimulating hormone or FSH.
The FSH has been communicating with the ovaries to start recruitment of a handful of ovarian follicles, each of which is a little balloon-like sac that contains a single egg.
So, between days 1 and 4, while we are on our periods, FSH continues to stimulate the follicles.
If you are testing your FSH, this is why it would be tested between days 2 and 4, to see whether it is at the appropriate level to be doing the all important job of stimulating the follicles on the ovary. This is the baseline level of FSH. Additionally, estrogen is supposed to be low at this time in the cycle, which helps get an accurate picture of FSH levels because higher estrogen will artificially suppress FSH.
Between days 5 and 7, just as menstruation is wrapping up for most of us, one follicle from the selected group is chosen. The rest of the follicles in the group will disintegrate.
Phase 2: The Follicular Phase
Now we’re moving into the non-menstruation half of the follicular phase, which is the time in the menstrual cycle when the ovaries continue preparing for ovulation.
It’s the length of the follicular phase that varies and will determine how long an actual menstrual cycle is. Once you ovulate, you’ll have a pretty good idea of when your period is coming.
Cells on the outside of the follicles produce androgens. These androgens are then converted into estradiol by the granulosa cells, which are on the inside of the follicle. This happens because FSH activates something called the aromatase enzyme in the granulosa cells, which converts these androgens to estrogens.
This is how the maturing follicles produce estradiol in increasing amounts. These higher levels of estradiol send a signal back to the hypothalamus to say all is well in ovary land, and the follicles are growing as they should.
As estradiol continues its ascent, it signals the hypothalamus to tell the pituitary gland to slow down FSH production and crank up luteinizing hormone production. Rising LH stimulates production of androstenedione and testosterone. Androstenedione will be converted to estrone and then estradiol. This ensures a steady supply of estrogen so that there is enough to trigger ovulation.
High prolactin levels actually decrease androgen conversion to estrogen in the ovary, causing higher androgens and lower estrogen. This becomes problematic because without a high enough level of estrogen, there won’t be the LH surge which kicks off ovulation. This is the mechanism by which elevated prolactin would prevent ovulation from occurring.
Around day 8 of the menstrual cycle, or halfway through the follicular phase, that chosen follicle dominates.
Now let’s talk about what is happening with cervical fluid during all of this hormone hullabaloo. As ovulation approaches, estrogen also prepares the uterus for pregnancy, thickening the blood vessels of the uterine lining. The cervix gradually moves higher in the vaginal canal and opens. And as for cervical fluid, after your period, you may notice little to no cervical fluid and a “dry” vaginal sensation. In other words, when you touch your vulva it feels only slightly moist, and when you wipe yourself it feels dry.
However, as estrogen builds during the follicular phase and stimulates the cervical crypts, you’ll start to see more cervical fluid and it begins to take on a wetter consistency, often looking pasty, creamy, or like lotion initially. And then as you approach ovulation it will change and become even more wet. You are most fertile in the second half of the follicular phase leading up to ovulation, and a barrier method of birth control should be used during this time if you are not planning to get pregnant. Consequently, this would be the time to have sex if you’re wanting to get pregnant. After ovulation, progesterone will take over and will make cervical fluid more sticky or tacky or even dry it up for the most part.
Phase 3: The Ovulatory Phase
Contrary to popular belief, ovulation, not menstruation, is the star of the menstrual cycle show. The ovulatory phase is the shortest phase, but it’s the one that packs the biggest hormonal punch, because ovulation is the driver of all the hormone production throughout the cycle. Essentially, it is the culmination of all the hard work your body has been doing throughout the follicular phase.
Estradiol levels continue to rise in parallel to the size of the maturing dominant follicle and the increasing number cells. A dramatic rise in estradiol from the maturing follicle tells the hypothalamus to trigger the mid-cycle LH surge from the pituitary that is needed to initiate ovulation.
An interesting fact. In order for the level of estradiol to reach the threshold that is needed to initiate the LH surge, the dominant follicle is almost always over 15mm in diameter when measured on ultrasound. Additionally, estradiol levels must be greater than 200pg/mL for approximately 50 hours in order for the LH surge to occur. These can be helpful pieces of information for those who are trying to get pregnant.
The LH surge starts about 35-44 hours prior to ovulation, and it typically occurs between midnight and 8am.
The start of the LH surge can be a good predictor for when ovulation will take place. However, it doesn’t mean ovulation will actually happen. There are times when LH rises but never reaches its peak, so ovulation doesn’t occur and then the body will likely try again to ovulate.
The LH surge will induce luteinization cells in the ovary, which, put simply, leads to the production of progesterone and ultimately, the formation of the corpus luteum once the egg is released.
Once an egg is released, it is viable for twelve to twenty-four hours. At this point, your cervix becomes soft, it moves up higher in the vaginal canal, and opens. In preparation for the sperm, your cervical fluid transforms into what is known as fertile-quality cervical fluid, becoming clear (aka translucent) and viscous (think raw egg white) and highly elastic or very wet and watery.
Phase 4: The Luteal Phase
Now we’re moving onto the luteal phase. This phase typically ranges from 11 to 17 days but is about 12 to 14 days in most women. When the luteal phase fits into this range, it’s considered to be a fertile cycle. The luteal phase is dominated by the hormone progesterone.
The length of the luteal phase is based entirely on how long the corpus luteum (the follicle that released the egg) maintains its progesterone production.
There is a condition known as Luteal Phase Deficiency, which is when a luteal phase is less than 9 days long. It is characterized by insufficient progesterone exposure to maintain the endometrium and allow for implantation of an embryo.
Generally speaking, a luteal phase needs to be at least 10 days long in order for that particular cycle to be considered a fertile cycle. This is because the egg (if it has been fertilized) needs a certain amount of time to travel down the fallopian tube and implant into the progesterone-prepared endometrium. If the endometrium starts shedding before it gets there, or if there isn’t enough progesterone to make it receptive to the fertilized egg, then there will be no pregnancy.
After ovulation, FSH and LH levels decline, with LH remaining low for the rest of the cycle and FSH rising slightly before menstruation to get the next round of follicles ready. Estrogen continues its sharp decline, while progesterone continues its climb thanks to the corpus luteum’s progesterone output. Progesterone will stay high throughout the luteal phase.
Progesterone is a thermogenic, or heat-inducing, hormone, meaning it raises basal body temperature for the remainder of the luteal phase. This rise in temperature is an important indicator of whether you’ve ovulated. Progesterone also further prepares the endometrium for a possible pregnancy. It transforms cervical fluid from stretchy and wet to opaque and sticky, or less fluidlike. If examined under a microscope, it would appear to have a basket-weave texture, which serves as your vagina’s very own sperm barrier. This is why it is referred to as infertile cervical fluid, as it’s particularly hard for sperm to swim through at this stage.
During the second week of the luteal phase, estrogen makes one more appearance, in a last-ditch effort to further prepare the endometrium for pregnancy. Due to the higher estrogen, you may notice an increase in cervical fluid resembling that seen in the lead-up to ovulation. Keep in mind, this is not fertile-quality cervical fluid, so you can’t get pregnant during this time.
If the egg is fertilized, it starts producing human chorionic gonadotropin (hCG) hormone and continues to make its way down the fallopian tube to the uterus. The hCG will signal the corpus luteum to keep making progesterone as well as estrogen, to support a pregnancy in its early stages. The corpus luteum’s production of progesterone will support a pregnancy for approximately nine weeks before the placenta begins taking over fully. This usually happens somewhere between 7-10 weeks after conception.
If there is no pregnancy, the corpus luteum function begins to decline about 9 to 11 days after ovulation. But as I said before, the luteal phase can be as long as 17 days, although this rarely happens. The drop in estrogen and progesterone that follows the corpus luteum breakdown will tell the uterine lining it’s time to go, and then you will get your period.
Our bodies are so amazing!
Female bodies are cyclical by nature, producing varying quantities of sex hormones at different points in our monthly menstrual cycle—namely, estrogen, progesterone, and testosterone.
Other hormones, such as follicle-stimulating hormone (FSH), luteinizing hormone (LH), anti-Müllerian hormone (AMH), prolactin , oxytocin , and cortisol, as well as neurotransmitters such as serotonin, epinephrine, and dopamine, also fluctuate during this cycle.
These hormones are all directly and indirectly responsible for four distinct phases of the menstrual cycle. Yes, our bodies are constantly ebbing and flowing, and each phase of the monthly cycle brings about significant physical and emotional changes.
For women and menstruators who are getting their period roughly every 25 to 35 days, this occurs on an almost weekly basis. Yes, that is correct, we are basically different people every week of our cycles. But contrary to what society says, this is not a bad thing! For those with longer cycles, the follicular phase will be longer and for those with shorter cycles, the follicular and/or the luteal phases could be shorter.
Mastering our internal rhythms is the key to feeling more connected to our bodies and generally, the first step to solving a lot of the physical and emotional complaints associated with our cycles. This knowledge will help prepare you for your own natural ebbs and flows and will provide important clues about whether your hormones are functioning the way they are supposed to in the various phases.
Phase 1: The Bleeding Phase (Menstruation)
Let’s start with phase 1, the bleeding phase, also known as menstruation. Day 1 of your menstrual cycle is the first day of bleeding. On average, the bleeding phase lasts about 3 to 7 days. Right before your period, progesterone levels plunge, causing the breakdown and shedding of the uterine lining. As menstruation gets underway, estrogen and progesterone are at the lowest they will be in the entire cycle, with progesterone staying low until ovulation occurs.
The cervix, the cylindrical-shaped tissue that connects the vagina and uterus, changes position throughout the cycle. In this first phase, it is firm to the touch, sort of like the tip of your nose; in a low position; and slightly open to allow menstrual blood to pass through.
The bleeding phase also marks the first half of the follicular phase - I call it the menstruation part of the follicular phase. At this point, the region of the brain known as the hypothalamus has already been secreting gonadotropin-releasing hormone (GnRH) since a few days before the end of your last cycle. Remember from the last lecture, GnRH instructs the pituitary gland (the “master endocrine gland”) to release follicle-stimulating hormone or FSH.
The FSH has been communicating with the ovaries to start recruitment of a handful of ovarian follicles, each of which is a little balloon-like sac that contains a single egg.
So, between days 1 and 4, while we are on our periods, FSH continues to stimulate the follicles.
If you are testing your FSH, this is why it would be tested between days 2 and 4, to see whether it is at the appropriate level to be doing the all important job of stimulating the follicles on the ovary. This is the baseline level of FSH. Additionally, estrogen is supposed to be low at this time in the cycle, which helps get an accurate picture of FSH levels because higher estrogen will artificially suppress FSH.
Between days 5 and 7, just as menstruation is wrapping up for most of us, one follicle from the selected group is chosen. The rest of the follicles in the group will disintegrate.
Phase 2: The Follicular Phase
Now we’re moving into the non-menstruation half of the follicular phase, which is the time in the menstrual cycle when the ovaries continue preparing for ovulation.
It’s the length of the follicular phase that varies and will determine how long an actual menstrual cycle is. Once you ovulate, you’ll have a pretty good idea of when your period is coming.
Cells on the outside of the follicles produce androgens. These androgens are then converted into estradiol by the granulosa cells, which are on the inside of the follicle. This happens because FSH activates something called the aromatase enzyme in the granulosa cells, which converts these androgens to estrogens.
This is how the maturing follicles produce estradiol in increasing amounts. These higher levels of estradiol send a signal back to the hypothalamus to say all is well in ovary land, and the follicles are growing as they should.
As estradiol continues its ascent, it signals the hypothalamus to tell the pituitary gland to slow down FSH production and crank up luteinizing hormone production. Rising LH stimulates production of androstenedione and testosterone. Androstenedione will be converted to estrone and then estradiol. This ensures a steady supply of estrogen so that there is enough to trigger ovulation.
High prolactin levels actually decrease androgen conversion to estrogen in the ovary, causing higher androgens and lower estrogen. This becomes problematic because without a high enough level of estrogen, there won’t be the LH surge which kicks off ovulation. This is the mechanism by which elevated prolactin would prevent ovulation from occurring.
Around day 8 of the menstrual cycle, or halfway through the follicular phase, that chosen follicle dominates.
Now let’s talk about what is happening with cervical fluid during all of this hormone hullabaloo. As ovulation approaches, estrogen also prepares the uterus for pregnancy, thickening the blood vessels of the uterine lining. The cervix gradually moves higher in the vaginal canal and opens. And as for cervical fluid, after your period, you may notice little to no cervical fluid and a “dry” vaginal sensation. In other words, when you touch your vulva it feels only slightly moist, and when you wipe yourself it feels dry.
However, as estrogen builds during the follicular phase and stimulates the cervical crypts, you’ll start to see more cervical fluid and it begins to take on a wetter consistency, often looking pasty, creamy, or like lotion initially. And then as you approach ovulation it will change and become even more wet. You are most fertile in the second half of the follicular phase leading up to ovulation, and a barrier method of birth control should be used during this time if you are not planning to get pregnant. Consequently, this would be the time to have sex if you’re wanting to get pregnant. After ovulation, progesterone will take over and will make cervical fluid more sticky or tacky or even dry it up for the most part.
Phase 3: The Ovulatory Phase
Contrary to popular belief, ovulation, not menstruation, is the star of the menstrual cycle show. The ovulatory phase is the shortest phase, but it’s the one that packs the biggest hormonal punch, because ovulation is the driver of all the hormone production throughout the cycle. Essentially, it is the culmination of all the hard work your body has been doing throughout the follicular phase.
Estradiol levels continue to rise in parallel to the size of the maturing dominant follicle and the increasing number cells. A dramatic rise in estradiol from the maturing follicle tells the hypothalamus to trigger the mid-cycle LH surge from the pituitary that is needed to initiate ovulation.
An interesting fact. In order for the level of estradiol to reach the threshold that is needed to initiate the LH surge, the dominant follicle is almost always over 15mm in diameter when measured on ultrasound. Additionally, estradiol levels must be greater than 200pg/mL for approximately 50 hours in order for the LH surge to occur. These can be helpful pieces of information for those who are trying to get pregnant.
The LH surge starts about 35-44 hours prior to ovulation, and it typically occurs between midnight and 8am.
The start of the LH surge can be a good predictor for when ovulation will take place. However, it doesn’t mean ovulation will actually happen. There are times when LH rises but never reaches its peak, so ovulation doesn’t occur and then the body will likely try again to ovulate.
The LH surge will induce luteinization cells in the ovary, which, put simply, leads to the production of progesterone and ultimately, the formation of the corpus luteum once the egg is released.
Once an egg is released, it is viable for twelve to twenty-four hours. At this point, your cervix becomes soft, it moves up higher in the vaginal canal, and opens. In preparation for the sperm, your cervical fluid transforms into what is known as fertile-quality cervical fluid, becoming clear (aka translucent) and viscous (think raw egg white) and highly elastic or very wet and watery.
Phase 4: The Luteal Phase
Now we’re moving onto the luteal phase. This phase typically ranges from 11 to 17 days but is about 12 to 14 days in most women. When the luteal phase fits into this range, it’s considered to be a fertile cycle. The luteal phase is dominated by the hormone progesterone.
The length of the luteal phase is based entirely on how long the corpus luteum (the follicle that released the egg) maintains its progesterone production.
There is a condition known as Luteal Phase Deficiency, which is when a luteal phase is less than 9 days long. It is characterized by insufficient progesterone exposure to maintain the endometrium and allow for implantation of an embryo.
Generally speaking, a luteal phase needs to be at least 10 days long in order for that particular cycle to be considered a fertile cycle. This is because the egg (if it has been fertilized) needs a certain amount of time to travel down the fallopian tube and implant into the progesterone-prepared endometrium. If the endometrium starts shedding before it gets there, or if there isn’t enough progesterone to make it receptive to the fertilized egg, then there will be no pregnancy.
After ovulation, FSH and LH levels decline, with LH remaining low for the rest of the cycle and FSH rising slightly before menstruation to get the next round of follicles ready. Estrogen continues its sharp decline, while progesterone continues its climb thanks to the corpus luteum’s progesterone output. Progesterone will stay high throughout the luteal phase.
Progesterone is a thermogenic, or heat-inducing, hormone, meaning it raises basal body temperature for the remainder of the luteal phase. This rise in temperature is an important indicator of whether you’ve ovulated. Progesterone also further prepares the endometrium for a possible pregnancy. It transforms cervical fluid from stretchy and wet to opaque and sticky, or less fluidlike. If examined under a microscope, it would appear to have a basket-weave texture, which serves as your vagina’s very own sperm barrier. This is why it is referred to as infertile cervical fluid, as it’s particularly hard for sperm to swim through at this stage.
During the second week of the luteal phase, estrogen makes one more appearance, in a last-ditch effort to further prepare the endometrium for pregnancy. Due to the higher estrogen, you may notice an increase in cervical fluid resembling that seen in the lead-up to ovulation. Keep in mind, this is not fertile-quality cervical fluid, so you can’t get pregnant during this time.
If the egg is fertilized, it starts producing human chorionic gonadotropin (hCG) hormone and continues to make its way down the fallopian tube to the uterus. The hCG will signal the corpus luteum to keep making progesterone as well as estrogen, to support a pregnancy in its early stages. The corpus luteum’s production of progesterone will support a pregnancy for approximately nine weeks before the placenta begins taking over fully. This usually happens somewhere between 7-10 weeks after conception.
If there is no pregnancy, the corpus luteum function begins to decline about 9 to 11 days after ovulation. But as I said before, the luteal phase can be as long as 17 days, although this rarely happens. The drop in estrogen and progesterone that follows the corpus luteum breakdown will tell the uterine lining it’s time to go, and then you will get your period.
Our bodies are so amazing!
Handouts and Resources
Action Items:
- Download each of the handouts and resources above
- Start to fill out the information in the 4 Phase Symptom Tracker - we will look at the info at the end of a month
- Start to implement the information in the downloads - we will review at next appointment
- Continue to to cycle tracking
- Continue to do affirmations, gratitudes, journal entries and food diary
- Do Pelvic Bowl exercise - you can use the MP3 or print the handout to use
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Join our Women's Health Facebook group and get extra support, ask questions and join in on the live Q&A sessions each month! We hold classes frequently on women's health where you can gather information on many topics.
