Female Fertility Finding Out Why Your Periods are Abnormal

Once we've ruled out uterine abnormalities and ovarian failure, we've confirmed that your periods are irregular because you are not ovulating (anovulation). For some reason your pituitary is not sending adequate amounts of LH and FSH to your ovaries. However, I have good news: the failure to ovulate, which affects 25 percent of infertile women, responds very well to treatment.

Symptoms of Anovulation
Although a few anovulatory women will have normal periods, most will have few or no periods at all (amenorrhea). Prolonged or heavy periods (menorrhagia), spotting during the middle of the cycle (metrorrhagia), and prolonged spotting may also occur. Women with anovulatory menstrual periods do not experience the typical menstrual discomforts often found in ovulatory women: breast soreness, mood changes, or cramping. The anovulatory woman's BBT chart will be flat (monophasic) and her cervical mucus will fern, indicating that progesterone (produced by the corpus luteum that forms after ovulation) never opposes the estrogen stimulation.

Tests Used to Determine the Cause of Anovulation
In the next phase of testing I try to determine why your pituitary gland is not stimulating your ovaries to ovulate. I need to answer a number of questions:

• Is your hypothalamus not "beating the drum" by producing regular pulses of GnRH?

   

• Is your pituitary gland damaged?

   

• Is your pituitary gland getting misleading feedback messages about ovarian function?

Several tests will give me the additional answers I need. Table 12-1, "Diagnostic Approaches for Irregular Menstrual Periods or Amenorrhea," and Table 12-2, "Hormonal Tests for Diagnosing the Cause of Anovulation," profile which tests I may order.

If You Are Ovulating If You Have Irregular Menstrual Periods or Amenorrhea

• Pregnancy test

   

• Basal body temperature (BBT)

   

• Cervical mucus smear

   

• Transvaginal ultrasound

   

• Progesterone withdrawal

If progesterone withdrawal does not result in a period:
      Administer estrogen and repeat progesterone withdrawal
  
If estrogen/progesterone withdrawal does result in a period:
      Cytology smear (to look at estrogen stimulation of vaginal cells)
      Estrogen blood test
      FSH test (if not elevated, may indicate pituitary 
         or hypothalamic failure)

If estrogen/progesterone withdrawal does not result in a period:
      Hysteroscopy (telescopic exam of uterine interior) 
      Hysterosalpingogram (uterine X ray)
      FSH test (if elevated, may indicate ovarian failure due to 
         genetic abnormality: may perform chromosome analysis)

Prolactin Pituitary Hormone
Excessive prolactin can suppress pituitary output (LH and FSH) and can act directly on the ovary to suppress follicular growth.

Thyroid Hormone
Hyper- and hypothyroidism can interfere with hormonal metabolism (the rate at which hormones are used up by the body) and with the delicate hormonal balance between the pituitary and ovary. In addition, through an intriguing mechanism (explained later) hypothyroidism may contribute to excess prolactin production.

FSH and LH Pituitary Hormones
Elevated FSH almost always indicates ovarian failure. If FSH and LH are depressed, I suspect one of three things: that a faulty hormonal feedback mechanism is inappropriately telling the pituitary to cut back production; that the hypothalamus is not "beating the drum" to stimulate the pituitary to function; or that a pituitary inadequacy prevents the gland from functioning normally.

Adrenal Androgens (DHEAS and Testosterone)
In the presence of excessive hair (hirsutism) or male secondary sex characteristics (enlarged clitoris or ambiguous genitalia), elevated male hormone (testosterone), elevated DHEAS, or elevated adrenal androgens may indicate a congenital enzymatic defect, polycystic ovaries, or a tumor in the pituitary gland, adrenal gland, or ovary. Testosterone or adrenal androgens can suppress ovulation as well as cause a number of other problems discussed later.

Solving the Mystery of Anovulation
Twenty percent of ovulation failures result from stress, obesity, diet excessive androgen production, thyroid gland dysfunction, or excess prolactin. In the sections that follow, I will explain how these conditions can be identified and treated to resolve fertility problems. Chapter 14 describes ovulation induction treatment, which I may use if you have idiopathic anovulation (unknown cause) and which I may also use with some of the conditions discussed below.

Coming Off the Pill
Let me lay one fear to rest. It's very unlikely that oral contraceptives cause amenorrhea or anovulation. Oh, but you say, when you stopped the Pill, your periods never returned. Or perhaps they returned but were irregular and spotty.

To that I must ask, "What were your periods like before you took the Pill?" Usually the answer is "My periods were irregular. But I've had regular periods ever since I began taking the Pill."

So what's happening? Oral contraceptives do suppress ovulation; however, your uterine lining continues to cycle between development and shedding. Can you guess why you have a period? You may already know that the Pill contains estrogen and progesterone. When you stop taking the Pill for one week each month, you experience estrogen and progesterone withdrawal, and so you begin to menstruate. Something else happens that's also logical. You don't cramp, you don't bloat, and you don't become depressed-and that's because you don't ovulate. (Women who do cramp and bloat on the Pill may have other problems, which should be discussed with their physician.)

Each year thousands of women go off the Pill, and within two to four months they begin ovulating. If it is their goal, they soon become pregnant. However, a few women stop the Pill and resume an abnormal menstrual pattern, which may indicate that they are not ovulating.

For some it's possible that a fertility problem arose while they were taking the Pill. The cyclical action of the Pill may have masked the symptoms (menstrual irregularities) until they stopped taking it. This is why some doctors recommend that you stop taking the Pill for a few months every couple of years: to see if everything is still working normally. I do not recommend this practice, however, since one frequent side effect of this procedure is pregnancy. To me it does not make any more sense to go off the Pill every couple of years than to stop using condoms to see if you can still get pregnant.

The few women who do become anovulatory as a direct result of using the Pill usually respond very well to ovulation induction treatment with clomiphene (Serophene/Clomid). (Chapter 14 describes how Serophene can be used to restore ovulation.)

Hypothalamic Malfunction
We suspect that a number of conditions may adversely affect hypothalamic performance: emotional stress, endorphins (nature's painkillers, which are synthesized by the brain in response to stress and pain), extreme exercise (amenorrhea athletica), dieting, poor nutrition, weight loss, low body fat, anorexia, and drugs, toxins, or medications. I discussed many of these conditions in chapter 9.

We cannot directly measure hypothalamic performance: we don't know for sure if the drum is beating. Sometimes, though, we can measure the results of insufficient hypothalamic stimulation. For example, we can test for low LH, FSH, and estrogen levels as described in Table 12-2. However, often the changes are too subtle to detect.

Except for estrogen, the test results for Kathy S., for example, were all normal. When I discovered this finding, I had to assume that, as a result of her excessive running (stress), Kathy's hypothalamus was not pulsing GnRH in a manner sufficient to stimulate her pituitary. As a result, her pituitary was not properly stimulating follicular growth, her ovaries did not produce enough estrogen, and she did not ovulate. When I prescribed Serophene to enhance her hypothalamic activity, she began to ovulate. You'll learn more about Kathy's experience with ovulation induction in chapter 14.

Pituitary Gland Malfunction
Hormones from the pituitary gland control a number of "chemical factories" throughout your body: your adrenal gland, your thyroid gland, and your ovaries, to mention a few. When your pituitary malfunctions, many different systems can break down. The single most common end result, however, is an excess production of prolactin (hyperprolactinemia).

Hyperprolactinemia
Nearly 10 percent of women with irregular periods and 20 percent of women with no obvious cause for amenorrhea have elevated prolactin levels. One-third of these women may have a milky discharge from their breasts (galactorrhea) and one-third of them will have a pituitary tumor (adenoma). Almost always benign, these tumors respond well to drug therapy (bromocriptine) and to surgery. You may wish to refer to Table 12-3, "Factors Causing Elevated Prolactin Levels," for an overview.

Excessive Exercise, Stress, or Suckling
Excessive stress and/or exercise may cause hyperprolactinemia. In addition, nursing a baby will release prolactin, nature's birth control hormone. When you stop nursing, relieve the source of your stress, or take Parlodel (bromocriptine), your prolactin levels will drop and ovulation will return. 

Hypothyroidism
When your thyroid hormone production drops below normal, an intriguing chemical process leads to excess prolactin. Your hypothalamus also controls thyroid hormone levels by producing TRH (thyroid-releasing hormone) which tells your pituitary to make TSH (thyroid-stimulating hormone). When your thyroid gland cannot respond to these chemical signals, your hypothalamus senses that there isn't enough thyroid hormone around, so it produces more TRH, saying, "Get to work. We need more thyroid hormone."

Due to a unique chemical association, TRH also tells your pituitary to release more prolactin. The excess prolactin not only interferes with pituitary function but also exerts a direct inhibitory effect on the ovary itself. Taking a thyroid supplement to quiet your hypothalamus will usually correct this chemical imbalance and restore ovulation.

Elevated Adrenal Androgens (DHEAS) We also find elevated adrenal androgens (male hormones) in one-third of women with excess prolactin. I'll discuss how these hormones can interfere with ovulation in the section on hormonal feedback below.

Severe Kidney Disease
Severe kidney disease, which impairs the body's ability to purify and filter the blood, may also result in the buildup of prolactin hormone. Dialysis, kidney transplants, or better management of the kidney disease may restore fertility to these women. The discussion on hepatorenal disease below will tell more about managing this disorder.

Medications
Certain medications may increase prolactin levels: phenothiazines and other tranquilizers; tricyclic antidepressants; methyldopa (Aldomet, an antihypertensive); Reserpine (antihypertensive); and narcotics. When these drugs are withdrawn, prolactin levels will return to normal. If you are concerned about a particular medication that you are taking, discuss it with your doctor.

Continued