Why Women Seek Functional Medicine PCOS Treatment

Many of my patients come to me looking for an alternative to the birth control prescription given to them by their OB/GYN. Others have friends or family with a PCOS diagnosis, and are wondering if that’s the reason for their own irregular and/or painful cycles. Some ladies worry if they’ll ever be able to have children, since PCOS has complicated their fertility, and still more patients come to me out of desperation—they’ve already worked with another “natural doctor” who had put them on an extremely restrictive diet and told them to lose weight. I have even heard of PCOS patients being prescribed gluten-free, dairy-free, low-carb, sulfur-free diets. Functional medicine PCOS treatment offers hope of realistic, sustainable treatment where most other providers give a grim prognosis or simply leave patients feeling overwhelmed.

In this post, we’ll be diving into the details about PCOS: what it is, what it isn’t, how it’s managed by most healthcare providers, functional medicine PCOS treatment strategies, and more. As a starting point, I encourage you to check out my fertility overview post (Female Fertility 101) if you aren’t familiar with the ins and outs of your menstrual cycle. That post lays the groundwork for understanding the status quo of periods, hormones, women’s health, and it’s important to understand these topics before we start talking about with cycles that fall outside of the norm. [Although it’s the most common, it’s not the only period problem faced by women. To learn more about what your period can tell you about your health, check out this post.]

What Is PCOS, and How Is It Diagnosed?

PCOS stands for Polycystic Ovarian Syndrome, one of the most common endocrine and metabolic disorders in women of reproductive age. The syndrome is defined by hormonal imbalances and ovarian dysfunction, and it’s diagnosed only after other causes for the patient’s symptoms have been ruled out (such as hypothalamic amenorrhea). Because of this, many women have to go through a frustratingly long and drawn out process in order to get answers for their health struggles. However, functional medicine PCOS treatment offers faster results because it gets to the root cause.

Functional Medicine PCOS Diagnosis

The name “polycystic ovarian syndrome” is a bit of a misnomer, because although ovarian cysts are common in PCOS patients, they aren’t part of the diagnostic criteria—many women with PCOS don’t have any cysts on their ovaries at all. Rather, a PCOS diagnosis is given when at least two of the three following criteria are met: [Reference]

• Hyperandrogenism (elevated androgen hormones, assessed via lab work)
• Anovulation or oligo-ovulation (absence of ovulation or infrequent ovulation, usually leading to irregular cycle length)
• Polycystic appearance of ovaries (assessed via ultrasound imaging)

The general consensus in the medical community is that a PCOS diagnosis should be given when a woman has either polycystic ovaries and/or irregular cycles in addition to high androgen levels on her blood work. When making the diagnosis, doctors are careful to rule out other causes of high androgens, such as adrenal disorders, thyroid disease, drug-induced androgen excess, and other hormonal disorders, as well as alternative causes for irregular cycles.

Types of PCOS

PCOS patients typically fall into two different categories: insulin resistant, and non-insulin-resistant types. As is the case with most hormonal disorders, more than one level is out of balance. The vast majority of women who suffer from PCOS also present with insulin resistance, glucose intolerance, dyslipidemia, and elevated levels of inflammation. Part of what makes treating PCOS so complex is that these hormonal imbalances feed off of each other: elevated insulin levels trigger a feedback loop via the HPATG axis that leads to further androgen levels, and vise-versa. Apart from the insulin resistance piece, functional medicine PCOS diagnosis further divides PCOS into 4 separate categories which you can read about here.

Symptoms of PCOS

The symptoms experienced by women with PCOS vary because not everyone meets the same diagnostic criteria, and the extent of those experiences can vary too. Some women experience only mild elevations in androgens, and symptoms are consequently lesser. Women who have cysts on their ovaries often experience pain related to the formation and/or rupture of cysts, which are symptoms that wouldn’t be experienced by women who do not have cysts. Likewise, symptoms for women who concomitantly deal with insulin resistance face different symptoms than women who do not.

• Symptoms Related to Excess Androgens
  • Excessive hair growth (face, chest, back, buttocks)
  • Thinning hair
  • Oily skin
  • Cystic acne
• Symptoms Related to Anovulation/Olig-ovulation
  • Long cycles (more than 35 days) or irregular cycle lengths
  • Difficulty conceiving or repeated miscarriages
  • Abnormal uterine bleeding
• Symptoms Related to Polycystic Ovaries
  • Painful periods and/or pelvic pain
  • Sudden, intense abdominal pain resulting from ruptured cysts
• Symptoms Related to Insulin Resistance
  • High blood pressure and/or high cholesterol
  • Fatigue after meals
  • Weight gain, especially in the abdominal area
  • Dark patches of skin, particularly along neck creases, in groin and under breasts (this is called ancanthosis nigricans)
  • Skin tags

Due to the fluctuating hormones, many women also experience generalized symptoms related to hormonal imbalances, which include (but are not limited to): fatigue, insomnia, anxiety, depression, headaches, etc.

Functional Medicine PCOS (Causes and Treatment)

The root cause isn’t really known. The current understanding is that it’s a mixture of genetic predisposition and environmental triggers, but other theories include nutritional conditions in the uterus, prenatal exposure to androgens, insulin resistance on an and more [reference]. Because of this, most treatments focus on managing symptoms—painful periods, irregular cycles, insulin resistance, etc. Hormonal contraceptive use also can induce a reversible type of PCOS, but the symptoms can continue for months or even years (called “post-pill PCOS”).

On a physiological level, we know that elevated androgens and insulin resistance result from dysfunction in the hypothalamic-pituitary-adrenal-thyroid-gonadal axis. In women with PCOS, the pituitary gland releases higher-than-normal levels of luteinizing hormone (LH), which stimulates the ovaries to produce more testosterone than usual. (Ovaries normally produce some testosterone, but problems result when they produce too much.) This over-stimulation of the ovaries by luteinizing hormone also cancels out the mid-cycle LH surge that typically triggers ovulation.

Pituitary Hormones and PCOS

At the same time, the pituitary gland releases lower-than-normal levels of follicle-stimulating-hormone, which prevents eggs from reaching full maturity. When this happens, the follicle does not release the egg (ovulation does not occur, AKA anovulation). The immature egg either dissolves, or remains in the follicle, forming a cyst. Since the follicular remnant after ovulation (called the corpus luteum) is responsible for producing progesterone during the luteal phase, many women experience additional symptoms related to low progesterone levels. (Read more about luteinizing hormone, follicle-stimulating hormone, progesterone, and the luteal phase in this post: Female Fertility 101)

The Birth Control Pill and PCOS

Most OB/GYNs prescribe oral contraceptives as a first line of treatment for PCOS, because the artificial hormones suppress the natural cycling of luteinizing hormone, follicle-stimulating hormone, estrogen, progesterone, and testosterone. The simulated hormonal environment causes the endometrial lining to develop and shed as it would in a natural period, but it take the ovaries out of the equation: no egg matures, no egg is released, and fertility is not possible.

My goal as a functional medicine doctor is to promote the natural fertility of my patients, empowering them to have healthy cycles rather than suppress the normal functioning of their bodies. That being said, sometimes the healthiest thing for a patient and her values is to reduce the pain, control the hormonal dysfunction, and reach a place where she feels that her health is manageable. If that means medication, that’s okay—the most important thing is that she is able to manage her wellbeing according to her values.

Prescription Medications for PCOS

Another medication used in the treatment of PCOS is spironolactone, which is typically used as a diuretic drug for individuals with cardiovascular disease. However, this drug also has a secondary effect of reducing androgen levels in the body, which can be helpful in controlling irregular bleeding, hair growth, and other symptoms of high androgens in women with PCOS. Like birth control pills, using spironolactone targets hormonal pathways of PCOS without addressing the root cause. This is where functional medicine treatment for PCOS can fill a huge gap and meet a huge need.

The third medication that is used in the management of PCOS is metformin, which is a drug typically given to patients with diabetes. Metformin improves insulin resistance, which can be helpful in the treatment of PCOS because of the amplifying effect that insulin plays in the production of testosterone. When insulin sensitivity improves, often testosterone levels follow suit. You can read more about the use of metformin as a fertility drug (and natural alternatives) in this post.

Functional Medicine Treatment for PCOS: Lifestyle & Supplements  

Most of my patients come to me because they are looking to avoid the use of prescription drugs in managing their fertility. If that describes you too, keep reading!

1. Lifestyle Factors for Balancing Hormones: The #1 thing we can do to support hormonal balance is building a foundation for well-being. This means taking nutrition, rest, exercise, stress management, and psychological/emotional health into account. Neglecting even one of these areas can create huge interruptions in the HPATG axis, making symptoms of PCOS and other hormonal disorders so much worse. These lifestyle factors include eating enough (in terms of calories, macronutrients, and micronutrients) as well as eating frequently enough to keep blood sugar stable. It also involves balancing exercise and rest to prevent elevations in cortisol, the stress hormone, which interrupts the production of sex hormones like progesterone. This is part of the reason why stress management, sleep hygiene, and social support are so important.
2. Eating a Diverse Diet:Gut health is a huge topic in the media lately, and research continues to show that the best way to support GI health and microbiological diversity is to eat a varied diet, with many different types of plant foods and fibers. The more restrictive our diet (limiting the types of foods we eat to just a few varieties), the more likely we are to disturb our gut microbiome, which plays a huge role in balancing our hormones. (Did you know that bacteria both produce and metabolize hormones When we disturb our gut microbiome, it affects our bodies ability to make hormones as well as clean out the old, broken down ones.) Gut health also helps modulate blood sugar control, which is an important consideration in insulin-resistant PCOS. Check out this study to learn more about the relationship between PCOS and the gut microbiome.
3. Micronutrient Balance: Research has shown that women with PCOS tend to follow certain patterns of vitamin deficiencies, including vitamin D and B vitamins (especially folic acid). Vitamin D plays an important role in supporting the thickness of the endometrial lining, which is often depleted in women with PCOS due to low progesterone levels. Likewise, B vitamins such as folic acid play an important role in follicular maturation, and supplementing with elvels at 700 μg/day can support successful ovulation. Other nutritional deficiencies have also been identified in the majority of women with PCOS, including calcium, zinc, selenium, and chromium. [Reference] While the best way to prevent nutrient deficiencies such as these is to eat a varied and balanced diet (and avoid restriction of food groups of calories), some women may benefit from using supplements—especially Vitamin D. Studies have also shown that supplementing with omega-3 fatty acids, such as those found in cod liver oil, prevent excess inflammation, help manage dysglycemia, and support hormonal balance in women. [Reference]
4. Evidence-Based Supplements:
   1. Inositol: Inositol is a type of sugar alcohol that has been shown to improve insulin sensitivity, lipid synthesis, hormonal signaling, and maturation of oocytes (female eggs) during the follicular phase. Supplementation of inositol in women with PCOS lowers androgen levels, improves insulin sensitivity, and increases rates of ovulation in women with anovulatory cycles. Supplementation is effective when administered in ratios of 40:1 of myo-inositol to D-chiro-inositol, at levels of 4000 mg per day in conjunction with 400 μg of folic acid.
   2. Alpha-Lipoic Acid: This chemical is a free-radical scavenger, meaning that it prevents premature breakdown of biochemicals and hormones in the blood stream. Studies show that supplementation with alpha-lipoid acid decreases prevalence of ovarian cysts and increases progesterone levels in women with PCOS.
   3. Melatonin:While this hormone is typically thought of as a supplement for promoting sleep, it is not a sleeping pill, but rather a hormone. (There are many reasons to avoid using melatonin as a sleep aid, but that’s a topic for another post.) When used in women with PCOS, supplementation at night has been shown to improve ovulation rates, corpus luteum formation, progesterone levels, and pregnancy rates for those who are trying to conceive. Melatonin supplementation also decreases hirsutism and androgen levels when used at 10 mg/night.
   4. Black Cohosh: As described in this post about fertility drugs, research has shown that dosing 20 mg daily of black cohosh at the beginning of the cycle modulates the LH surge during the follicular phase, improving rates of ovulation. This supplement also results in higher progesterone levels during the luteal phase, improving the thickness of the endometrial lining and supporting a luteal phase that is long enough for implantation and pregnancy in women who are trying to conceive.

Closing thoughts…

As if the symptoms of PCOS aren’t difficult enough, the journey towards a diagnosis to explain the symptoms, and finding a treatment strategy that works for you in the context of your own life can add enormous loads of stress to an already challenging life experience. There is a whirlwind of information out there, which only adds to the confusion and frustration of trying to manage your health. It can be a lonely and scary place, but I want you to know that you’re not alone. Consider making an appointment with a functional medicine doctor who can deliver personalized care and help you achieve your health goals.

I’m Dr. Alexandra MacKillop, a functional medicine doctor, food scientist and nutrition expert.

I specialize in women’s nutrition & hormonal health, addressing concerns like longevity, fertility, postpartum, PCOS, endometriosis, and gut symptoms like bloating, constipation, diarrhea and more.

If you’re looking for a new way to approach your health, I’m here to help you through it.

Become a Patient

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Sign Me Up!

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Want more Grab a copy of my new book, The Postpartum Check-In !

Reminder: The information on this post or anywhere else on this blog or other writing is purely educational, and is not intended to diagnose, treat, prevent, or cure any health condition.

The post Functional Medicine PCOS Treatment appeared first on Dr. Alexandra MacKillop.

Progesterone is a tiny molecule that plays a big role in the hormonal picture. When levels start to go awry, our health and well-being suffers. Understanding how our hormones affect wellness is not only an important tool for self-care, but this knowledge also gives us the power to advocate for ourselves so we can access the care we deserve. Whether your goal is to regulate your cycle, conceive and carry a healthy pregnancy, reduce the long-term risks associated with hormonal imbalances, or just gain some good, old-fashioned information about how your body was designed, read on!

Hormones throughout Your Cycle

Throughout the female cycle, two hormones tend to be held responsible for triggering key events such as ovulation and the start of a period:

• In the first half of the cycle, estrogen rises and falls, correlating with a hormonal signal from the brain that triggers the release of an egg.
• Following ovulation, the corpus luteum produces progesterone, which is responsible for thickening the uterine lining in anticipating of pregnancy.
• After about seven days, progesterone levels peak and begin to steadily decline; once they drop low enough, the lining starts to shed, signaling the start of a period and another cycle.

When progesterone levels drop too low, or aren’t produced in a functional ratio in comparison to other sex hormones like testosterone and estrogen, our health suffers. Chronically low progesterone can increase risk of osteoporosis, poor blood sugar control and diabetes, breast cancer, depression, anxiety, and other neurocognitive disorders. Low progesterone also leads to symptoms such as:

• Migraines
• Absent or irregular periods
• Bleeding or spotting between periods
• Low libido
• Recurrent miscarriages
• Painful periods
• Insomnia
• Luteal phase defect
• Infertility
• and more…

What Causes Progesterone Deficiency?

The production of progesterone from the ovaries is regulated by the hypothalamic-pituitary-gonadal axis, a delicate web of signals between the brain and reproductive organs. Progesterone deficiency can result from interruptions along the entire axis, whether from a signaling problem at the brain level, or from dysfunction of the ovaries themselves. One of the most common reasons for low progesterone is chronic stress. Elevated stress hormones create a negative feedback loop that interrupts the signaling between the brain and ovaries, decreasing progesterone production. In many cases, especially with women who are over-exercising or under-eating, stress acts on the HPG axis to prevent ovulation altogether. Without ovulation, the corpus luteum doesn’t form, and the main mechanism for producing progesterone during the luteal phase is completely taken out of the picture.

Here are a few other reasons for low progesterone:

• Adrenal dysfunction
• Perimenopause
• Vitamin deficiencies
• PCOS
• Low body fat
• High prolactin (such as in breastfeeding women)
• Calorie or carb-restricted diet
• Too much exercise (especially high-intensity or weight training)
• Use of contraceptives containing synthetic progestins
• Oophorectomy (surgical removal of ovaries)
• Hypothyroidism
• Inflammation
• Estrogen Dominance (creating a relative progesterone deficiency)

What to Do About Progesterone Deficiency

As with any hormonal imbalance, effective treatment starts with identifying the root cause. This is why it’s so important to work with a naturally-minded healthcare provider to review diagnostic tests and lifestyle/history to get to the bottom of the progesterone deficiency. If undereating is the driving force behind low progesterone, for example, no amount of vitamins or supplements will effectively solve the problem. The nutrition (and the relationship with food) needs to be addressed, first!

Note: I explain the details of what is and isn’t normal and how to explore natural treatment options in my book, Go with Your Flow. Click here to learn more.

Once an appropriate diagnosis is made and healing efforts are underway, there are a number of steps that can be taken to help the body natural restore progesterone production, balance out the production of estrogen, and get the hormone levels back to a functional status quo.

Lifestyle

Diet and Exercise: Overdoing it in the gym and under eating are the main forces behind low progesterone. These create a state of allostatic overload, lowering progesterone output or altogether inhibiting ovulation—a condition called hypothalamic amenorrhea. When I’m working with a patient whose history and labs point to progesterone deficiency, the first place I start is with cutting back on exercise, and upping her intake of carbohydrates and fats. Hormones are produced from fat and cholesterol, so adding in foods like eggs, butter, and oily fish are essential. Carbs are also extremely important for women, and we can’t menstruate without them. Low-carb and calorie-restricted diets also affect production of all kinds of other hormones, including thyroid, immune, metabolism, and more.  

Stress: In my clinical experience, the most common cause of hormonal imbalances among women are related to stress. Whether that source of stress is emotional, relational, physical, nutritional, or otherwise, stress management is key. Progesterone and cortisol are both produced from the same hormonal precursor, called pregnenolone. When stress levels are high, the body allocates its resources towards producing cortisol, which means there aren’t many leftovers for producing progesterone. (This is called pregnenolone steal.) The end result is a low progesterone level. Stress also inhibits the HPG axis at the brain level, preventing the LH surge that triggers ovulation. Without ovulation, it’s impossible for progesterone levels to remain high enough for health and fertility.

Sleep: Sleep and stress go hand in hand. When we aren’t sleeping enough, cortisol production goes into overdrive, creating all the problems described above. Lack of sleep also distorts the circadian rhythm, changing the natural patterns of sleep hormones and neurotransmitters that regulate cyclical patterns in the body—everything from the sleep/wake cycle to the menstrual cycle. Lack of sleep also tends come along with over-use of stimulants such as caffeine and nicotine, which create their own subset of hormonal fallout.

Progesterone has a reciprocal relationship with sleep deprivation. Since one of the roles of progesterone is to create a feeling of calm and relaxation, low progesterone can feed forward into insomnia symptoms, furthering the degree of sleep disruption and deprivation. Targeting issues like insomnia at their root cause is essential for true health and healing.

For more information about lifestyle methods for balancing hormones, checkout this post: 5 Ways to Balance Your Hormones, Naturally

Supplements

Progesterone Cream: Progesterone cream is a supplemental form of progesterone that is applied as a lotion to the skin and absorbed into the blood stream. Just like a pill, progesterone cream supplements the existing amount of progesterone produced by the body, but does not address the root cause behind the progesterone deficiency. However, progesterone cream can be a helpful temporary step for women who are suffering from extremely painful periods, or who are experiencing fertility struggles due to low progesterone.

Vitamin D: Vitamin D really is more appropriately classified as a hormone than a vitamin. Like other hormones, it is derived from cholesterol and circulates throughout the body, communicating with almost every organ system. Vitamin D also plays a regulatory role in the production of sex hormones. Because of our largely indoor lives and the risk of skin cancer from UV exposure, most Americans are deficient in vitamin D. In my clinic, I test every patient’s vitamin D levels so that I can safely prescribe supplements to restore functional vitamin D levels and hormonal balance.

https://pmc.ncbi.nlm.nih.gov/articles/PMC4507331/Vitamin B6: In women suffering from a luteal phase defect (a luteal phase that lasts 11 days or fewer, which is a consequence of low progesterone), supplementation with vitamin B6 has been proven to extend the length of the luteal phase. This helps correct for associated fertility struggles, in which the fertilized egg doesn’t have sufficient time to implant in the endometrial lining before menstruation begins—an event triggered when progesterone levels dip.

DHEA: Like cortisol, testosterone is produced from the same precursor as progesterone: pregnenolone. When cortisol levels or testosterone levels are high, progesterone production tends to suffer. DHEA is an intermediate between pregnenolone and testosterone, so supplementing with DHEA in women who are suffering from low progesterone because of elevated testosterone can reduce the consumption of pregnenolone for testosterone production. That leaves more available for progesterone production. DHEA can also cross-react with the pathway for progesterone production, elevating levels even in women whose deficiency is not the result of hyperandrogenism.

Vitex: Naturally occurring iridoids and flavonoids present in Vitex mimic the role of the corpus luteum, acting on the ovaries to stimulate the production of progesterone. In this study, Vitex was dosed at levels of 20 mg tablets daily.

Closing thoughts…

As if the symptoms of progesterone deficiency aren’t difficult enough, the journey towards a diagnosis to explain the symptoms, and finding a treatment strategy that works for you in the context of your own life can add enormous loads of stress to an already challenging life experience. There is a whirlwind of information out there, which only adds to the confusion and frustration of trying to manage your health. It can be a lonely and scary place, but I want you to know that you’re not alone. Consider making an appointment with a functional medicine doctor who can deliver personalized care and help you achieve your health goals.

I’m Dr. Alexandra MacKillop, a functional medicine doctor, food scientist and nutrition expert.

I specialize in women’s nutrition & hormonal health, addressing concerns like longevity, fertility, postpartum, PCOS, endometriosis, and gut symptoms like bloating, constipation, diarrhea and more.

If you’re looking for a new way to approach your health, I’m here to help you through it.

Become a Patient

Don’t miss out! Join the email list.

Sign Me Up!

Love this post Share it!

• Facebook
• Pinterest
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Want more Grab a copy of my new book, The Postpartum Check-In !

Reminder: The information on this post or anywhere else on this blog or other writing is purely educational, and is not intended to diagnose, treat, prevent, or cure any health condition.

The post Natural Treatment for Progesterone Deficiency appeared first on Dr. Alexandra MacKillop.

Maybe you can relate: for most of my life I preferred not to think about my period very much. I found it to be inconvenient and, at times, embarrassing. (We’ve all been there…) Once I got married, though, I started paying more attention to everything going on in relation to my cycle. At first it was for family planning purposes, but I slowly started to notice cyclic, predictable changes in my body that had nothing to do with “that” time of the month—energy levels, hunger patterns, motivation, introversion versus extroversion, and more. I found it super fascinating, especially when I started comparing those changes to the hormonal patterns I’d learned about in school.

In the same way that gentle nutrition practices have helped me build trust with my body, learning about my cycle in a more personal way (rather than just reading a textbook) has helped me manage my health more confidently. It feels so good to know that everything is working as it should, and what to do if something seems amiss. If you’re interested in learning about that too, this post is for you! (Want to go deeper Check out my book, Go with Your Flow: a revolutionary guide to better periods, balanced hormones and a cycle that works for you)

Hormones and the HPATG Axis

If you’ve read my post about the hypothalamic-pituitary-adrenal-thyroid-gonadal axis, or HPATG axis for short, you’ll remember that our monthly cycles begin and end in our brains. Part of the brain called the hypothalamus sends hormonal signals to the pituitary gland, triggering another hormone cascade that tells our reproductive organs what to do, and when. Although different circumstances can interfere with that communication axis, for the most part, the hormonal pathways work like this:

The main signals sent out by the pituitary gland are luteinizing hormone (LH) and follicle-stimulating hormone (FSH). These hormones travel through the blood stream to the ovaries, stimulating the production of estrogen and progesterone. These four hormones rise and fall in predictable patterns throughout the menstrual cycle to trigger ovulation, thicken the endometrial lining, and shed unused tissue if pregnancy doesn’t occur.

The menstrual cycle is divided into two main stages: the follicular phase and the luteal phase. Within those two phases we have two pretty noteworthy events (ovulation and menstruation), so I like to think of the cycle as having 4 phases, beginning with the first day of your period (cycle day 1 [CD 1]). Although the length of normal cycles can range anywhere from 21 to 35 days, most textbooks use a time frame of around 28 days, so that’s the reference range I’ll be using in this post.

• Phase 1 (Menses [Cycle Days 1-7]): This is probably the part of your cycle you’re most familiar with: your period. When counting the days of the menstrual cycle, we count the first day of the cycle as the first day of a period. Some women experience light spotting in the days leading up to their period, but those days are counted as part of the luteal phase (phase 4). Cycle day 1 (or CD 1) is counted as the first full day of bleeding. Technically, the days of your period fall within the follicular phase, because they start the beginning of the hormonal processes that lead to menses in the following month’s cycle. In terms of your hormonal cycles, the formal end date of your period doesn’t matter so much as the first day of bleeding.
• Phase 2 (Follicular Phase [Cycle Days 1-13]): During this phase (yes, even starting on the first day of your period), your body is starting to prepare for next month’s period—or a possible pregnancy. The first day of the follicular phase, CD1, is the day when hormone levels are at their lowest. Estrogen and progesterone are at their minimum, and follicle-stimulating hormone (FSH) and luteinizing hormone (LH) are laying low, too. Over the course of the first week, FSH levels slowly start to rise, stimulating ovaries to slowly ramp up production of estrogen. The estrogen circulates throughout the body playing a number of different roles, but the most noteworthy action in terms of fertility takes place locally, at the ovary. When estrogen levels begin to rise, about 12-18 ovarian follicles start to ripen. Eventually, most of these follicles die off, and just one finishes the maturation process, an event that corresponds to the day when estrogen is at its highest. Estrogen production peaks at around days 11-13, then sharply falls. The pituitary gland senses this drop in estrogen through a feedback loop. Its response is to send out a surge of FSH paired with an even stronger surge of LH to trigger ovulation.
• Phase 3 (Ovulation [Cycle Day 14]): On the day of ovulation, the sharp rise of FSH and LH stimulate the mature ovarian follicle to burst open, releasing the egg. The egg travels down through the fallopian tube, and if unfertilized, dissolves within 24-36 hours. What’s left of the follicle collapses, becoming the corpus luteum, and begins producing progesterone which is the dominant hormone of the luteal phase.
• Phase 4 (Luteal Phase [Cycle Days 14-28]): After ovulation, FSH and LH levels drop back down again, and hormones in generally reach another realative low. Beginning with the day of ovulation, however, the corpus luteum takes over hormone production, secreting progesterone and some estrogen, which thickens the uterine lining to prepare for a possible pregnancy. Progesterone levels peak at about CD 21, followed by a gradual decline of both estrogen and progesterone. (Eventually the corpus luteum breaks down into the corpus albicans, ultimately dissolving completely.) When the hormones levels bottom out, the menstrual lining begins to slough off and the cycle starts all over again.

Getting to know YOUR cycle

In my experience, women typically express an interest in their cycle when they start the process of trying for a baby. While unprotected intercourse technically could lead to a pregnancy at any point in the follicular phase depending on each individual woman, there are really only 5-7 days each cycle that conception is really possible. These days correspond to the 5 days leading up to ovulation, the day of ovulation itself, and then the day after ovulation.

Fertile Days

These fertile days really depend on the lifespan of sperm. The actual union of sperm and egg can only take place on the day of ovulation and the 24-36 hours thereafter, until the egg dissolves. Sperm, however, can live up to five days in the uterus and fallopian tubes, waiting around for the egg to be released. In a 28 day cycle, these fertile days would correspond to CD 10 through CD 15. Having unprotected sex on any other day corresponds to a very, very, very low chance of conception, and this awareness serves as the basis for Fertility Awareness Methods of family planning.

But of course, not every woman’s cycle lasts the textbook length of 28 days. In order to get to know you and your cycle, there are a number of personalized methods you can use. I explain these in detail in my book, Go with Your Flow, but here is an overview:

Cycle Tracking Method #1: Hormone Testing

At-home urine hormone tests can be used to predict and confirm ovulation, and they’re pretty inexpensive. The testing procedure involves placing a urine dipstick into a sample of urine. If the hormone target is present in the urine, it will react with a reagent and bind to a dye strip—similarly to a home pregnancy test.

Ovulation predictor test strips qualitatively measure levels of luteinizing hormone in the urine, and generally show a pale pink line on most days of the follicular phase. On the day of LH surge, the test strip will turn dark pink, indicating a sharp increase in the level of LH. This LH surge means that ovulation will likely take place within the next 24-48 hours. (Note: LH typically peaks between midnight and 8:00 am, so the first morning urine tends to catch the LH surge better than other times of day.)

Affiliate Link: Ovulation Test Strips (LH)

In a small percentage of women (particularly those with PCOS), the pituitary gland sends out a surge of LH, but the follicle fails to release an egg. Because of this, many women prefer to confirm that ovulation has taken place by testing for progesterone metabolites in the urine. During the luteal phase, as progesterone production ramps up, so do the levels of the breakdown products detectable via urine test strips.

Progesterone test strips function similarly to ovulation predictor kids, except in reverse: a second pink line showing up (in addition to the control line) indicates a negative test, and the absence of a line indicates a positive. (Note: progesterone test kits typically recommend testing the first morning urine.)

Affordability: Good. LH test strips each cost less than 50 cents each, but the downside (especially with ovulation predictor kits) is that you need to test every day—sometimes multiple times per day. (Progesterone test strips are a little pricier.) If you have no idea when you might be ovulating, using these strips regularly, or for multiple months in a row, can add up.

Ease: Excellent. Open, dip, read, move on.

Validity: High. The test is either positive, or it isn’t. When both the LH and progesterone tests are positive in a given month, there is a near-perfect likelihood that ovulation has taken place.

Accuracy: Pinpointing ovulation with urine test strips is not really possible. The LH surge simply means that ovulation will take place sometime in the next day or two. Progesterone test strips mean that it has taken place sometime in the week, give or take. Using urine strips alone would not be considered a reliable way to prevent pregnancy if you are tracking your cycle for contraceptive purposes.

Cycle Tracking Method #2: Basal Body Temperature

If you look back at the chart at the top of the post, you’ll see that the very top line corresponds to body temperature. Sometime throughout history, women realized that the menstrual cycle creates predictable changes in basal body temperature (BBT)—our core body temperature while at rest.

Throughout the follicular phase, our BBT is at its low point. The day after ovulation, it takes a sharp rise, usually of more than 0.2 degrees. This temperature rise is sustained until a few days before your period, when it slowly drops back down again. After tracking your BBT for a few cycles, you’ll have a pretty good idea of when you ovulate and when to expect your period, which can be helpful whether you’re trying to conceive, or altogether avoid pregnancy.

Affordability: Excellent. However, measuring BBT requires a more precise measurement than most at-home thermometers are capable of. In order to offer the level of precision needed for accurate monitoring, the thermometer needs to read more than two places past the decimal point. Thankfully, this method is popular enough that BBT thermometers are extremely affordable—less than $10. [Affiliate link: Basal Body Temperature Thermometer]

Ease: Medium. Basal body temperature readings are only valid if they are taken first thing after waking up, even before getting up to use the bathroom, get a drink of water, or anything else. The reading also must be taken after at least 3 hours of uninterrupted sleep. If you’re a restless sleeper, struggle to remember to take your temperature, or snooze abuse, this method might not be right for you.

Validity: Medium. BBT can easily get thrown off from things like illness, alcohol, sleeping next to a warm person, or even temperature changes in your bedroom. But when the conditions are right, BBT charting can be highly effective.

Accuracy: When done correctly, BBT charts are a highly accurate method for tracking fertility. The post-ovulatory temperature rise is a pretty clear indication that ovulation has successfully taken place.

An additional benefit of this method is that sometimes it can serve as an early method for detecting pregnancy. Many women experience an “implantation dip” about 6-12 days after ovulation, when the temperature drops around 0.3 degrees, and then rises back up again. If the temperature remains high and doesn’t start to drop off, as is the case before menstruation, this usually is an indicator of pregnancy, sometimes even earlier than a home pregnancy test.

Cycle Tracking Method #3: Tracking Cervical Mucus

This method is the most…intimate of all. It requires that you get really comfortable with yourself and your anatomy.

Vaginal discharge (AKA cervical mucus) is a normal part of female health. Significant changes in color or odor can indicate infections, but outside of these instances, clear, white, or pale yellow discharge is a predictable part of being a woman. Throughout the cycle, the texture and color of cervical mucus changes in predictable patterns:

To accurately assess your cervical mucus, you can wipe your vaginal area before urinating, and observe the tissue. Alternatively, with clean hands, you can insert a finger or two slightly inside your vagina and observe the color and texture of the mucus between your fingers.

On days when cervical mucus is scant, fertility is low, meaning pregnancy is highly unlikely. But on days when cervical mucus is more abundant, and especially when watery and stretchy in the days leading up to ovulation, fertility and chances of conception are very high. Typically in the few days leading up to ovulation, cervical mucus will become clearer and more abundant, resembling raw egg white. Not only do these days signify pending ovulation and a time frame in which sperm can survive, but the egg white cervical mucus (EWCM) actually serves to promote sperm survival. It contains high levels of water and nutrients, promoting sperm fertility as well as a nutritious environment to help them traverse the journey up through the fallopian tube to wait for an egg. If you’re trying to conceive, the days you notice EWCM are the days you and your partner should focus on physical intimacy.

Affordability: Excellent. All you need are your own two (clean) hands and/or some toilet paper.

Ease: Medium/Low. This method of cycle tracking requires a degree of personal intimacy and comfort that the other methods don’t. Learning how to differentiate among the different textures and quality of cervical mucus can also be really challenging during the first few months. It’s not as cut-and-dry of a method as taking your temperature or using a test strip.

Validity: Medium. The results are mixed with this method, as not all women follow quite the same patterns. For example, some women may produce low amounts of EWCM, making it difficult to identify fertile days.

Accuracy: Medium. When EWCM is present, chances of conception are high. However, for women trying to avoid pregnancy, tracking cervical mucus alone may not be sufficient to identify fertile days.

Cycle Tracking Method #4: Symptom Spotting

I’m listing this method last because it really shouldn’t be used as a method for pregnancy prevention, or even timing intercourse for conception. However, paying attention to your internal, bodily signals at different times of the month can give you valuable insight into your own body’s needs, informing your self-care routine throughout the month.

Menses: Letting Go

Most women tend to feel lethargic and less social during the first few days of their periods. Looking back at the rise and fall of hormones throughout the cycle, this totally makes sense. Estrogen and progesterone are at their all-time low during the first few days of your period, and low levels of these hormones are known to correspond to feelings of anxiety, depression, and fatigue.

I used to find these low-energy feeling extremely inconvenient, but as I gained knowledge of and trust in my body, I slowly came to recognize that things go so much better when I accept my natural design instead of trying to battle against what my body is doing. Menstruation is a natural part of life as a woman, and when I set aside my pride, I can see that this natural time of release and letting go can be really healthy depending on how I respond.

Many women (myself included) find that symptoms like cramps and breast tenderness are less severe when I accept my body’s invitation to slow down and rest. I tend to naturally feel more introverted and tired during the first few days of my period, and I’ve realized that I feel so much better if I don’t push myself to perform or be social, and take it easy with exercise. Instead of focusing on my productivity, I try to use this time to relax, reflect, and let my body go through its own process of restoration.

Follicular Phase: Estrogen for Energy

On a biochemical level, estrogen is an energizing hormone. As levels start to rise during the follicular phase, we tend to feel motivated, energetic, and productive. I personally find that intense exercise feels really good in my body throughout days 5-15 of my cycle, and I’m madly efficient when I work on things (like writing this monster of a blog post, for example…)

I also find that I’m much more willing to get things done around the house, participate in trips and social events, and tie up loose ends at work. While I don’t necessarily go so far as to make special plans during this time, the knowledge that I’m not always so energized allows me to have a little more grace on myself when I realize that my hormones have such a profound affect on that areas of my life.

Ovulation: Transition

I personally don’t notice any remarkable changes in my body or mind during ovulation, but many women report slight cramping (mittelschmerz), breast tenderness, or light spotting on the day leading up to or day of ovulation. This can serve as another means for tracking your fertility if you find yourself with these sorts of symptoms.

Luteal Phase: Rest and Restore

Progresterone is the hormone responsible for PMS symptoms. As the corpus luteum starts to ramp up its secretion of progesterone, levels of fatigue, breast tenderness, cramping, irritability, and bloating tend to follow suit if stress levels also remain high. Digestion slows way down, electrolyte levels fluctuate (leading to water retention), and mammary tissue starts to develop in the event of a possible pregnancy—leading to swelling and tenderness.

As with the first days of my period, I tend to feel sluggish, tired, and sore during the last few days of my luteal phase. By tracking the symptoms of my own cycle, I’ve come to recognize that feeling slow and tired during exercise, mild tension headaches, and a predisposition to feel a little more introverted is normal for me. While I find these things to be a little inconvenient, they aren’t debilitating, and I generally feel pretty good when I respond appropriately to my body’s signals for rest. As it says in Ecclesiastes chapter 3, “For everything there is a season, a time for every activity under heaven. A time to be born and a time to die, […] A time to tear down and a time to build up. A time to cry and a time to laugh.”

To sum things up…

The female body is an incredible, awe-inspiring creation. I am truly amazed every time that I sit down and study the details of hormonal balance, the delicate web of connections between our hormones and our bodily systems, and the amazing miracles of pregnancy and birth. The beautiful, graceful way that everything works together inspires a deeper sense of respect for everything that my body is—and isn’t—and drives me to take self-care seriously so that I can continue to live a healthy, vibrant life. How about you?

I’m Dr. Alexandra MacKillop, a functional medicine doctor, food scientist and nutrition expert.

I specialize in women’s nutrition & hormonal health, addressing concerns like longevity, fertility, postpartum, PCOS, endometriosis, and gut symptoms like bloating, constipation, diarrhea and more.

If you’re looking for a new way to approach your health, I’m here to help you through it.

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Reminder: The information on this post or anywhere else on this blog or other writing is purely educational, and is not intended to diagnose, treat, prevent, or cure any health condition.

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