Rhythms of Reproduction: Decoding the Menstrual Cycle

Join Dr. Mark Amols on this fascinating journey into the world of reproductive health in the latest episode of Taco Bout Fertility Tuesday! This week, we're diving deep into the nuances of the menstrual cycle, a cornerstone of female fertility. Dr. Amols demystifies this complex biological process, explaining its three phases - the follicular phase, the luteal phase, and menstruation - with his characteristic blend of humor and clarity. Learn how these phases impact fertility, the role of hormones like estrogen and progesterone, and why a regular cycle is a crucial indicator of reproductive health. Whether you're trying to conceive, curious about reproductive medicine, or just a science enthusiast, this episode is packed with insights and analogies that make understanding the menstrual cycle both entertaining and enlightening. Don't miss out on these vital insights – tune in to Taco Bout Fertility Tuesday for your weekly dose of reproductive knowledge served up with a side of laughs!

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Transcript

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Today we talk about the menstrual cycle. I'm Doctor Mark Amos and this is taco. About fertility Tuesday the menstrual cycle is not a very sexy topic. Matter of fact I dont think most men wont even talk about it. But if you like science and you like understanding things, this episodes for you. The menstrual cycle by itself is meant to prepare the uterus every month to be able to get pregnant. But the menstrual cycle in medicine is used like a vital sign where were. Able to watch it like a heart. Rate and determine if there's problems. Because the menstrual cycle tells about the. Health of the hormones as well as the health of the uterus. The menstrual cycle is broken up into approximately, three phases. The follicular phase, the luteal phase and menstruation. Now the follicular phase is essentially where the follicles grow to be able to be ovulated. After ovulation. We call it the luteal phase. And then menstruation is obviously when someone has their menses. Now what's really unique about the menstrual cycle is it's very regular. And the reason why it's regular is. Because of the luteal phase. The luteal phase is where after you ovulate, the sac remaining makes progesterone. And it keeps making progesterone for about twelve to 14 days. And then if not pregnant, it dies. And then what happens is progesterone levels. Drop and you get a period. But that luteal phase is pretty exact. Which means when cycles are not regular. It'S the follicular phase that is changing. For example, if the luteal phase is 14 days and the woman has a. Follicular phase of ten days, her cycle will be 24 days between menses. If she has a 14 day follicular phase, it will be 28 days. And if she has a 20 day follicular phase, she's going to have a 34 day cycle. Now having cycles at different lengths are. Normal, but what's not normal is for one month to be 14, next month. Be 20, next month be 34 and jumping all around. And that's because most people, the follicular phase stays the same overall. It can change over time, but it. Shouldn'T be changing month to month, especially not in a short period of time. So what this tells you is that if you have a predictable cycle, let's say it's 28 days or 33 days, whatever it is, and it's the same. Every month, then you know things are. Working normal because you have the normal. Regularity of your period. But if your period is 33 days, one month, the next month, 24 days. Something is wrong because we know that luteal portion is always going to stay 14 days. So it means the follicular phase is changing, and that's not normal. It's normal once in a while to have a long period or a short one because you maybe have a cyst or something like that. But overall, it's going to have regularity. So let's dig a little deeper. Before you ever get your menses, your. Ovaries are already there with follicles ready to grow. They haven't grown yet. What happens is the pituitary gland in the brain starts releasing follicle stimulating hormone known as fsH. And that will start making the follicles. On the ovaries start to grow. Now, every month, multiple follicles will grow. But at first, when the FSH is. Coming out, it's because the estrogen levels are low. See, the brain's not trying to make eggs. It's looking for estrogen. And what makes the estrogen are the follicles, which have eggs in them. So before the first menses, the estrogen. Levels are low when you're prepubescent and. Then they start to rise because your body starts to make FSH and eventually starts to make some of those follicles grow. As those follicles rise, multiple follicles are growing. But eventually what happens is because those. Follicles are making estrogen, that estrogen goes back to the brain and says, hey. Im making estrogen in the brain need to make so much. So it starts lowering the FSH levels. By lowering the levels, all those follicles. Cant keep growing because theres not enough hormone to make them all grow. So what happens is the multiple follicles. Start to regress and one lead follicle starts to grow. And eventually that lead follicle gets to the point where it becomes what we call gonadotropin independent. Meaning even if it doesnt have fsH, it can keep growing. But all the smaller ones, those will fall out because they are not gonadotropin independent. They need more fsh to grow. This is why humans make singular follicular. Recruitment versus things like cats and other animals. And when you do things like iuis, and IVF and your doctor gives. You more hormones, what theyre doing is. Theyre forcing more of those gonadotropin dependent follicles to grow and keeps giving the hormones. So that way you get multiple follicular recruitment. So this feedback loop is what allows you to only release one egg per month. But the other thing the estrogen is doing is at the same time not. Just making the feedback loop work, but. Its also providing the lining of the. Uterus to build up, because the first. Time before you have amenses, your lining is thin. But now the lining starts to build up because the estrogen causes the receptors. On the uterine lining to build tissue. And that tissue thickens and thickens up. And eventually, then you ovulate. Now, when you ovulate, your body then makes progesterone. And thats because the sac that releases the egg becomes a cyst called a corpus luteal cyst. And that corpus luteum is what makes progesterone. Its the only time your body makes progesterone. Matter of fact, you'll hear people say, oh, I don't have enough progesterone in my body. And so my naturopathic doctor put me on progesterone. That is not true. You are not supposed to have high progesterone levels during the follicular phase of your cycle. Now, in your luteal phase, that could be abnormal. But in your follicular phase, you should not have progesterone, very minimal amount. Once the progesterone starts being made, what. Happens is that also feedback on the pituitary gland to suppress the hormones because it says, hey, I have a follicle. And I'm making a progesterone now. So now the pituitary gland releases lh, which stands for luteinizing hormone. And that is what keeps the corpus. Luteum to make progesterone. The progesterone then goes to the lining of the uterus and organizes the endometrium, helps it with blood supply to be ready now to accept an embryo. Now, on that first menses, you're not having intercourse. So what happens is you don't get pregnant because there's no sperm around to fertilize with the egg. And so that corpus luteum goes to. 14 days and then it dies, undergo a process called atresia. The progesterone levels then drop very low. And now the estrogen levels, the progesterone levels have both dropped, and that causes the lining of the uterus to now shed because the progesterone was supporting it at that thick volume. But now thats gone, it will shed and go back to its thinnest point. At this moment, its progesterone dominant, but its dropping now and then both the estrogen and progesterone levels will be very low. At that point. Its back to the start. Now the pituitary goes, hey, my progesterone is low. My estrogen levels low. I need to do something. I need to make some more estrogen. And it does that by releasing now FSH again to cause those follicles to grow and start the entire cycle again. So what about the situation where there is sperm? Well, when there's sperm, there sperm will. Then fertilize the egg. And then when that embryo implants into. The endometrial tissue in the uterus, the. Cells will start invading into the tissue, and eventually there's these cells called syncytiotrophoblast cells. What those cells will do is they. Will start making a hormone called hCG. HCG looks very similar to LH luteinizing hormone. And what it will do is it will rescue the corpus luteum from undergoing atresia. Instead of disappearing, it will keep making progesterone to support the pregnancy. This is why some women will not get a period, and then theyre checking to see if theyre pregnant. And obviously, if they are, congratulations. But sometimes you dont get a period and you're not pregnant, and sometimes your. Breasts are tender and it feels like you're pregnant. Well, in that situation, it could be. One of a few things. One is that you could end up. Having a cyst, if that cyst is. Producing estrogen, the estrogen level may be. High enough where you might get some. Spotting, but won't have a full period, whereas with the progesterone level being elevated, you will also not get a period. And it will come late, but your. Breasts will still be tender because you have the hormone from the progesterone causing those symptoms, which are also the symptoms of pregnancy. And that can be quite frustrating because. You feel like you're pregnant, and then. You find out you're not. So, as a patient, how does this help you? Well, one of the things I get asked a lot is, why do I not get a period? What happens after, IVf cycle when I don't get my period on time? Well, as we just talked about, you could have that cyst, and that can be part of what's going on. But the other thing I get asked. Is, what's the first day of my cycle? Generally, we consider the first day of your cycle the flow. Now, why not the spotting? Because we just got done talking about this whole process. And what you learned is its when. The progesterone levels drop really low, that. Then you shed the lining. And shedding that lining is really the first day that your hormones are low. Spotting could just be when the progesterone is starting to go down and you start losing a little bit. But it's not enough to call it the first day because what we mean by the first day is truly saying. When are the hormones level gonna be low? This is why we draw cycle day. Three labs on the third day. Now, clearly they're called cycle day three because they're on the third day. So I don't think I impressed anyone with that. But the point is, your hormones, your estrogen levels are the lowest. That's when they hit the nadir at the bottom. And at that point, we know thats. When your brain is going to work. The hardest to make a follicle because. Your hormones are the lowest. And the brains like, hey, we got to get going. And this is when we test for. Things like what your egg quality is. Because the FSH level is going to be inversely related to the quality of your eggs. If that FSH level is very high. Then we know things arent working that well. Your brain had to work too hard. To try to make eggs again. If its low, we know things are. Working very well when it comes to starting treatment. The reason why we start treatment early on in cycle day three is because thats before your body has developed follicles. If you start treatment, lets say on day seven, your body has already developed a follicle. So now if I give you medicine, ill make that lead follicle grow because its already ahead. But everything else behind it doesn't have time. But by starting on day three, it's at the point when all those eggs are ready and just starting. And so they're all going to grow at a similar rate. And at the same time, this is. The same reason why you start birth control, usually in the early portion of your cycle, before the foggle has developed. If you start birth control on day seven, there's already follicle. It's not going to suppress it because that follicle is gonna nadotropin independent. So even though you're on the birth control, the follicle keeps growing, it ovulates, and now you have a cyst. So when you find these programs that tell you that they're telling you your. Menstrual cycle, they really aren't. All they're doing is doing a calculation. They're assuming which is a very fair assumption that your luteal phase is going to be 14 days. So it takes how many days there is between two periods and subtracts 14 days and says that's when you're ovulating because that is the part that's consistent, whereas the follicular portion is not consistent, that can change. So if you have a regular cycle. Every month and it's always on the. Same time, then those apps work very well. If you don't have a regular cycle and it moves around, those apps are practically worthless because they can only tell you what happened the month before, they can't tell you what's happening the current month because until you have your period it doesn't know how many days the follicular phase was, it can only tell you how many days the luteal phase was. Some other interesting facts about the menstrual cycle is it can be used to also tell other problems. For example, if a woman hasn't got her menstrual cycle and she's becoming 16 1718, that tells us something is wrong and then we can look at multiple things, not just her menstrual cycle, but did she develop breast? A woman who doesn't have a period and doesn't have breast tells us one, there's no hormones going on because she didn't have any breast development and two, there could be something wrong with the uterus where either it's not there or. There could be a blockage. But if there's a blockage usually there's. Hormones and there'd be breast development. On the same token, if someone has breast development but not having a period, then you worry about things like blockage. So using those things like the menstrual cycle, looking at a physical exam we're able to diagnose things that could be wrong with someone very early on when they're very young. Now what's interesting is there are some. Women out there who don't ovulate yet, they bleed every month. So what's happening there? Well, in that situation their lining is. Building up every month from the estrogen because the brain is still making hormones. But instead of ovulating and making progesterone. And having a withdrawal bleed, basically the. Tissue is building up, its not being supported and its just shedding out through bleeding. Think of it like jenga, eventually gets. So high it starts falling down and thats what youre seeing, but it never. Sheds to get thin. Whereas when you take lets say a medicine called provera or prometrium and youre. Not ovulating, then thats going to increase. The progesterone levels for ten to 14 days. And then you stop it and you actually get thinning of the lining because it sheds the entire lining. That is very similar to a real period. But technically it's not a menstrual cycle. Because it didn't have ovulation, but it. Still went through the same hormone progression. To have a period. And that's exactly how birth control works. Birth control gives you both estrogen and. Progesterone, and then at near the end. Of the month, you take sugar pills that have no progesterone or estrogen in. Them, and that causes the lining to shed. Now, the reason the menstrual cycle ends up being perfectly timed is because you have a certain amount of days, youre on it and you stop it. And thats the same every month. So I hear patients come to me all the time and say, well, my period was perfectly normal when I was on birth control. Well, thats because it wasnt a period. You might have bled like a period, it might have felt like a period. But at the end of the day. That was just a, withdrawal bleed created by the birth control. And only when you ovulate do you actually go through the hormonal changes that. Lead to a, natural menses. But in the end, does it matter? Well, it depends what the goal is if you're trying to get pregnant, yes, it matters if you're not having a natural menstrual cycle every month. But if your goal is just to. Shed your lining because you dont want to get, lets say, a cancer of the endometrium or youre ready to start ivf treatment and get on birth controls or even just getting ready for whatever reason, maybe you dont want to have a period. Being on birth control to manipulate is. Perfectly fine and youre able to do. What you need to do. But like I said, that isnt a true menses. And thats why its important, because if youre someone whos not on birth control and not having regular cycles, theres a problem. You cant feel that things are fine because theyre normal. One, youre on birth control because thats being manipulated, just like taking provera or. Prometrium, thats manipulating your body to have a period. So when the doctor says theyre going to induce a period, theyre not saying theyre going to make your body go through the natural process of having a period. Theyre saying theyre going to give you. A drug to make it feel like. You'Re having a period and they're still getting the same consequence, which is shedding your lining, but they technically did not make you go through a natural menses. The last part about this is how. Does the menstrual cycle then help in fertility treatments? Well, we talked about a few of them. We talked about when to start treatment. We got to start it when it's. Early, and starting it late can cause problems. So, for example, when you're doing iuis, and let's say you keep getting one follicle each time you want to start the medicine early, before the follicles have developed. So you need to give injections early on. Some people will call that front loading. But if your problem is you make. Plant follicles, but you don't want them. All to grow, you then backload it, because now you want to capture it when the other follicles disappear, and then you just make a few grow. So, depending on the problem, if you don't recruit enough, you do it early. If you crew plenty, then you start it later, so you don't make too many grow. When it comes to starting for IVF and we start things like birth control, we start in the beginning of cycle. Before you develop a follicle. Sometimes we even start treatment in the middle of the cycle, in the luteal phase, before your body has developed a follicle, such as what we call mid luteal estrogen start. There are some clinics that even start in the luteal phase. And basically that's like saying your body. Can'T cause any follicles to grow because. It'S already in the phase where it's not growing. It's in the progesterone phase. And so that is one way to do it. A luteal phase start. You start the stimulation in that luteal phase, and then your body can't develop things like early recruitment or issues like that. I tend to start medicines in the luteal phase for the same reason. So using that menstrual cycle, it gives. Us lots of ability to start treatment and ways to do treatment. Hopefully this was helpful. Hopefully it wasn't too boring. But the menstrual cycle is a really important thing. It really is the lifeline to women. It tells us how things are going, and most important, it helps us help you get pregnant. And so, you know, when you go for your initial visit, this is something the doctor is going to talk a lot about. They're not obsessed with menstrual cycles. It's just that that helps us understand what's going wrong, and then we can use that menstrual cycle to be able to help you get pregnant. As always, if you like this podcast, please tell your friends about us. Give us a five star review on your favorite medium. But as always, as I say, please come back for more. I'm always going to be here the following week, and I'll see you next week on Taco Belt fertility Tuesday.