See Fact sheets
– PCOS
and General
infertility
What is a normal period?
When to see a doctor
Concerned about infrequent periods
What is “day 1” of bleeding?
PCOS restarting menses after exercise
Irregular bleeding type 1 diabetes
Irregular bleeding after Depo-Provera
Menstrual bleeding only during the day
Hypothyroidism
“Short” periods
Painful periods (dysmenorrhea)
PCOS, stopping the “pill”
PCOS, natural approaches to menstrual regulation
Delayed ovulation
Irregular menses after oral contraceptives
Low progesterone
Question: How do I know if my periods
are “normal”? How abnormal or irregular must they
be before I see a doctor?
Comment: The average menstrual cycle length is between 28
and 29 days. The statistical range of normal is from 26-35
days. Variation outside these limits is abnormal and may have
health consequences. If periods are very infrequent, a physician
consultation is clearly needed and a diagnosis warranted.
For those desiring fertility, if menses are over 35 or under
26 days, there is an excellent chance that ovulation is not
occurring. This does not means that pregnancy cannot occur
even with very erratic bleeding; rather, the possibility of
conception is much less and the likelihood of miscarriage
is increased. If periods are not regular, basal body temperature
charting or use of ovulation detection kit (LH surge testing)
is a waste of time and money. It can be assumed that there
is an ovarian disorder and intervention warranted. If there
is a desire for fertility, clomiphene is usually first line
treatment. If there are no immediate plans for pregnancy,
oral contraceptives are often the best option. The non-contraceptive
benefits of the "pill" often far outweigh the side
effects and risks. Still, there is no single therapy that
is right for all. Even if one therapy seems theoretically
to be a great choice, it may fail miserably. The second option
for regulation is the periodic use of a progestin such as
Provera (medroxyprogesterone acetate), Aygestin (norethindrone)
or progesterone. sst
Question: When is the correct time to begin seeing a gynecologist?
I am having irregular menses, but I'm not sure if it’s
serious enough to see my gynecologist. Should I go?
Comment: If you ask the question, the answer is yes. Better
to have your questions answered. sst
Question: I’m 21 years old and do not yet have a regular
cycle. Sometimes I will
go three months without it. At other times it will be six
months. I live with five VERY regular girls, and I would have
thought by now that it would have been regulated. My mother
(who is an RN) says I have nothing to be concerned about,
but the fact is I am concerned. I want to be able to have
children someday and fear that my irregularity might be the
symptoms of something detrimental. What should I do? Thanks.
Comment: With my apologies to your mom, I am concerned too.
While irregular menses is virtually never life threatening,
I believe a diagnosis of why your periods are irregular is
in order. Besides the constant PMS feeling that some have
with long time spans between periods, there can be medical
consequences as well. Irregular cycles may be associated with
increases in male hormones (androgens) and cause skin problems.
Some with irregular periods have increased insulin levels
and are at higher risk for developing of diabetes. While the
risk of endometrial cancer at 21 is very low, almost all cases
of cancer of the uterine lining (endometrial) occur in women
with irregular periods. Periodic sloughing of the lining of
the uterus promotes good uterine health. Regardless of sexual
activity, the pill may be a reasonable intervention. I know
it sounds like I work for the pharmaceutical industry, but
there is a general consensus that the pill may enhance later
fertility by decreasing the incidence of endometriosis, fibroids,
and pelvic infection. There is no doubt that it decreases
the risk of ovarian cancer later in life. sst
Question: What is considered the first day of a menstrual
cycle? Mine always is a few days of brown, before it turns
red. Is it the first day of brown or the first day of red?
No body seems to have an answer for this.
Comment: You are right. Nobody has the answer for this and
it is amazing how often the question is asked. I once performed
a study that examined hormonal levels in relation to day of
bleeding in the last days of the menstrual cycle. There was
little correlation. Some women bled when the levels of estrogen
were quite high and other waited until they had fallen to
very low levels. One way of calculating day 1 is to start
with the assumption that ovulation occurs 12-14 days before
a period. Sometimes a basal body temperature tracking can
help in this calculation. The greatest problem usually comes
in knowing when to start fertility therapy. Clinics vary in
their definition of day 1. Some use the first day of heavy
bleeding. At my clinic we consider day 1 as the first day
of any spotting, but then if we give clomiphene, we do not
start before day 5. This really may be day 2, 3 or 4 for some.
Often the day 1 will become more predictable after therapy.
sst
Question: I have PCOS and have always had cycles from 34-42
days that are normal for me. Recently I have been working
out down at the gym, as well as taking EPO, Vitamin C, Folic
Acid, and one St. John’s wort tablet a day. While at
the gym last month I experienced a mid-cycle bleed. It occurred
after doing some weight training (not abdominal) and I bled
just for a couple of hours. My period came at day 29 that
month. The same thing has happened again this month. Last
week while at the gym I had a bleed for that day (day 15 of
cycle). The blood looks bright red and is fluid. I feel as
though something has burst and was wondering whether this
is just a cyst that bursts or actual true ovulation. This
has never happened to me before. I am about to have IVF starting
in Dec/Jan and I don’t want to have anything else to
worry about!
Comment: Bleeding, or at least spotting at time of ovulation
sometimes occurs. It occurs with the sudden fall of estrogen.
It may be a positive sign of improvement with your exercise
program. It also might be another indication that you still
don't ovulate. I would use an ovulation predictor kit and
/or temp chart to see if you are making progress toward ovulation.
Ovation detection kits and temperature charts are relative
useless your cycles are 26-32 days. Longer or shorter and
it can be assumed that ovulation is not occurring in a timely
fashion and intervention is indicated. sst
Question: I have regular, irregular menses. Meaning, I'm on
one month, off the other, on a regular basis without fail.
It has been over three months since my last menses and I am
wondering what could be the cause. I have had Type I Diabetes
for 13 years (I am now 23), and have read that menstrual period
changes are usually a symptom of some underlying physical
or hormonal imbalance. I have a doctor’s appointment,
and wanted to know if there are any specific questions that
I should ask when I go in.
Comment: Insulin is a potent hormone that affects many organs
including the ovary. Polycystic ovary syndrome (PCOS) is associated
with insulin resistance and type 2 diabetes. However, long-term
insulin use that characterizes type 1, or insulin deficient
diabetes, may cause some of the same effects on the ovary.
I have seen a number of patients with type 1 diabetes and
irregular bleeding. An ultrasound scan of the ovary on these
patients often shows a PCO pattern. Often oral contraceptives
are used in type 1 diabetes to control bleeding. They may
not be best option for all, but it may be worthwhile to discuss
this issue with your doctor, especially if there is excessive
hair growth or acne. Another alternative would be to use monthly
progesterone, or a progestin, to regulate cycles. sst
Question: My wife has just come off the Depo-Provera injection
after three years being on it. She has been off the injection
for five months and has only had one period, and now seems
irregular. Is this a common factor after coming off the injection?
Comment: Yes, very common. Six months to reestablish menses
is usual. Personally, I believe the reasons to use Depo-Provera
are quite limited. It is a good contraceptive agent, but the
side effects and intermediate/long term effects on menstruation
often are problematic. While rare, some women never regain
normal menstrual function. This is probably more due to an
inherent and unrecognized problem in the user than the mediation
itself. Women who had irregular menses before use of Depo-Provera
are at increased risk of the same or worsened menstrual function
after the medication is stopped. sst
Question: When I am having my period my flow is normal, except
for at night when I don't bleed at all. All my friends say
that they all bleed at night, but I never have. Is something
wrong?
Comment; I believe you probably are bleeding at night, but
the blood is only seen with physical activity the next day.
I venture to guess that your periods are overall light. I
have never seen a patient that bleeds heavily, but only during
the day. I know of no specific problem that could cause or
result from this pattern of bleeding. sst
Question: I am 31 years old and have hypothyroidism. As a
result I have gained a lot of weight. I am obese. My husband
and I have been trying to conceive for almost a year. Despite
being hypothyroid, my periods were very regular -- every 28
days, prior to trying to conceive. However, over the past
year my cycle has changed from anywhere from 28 to 36 days.
I am concerned with the change as it only started changing
after we started trying to conceive. Is this normal? I know
I ovulate as I have a fertility monitor. My concern is this:
how does the change in my cycle, along with being obese/hypothyroid,
affect my chances of conceiving?
Comment: Irregular menstrual cycles are common problems in
patients with either an over active (hyperthyroidism) and
under active (hypothyroidism) thyroid gland. I know this will
be an unpopular statement, but weight gain due to an underactive
thyroid has been shown in numerous studies to be relatively
small. Still, small changes in thyroid function can markedly
alter the way you feel as well as fertility. Clearly, hypothyroidism
can cause infertility and fertility therapy can be as simple
as thyroid hormone replacement. Replacement therapy should
not be used unless there is documented hypothyroidism. In
the past some have tried thyroid hormone to improve fertility
or to help with weight loss. It doesn't work. Individuals
taking replacement therapy should have periodic measurement
of thyroid stimulation hormone and the levels should be kept
in the mid-normal range (usually 1.5-3.0). Normalization of
TSH levels is a very important first step. I am concerned
that your cycles are as long as 36 days and would search for
a reason as to why this has occurred. Cycles over 32 days
are associated with significant decrease in fertility. A more
detailed endocrine evaluation, possibly including insulin
levels is in order, followed by a consideration of strategies
to promote timely ovulation. There is a possible association
of thyroid disease and PCOS. sst
Question: My husband and I have recently started trying to
have a baby. I am concerned about infertility because I have
a history of ovarian cysts. I have never been given a clear
answer on whether this will be a problem in trying to conceive.
Also I have pretty short periods (4-5 days), and I was wondering
if this meant anything.
Comment: There is a wide normal range. We are much more concerned
by long heavy menses than short ones. We are usually more
concerned about the length of time between menses than the
number of day of flow. Most women t do not bleed for over
7 days, or have heavy flow for over 3-4 with several days
of light flow or spotting. Very light flow may indicate lack
of ovulation. Very heavy or prolonged flow may signal anatomic
problems such as fibroids or polyps, which are best evaluated
by ultrasound scan Most causes of abnormal bleeding in reproductive
age women are hormonally related. Most visits to gynecologists
are concerned in changes in menstruation. problems are seen
as a change in pattern. Ovarian cysts can be a sign that the
ovary is not working (ovulating) properly. The first step
is to determine whether ovulation is occurring. Good first
steps are basal body temperature tracking and ovulation prediction
kits. After this, it is probably best to have a consultation
with a fertility specialist. Mild ovulatory defects are often
easy to fix. sst
Question: I have been trying to conceive for two years now
and recently I read an article about dysmenorrhea. I feel
that I have some signs of this, like painful periods that
bring me to tears. I also read that it can cause infertility.
How true is this? Should I discuss this with my doctor before
getting fertility tests done?
Comment: The two signs/symptoms of endometriosis are pain
and inability to conceive. You seem to have both. Menses associated
with changes in bowel pattern/intestinal pain and/or painful
intercourse are two more symptoms of endometriosis. Individuals
who have endometriosis often have family members with endometriosis,
have longer heavier menses with shorter menstrual cycles and
have not used oral contraceptives. About 30% of infertile
women have endometriosis. Endometriosis may be suspected by
history, and further supported by pelvic exam and/or ultrasound
showing an endometriotic cyst. The diagnosis can be made only
by surgical evaluation. This is most often at the time of
a laparoscopy. A laparoscopy may be indicated solely on the
basis of pain. If a laparoscopy is performed, I suggest choosing
a surgeon experienced in the diagnosis and treatment of endometriosis
and one prepared to treat the abnormal findings at the time
of surgery. The vast majority of the cases of endometriosis
can be treated by laparoscopy. A video or detailed photographic
record should be made for further reference. It is also useful
to have a hysteroscopy at the same time to exclude uterine
problems as a cause of infertility and pain. In women of childbearing
age, I always suggest the tubes should be tested to ensure
that they are open (chromotubation). Whether to have a laparoscopy
in your particular case requires a detailed discussion between
yourself and your physician. sst
Question: I was diagnosed with PCOS when I was 19 and was
put on the pill to help regulate my cycles. I am 26 now, and
my husband and I would like to try for a baby. I will be going
off the pill soon. My question is, should I expect my periods
to go back to being very irregular. Also, do women with PCOS
ovulate at all? I don't know what to expect -- and I don't
want to waste time trying to conceive when I should be put
on some sort of medication right away.
Comment: I am a big supporter of oral contraceptives for those
with PCOS who have no contraindications and do not want to
be pregnant. Contrary to what many advise, I suggest trying
in the first month off the pill. The chances of miscarriage
may be slightly higher, but this may be the best chance for
a pregnancy. It is surprising how many women say, "I
had no problems getting pregnant the first time. It happened
the first month off the pill." There may be a rebound
effect and ovulation. I would not worry about temperature
tracking or ovulation detection kits until you have demonstrated
that you will have regular periods. If a period does not begin
after 45 days, it may be reasonable to perform a home pregnancy
test. One of the best ways to regulate periods is with "natural"
progesterone usually as the brand Prometrium™. Evaluation
should be started including tests for insulin resistance if
periods are not regular (26-35 days) after about 3 months.
sst
Question: I have PCOS; however, I am not overweight nor do
I have a facial hair problem, so I went undiagnosed for years.
The only telltale sign was having no regular cycle (perhaps
1-3 periods a year). I conceived my daughter with metformin
(Clomid did nothing for me). Now I want to conceive again.
I'm sure I will have to use Metformin again. My question is,
IS there any way I can get regular fertile cycles back without
the pill or using metformin in the short term. If not, will
this mean that I will never have regular periods?
Comment: Unfortunately, PCOS is for life. The pattern of menstrual
cycles is very individualized and is impossible to predict.
We know that periods tend to become more regular after age
35. Periods often become more regular after pregnancy, but
this didn’t seem to work for you.
Generally, I believe it is better to have periods than not.
One direct and proven benefit of regular menstruation is a
reduction in uterine cancer. An alternative minimalist therapy
that usually does not impede fertility and may promote it
slightly is the periodic use of oral progesterone. This may
be preferred over Medroxyprogesterone acetate that you have
probably used in the past.
In at least one way, you are lucky that metformin did so well
for you. However, because it worked this may be an indication
of insulin resistance and therefore, you are at higher risk
for type 2 diabetes. Trials are underway to see if long-term
metformin may protect against development of diabetes. We
do not know the answer to this question. Perhaps, you should
not consider metformin only as a fertility agent. A good sit
down with your physician to discuss the options may be in
order. sst
Question: Any idea what is going on here? I had fairly regular
cycles of 32-34 days. I charted temperature for one cycle
just before starting to try conceiving (IUI) and it looked
picture perfect. I even had the small temperature dip before
ovulation. Then, the next cycle, when I was going to try I
had a 52-day cycle with no ovulation. Then, this cycle, I
am on day 23 with no ovulation so far (am using OPKs and temperature)
but I have had lots of clear egg white cervical mucus for
over 12 days so far. Any ideas?
Comment: The average cycle length is 28-29 days. The farther
one deviates from the norm the greater the likelihood of poor
egg quality, lack of ovulation. Delayed ovulation is also
associated with an increased risk of miscarriage. The rate
of infertility is very high when cycles are over 35 days and
I do not even recommend testing for ovulation, just progressing
with therapy. At 32-34 days you may be somewhat borderline
for normal ovarian function. Then too, there could be other
problems such as male and anatomic factors. Still my first
thought with the above scenario is that there is an ovarian/ovulation
problem. sst
Question: I am 26 years old and was recently diagnosed with
PCOS. I have a 3-year-old and I became pregnant the first
month after stopping the pill. My periods used to be very
regular when I started the pill at age 18. had problems with
my period and there is no family history of any reproductive
or menstrual problems. I am 5’4" and weigh 126
lbs. I visited my doctor and he did blood tests. He says I
am in good health and my blood tests are normal, but still
no period for 9 months He did an ultrasound after giving me
Clomid and tells me , I have PCOS. I do not have any of the
other symptoms and I got pregnant easily. How can this be.
Did the pill do this to me?
Comment: The "pill" did not cause any of the above
problems; in fact, it may have preserved fertility while you
were taking it. Many with PCOS become pregnant in the first
month off the pill. PCOS covers a wide spectrum of hormonal
disturbances. PCOS is the most common cause for infrequent
periods. Ultrasound may be the most sensitive test for PCOS
that we have, but it does not give up the entire picture.
In the United States many question whether the diagnosis of
PCOS can be made by ultrasound findings alone, but I believe
it is a good diagnostic tool. Not all with PCOS have the commonly
suggested findings of weight, skin and period problems. Obviously
you have period problems and obviously you do not have weight
problems. I am surprised that all of your blood testing is
normal. One diagnostic test in individuals with your symptoms
is a reverse in the LH: FSH ratio. In PCOS the ratio is usually
over 1. Thin individuals are slightly less likely to have
an increase in androgens (male hormones) that also characterize
PCOS. If there is a familial history of diabetes, a glucose
tolerance test with insulin levels may be in order. In one
way it matters less about the diagnosis of PCOS than the fact
that you are not ovulating. Consideration should be given
to the use of ovulation promoting agents, the first line therapy
is usually clomiphene. sst
Question: I was diagnosed with PCOS and hypothyroidism two
years ago. I have been taking thyroid replacement and metformin
(Glucophage) for the PCOS. I had regular periods for several
months. Now I am back to being irregular and I have been spotting
quite a bit, which I never did before. I am hoping to get
pregnant within the year and now I am discouraged. Do you
think I am low on progesterone? Is the metformin not working
anymore?
Comment: I believe that patients and even doctors often have
a misunderstanding of what a low progesterone level indicates.
For a progesterone level to be valid it must be obtained 7-8
days after ovulation. Ovulation is the key word here. Low
progesterone levels most often indicate either that ovulation
has not occurred, or that there was improper timing of the
blood sample. If ovulation is the problem, all the progesterone
in the world will not increase the chance of pregnancy. Having
said that, progesterone use in one cycle may improve chances
of ovulation in the next cycle and progesterone use may help
in cycle regulation. So, low progesterone levels mean that
we need to concentrate on ovulation, not on progesterone supplementation.
Individuals on metformin often will gain additional benefit
by lifestyle changes including a modest increase in exercise
and calorie (carbohydrate) restriction. Larger doses of clomiphene
may be required, up to 150 mg. If ovulation is not occurring
on 150 mg, a trick that is sometimes successful is to try
two months of birth control pills and then repeat the clomiphene.
If clomiphene is going to work it usually does so in the first
6 cycles of use. If the above conservative approach has failed
to induce ovulation, the next step is often gonadotropin injections
with a consideration of IVF. sst
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