Excercise Induced Amenorrhea Leads To Poor Health & Infertility

QUESTION: I have been over exercising for about 10 years now. I get my period fine on birth control pills but when off birth control, I do not get it. I have been off it now for 6 months because the pills are expensive. Is this harmless not to get my period because of over exercising? I got a scan back in June and my gyno ruled out polycystic ovarian disorder. Since I know it's from the exercising and don't want to cut back, could this cause a problem with my fertility? What if I wanted to get pregnant right now? Would that even be possible? Thank you. N. from the U.S.

ANSWER:

Hello N. from the U.S.,

If in fact the reason why you are not getting a period is because you have "exercise induced amenorrhea", that is the result of a dysfunction of the hypothalamus. It is detrimental to your health because, you are not forming the hormones that your body needs. The purpose of the birth control pill was not mainly to have a period, it is not needed in a person who is not making a uterine lining, but the birth control pill gives you the essential hormone estrogen. In addition, the hypothalamus is important for production of other hormones as well including thyroid hormone.

In terms of your fertility, your ovaries will be shut down so that you will have difficulty getting pregnant unless you decrease your exercising so that you have normal ovarian function (have natural periods) or you use fertility medications to replace the hormones the hypothalamus is not producing, to stimulate the ovaries to ovulate.

So, I know that you are an exercise junkie, but keep in mind that instead of making you more healthy, it may actually be more detrimental to your health in many ways, including achieving pregnancy.

Follow-up Question:

You mentioned the hypothalamus being important for the production of hormones including the thyroid, well I have an underactive thyroid and have been taking Levoxyl for at least 5 years now. Is this giving me the hormones I need? Also, I explained not getting my period to my OBGYN and after a scan of my area, he told me nothing was wrong. Why do you think he would say that when he knows of my period problems?

Follow-Up Answer:

Hi Again,

Adequate levels of thyroid hormone is measured by a blood test. We usually use TSH. If your thyroid replacement is adequate, the TSH levels should be in the normal range.

A vaginal ultrasound is only for anatomical abnormalities. It can see the ovaries and uterus, but cannot diagnose ovulation or hormonal problems. That is done by other testing as mentioned previously. If your doc only checks you out by doing an ultrasound, he is inadequately evaluating you for menstrual problems. Most menstrual problems are caused by hormonal problems, as mentioned previously. At least by the ultrasound you know that your ovaries, tubes and uterus are normal, but you don't know anything more than that. So from that point of view, anatomically nothing is wrong, but that is only anatomically. I would suggest you find a better doctor!

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California

No Period, Low BMI Can Equal Hypoganodotropic Hypogonadism

Question:

I'm a 27 year old woman. I'm not pregnant. I went off the pill 7 months ago, and have not had a period since, though I had light spotting in response to a progesterone challenge. I'm about to be evaluated for PCOS, but I have a hard time believing this is what I have.

I have always been thin, and in the past I was told this was why I did not menstruate when I tried to go off the pill. I have made the effort to gain a little weight and my BMI is about 19 now. I work out regularly, though not more than 50 minutes a day. I have no family history of PCOS, diabetes or insulin resistance.

In the past 7 months I have developed benign PVC's of my heart, and have had a mild increase in facial hair and hair around my navel (this is why they think I might have PCOS).

My question is, are there any other conditions that might cause my symptoms that I should be aware of when I go to have the blood tests? Should I be tested for premature ovarian failure and hyperprolactinemia as well?

Thank you so much!

Answer:

Thank you for your question.

Your history does not quite fit PCOS. The most likely diagnosis is hypoganodotropic hypogonadism. It is a long name for saying that your brain is probably not stimulating the ovary. It is likely due to a lack of adequate body fat. Not premature ovarian failure. Since you had a little response to the Provera challenge, that shows that you are making a little estrogen, but the increase in hair growth is consistent with an elevation of the male hormone testosterone. If the ovary is not stimulated to ovulate, it does not produce estrogen and the available hormone precursors go to make testosterone.

Body fat is important because it is the chemical basis for the production of all hormones. If the body fat is too low, because of excessive exercise or anorexia or bulimia, the brain shuts down the production of FSH and LH. This leads to a lack of stimulation of the ovary, hence the above result.

This diagnosis can be made with blood testing. You should be tested for FSH, LH, Prolactin, TSH, Estradiol and Testosterone. This would test all the possible sources of your lack of menstruation. They will probably find that your FSH and LH are very low. Your thyroid may also be out of sync because of the same problem. TSH is the preliminary test for thyroid function.

It would be best if you could get your BMI up above 20, and increase your body fat content.

I hope this helps.

Sincerely,

Edward J. Ramirez, M.D.
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.montereybayivf.com/

Monterey, California, U.S.A.

Tips On How To Boost Your Fertility & National Infertility Awareness Month

The month of October is National Infertility Awareness Month. Understandably, we appreciate the opportunity to educate the public regarding issues and current advances in this field. The American Society for Reproductive Medicine's annual meeting will be held in Atlanta October 18 - 21st. You can follow along on Twitter to see some of the issues that will be discussed by entering #ASRM09 on those days!

I would like to share some tips on how to improve your fertility. This issue affects some 7.3 million women and men in the United States, representing 15% of couples in their prime reproductive years.

AGE
I want to start with age, because it is one of the biggies. Women are born with 1-2 million eggs and by the age of 37 they have 25,000 left. How well you reproduce depends on an number of factors but one of the most important is the age factor. The quality of those eggs begins to deteriorate after 30, and more significantly after 35, due to poor egg quality. There is no way to change egg quality. Consider trying to start your family earlier rather than later. If that is not possible, staying on birth control pills might extend the viability of the eggs in a woman's ovaries by putting the ovaries at rest. Seek out help for infertility issues early instead of putting it off. If you are over 35 years old, make a well defined, aggressive treatment plan with a set time-line. Don't let your doctor reassure you that "everything is just fine and you just need to wait for it to happen." Basically I counsel my patients over 35, if no pregnancy after 6 months, see a fertility specialist for a complete and thorough evaluation (which should only take 1-2 months to complete), create a treatment plan in a set amount of time and move through that plan sequentially. For example, if you start with ovulation induction and intercourse, use that for 4-6 months, then move to IUI for 4 attempts only, then move to IVF. As time passes, your chances are only getting less, even with IVF.

HEALTH
The key ingredient here is good health and exercise in the years before trying to conceive. Exercising for at least 5 hours each week is recommended. Good habits start early, but it's never too late to start! Weight can also affect your ability to get pregnant, in some cases, and being too much above or below your ideal BMI (body mass index) can be detrimental. See the National Institute of Health's website to calculate your BMI: www.nhlbisupport.com/bmi/. Aim to be at an ideal BMI, however, don't postpone pregnancy for weight reduction if you are over 35.

DIET
A good diet prior to beginning your efforts to conceive is important as well. It makes sense to eat plenty of fruits and vegetables, but did you know that it's been found that milk products and yogurt are equally important? A Harvard Medical School study suggests that whole milk products, not skim, are responsible for protecting against ovulatory infertility. Another interesting finding has been that folic acid improves ovulation in women, and in men, sperm quality! It can be taken as a multi-vitamin and found in foods such as oranges. Eliminating trans fats in women who have diabetes seems to help as well. Moderate caffeine and alchohol intake is important as well. Again, ideal weight is beneficial. No matter what anyone says, there are no diets or foods that "enhance" fertility, but a healthy diet can help overall.

TIMED SEXUAL ACTIVITY
Many couples trying to conceive use over the counter ovulation kits. There are some things to keep in mind though. Most women ovulate 14 days before their next period. For example: If your cycles are 25 days, then you are most likely ovulating around cycle day #11. Your fertile period would then be CD# 9-13. Those are the days I would recommend intercourse. You should stop intercourse on CD#7 and wait until CD#9 to start. Have intercourse once per day on those five days, only one ejaculation per day. Start using your ovulation kit on CD #9 (counting back 16 days from the end of your average cycle). Remember, once the egg is released from the ovary, it’s only receptive to sperm and able to be fertilized for about 12 hours. If you have irregular cycles you may have another problem and you need to see a specialist to determine what is going on. But the absolute bottom line with timing is this, make it fun NOT scientific!! You husband will become a reluctant participant if it is forced. Don't tell him, "honey its my fertile time again we have to have sex", rather, he shouldn't even know. You should just set the stage to get him interested, excited and "horny." That way, you'll both enjoy the experience, and trying won't be a chore.

KICK THE SMOKING HABIT
Virtually all studies show that smoking impairs fertility. In women, 10 or more cigarettes a day reduces egg quality. Post-conception smoking has been linked to miscarriages and ectopic pregnancies. In men who smoke there is a problem of lower sperm counts and lower sperm motility as well, which means, lower sperm functionality. Even worst is smoking marijuana. Any chemical that goes into your body, goes into your blood stream, into your cells and into your sperm and/or eggs. This is an absolute no no! Same with other forms of recreational drugs including large amounts of alchohol. My rule of thumb is, if it affects your brain cells, then it affects your reproductive cells as well.

RELAX
Couples who are trying to conceive can become stressed, especially if they have been trying for more than a few years. Yoga, acupuncture, massage and meditation tapes expressly made for infertility patients all help. My patients are encouraged to use relaxation techniques. It helps them through the emotional ups and downs of the IVF process. The patients approach the procedure day in a much calmer, relaxed manner and it may make a difference in how well the retrieval and transfer goes. Going to see a therapist for massage therapy or meditation therapy may also be covered by insurance, if it can be shown that there is an anxiety disorder. As mentioned above, make it fun and enjoyable, not homework.

SCRUTINIZE YOUR DOCTOR

You want a doctor that knows fertility through and through. Most of these types of doctors will be able to offer ALL levels of infertility treatment. Just as you don't want a doctor that only does Clomid, your don't want a doctor that only does IVF. You'll be thrust into the only thing they can do for you, Clomid or IVF. It is easy to screen for this. . . just ask, "what levels and types of treatment can you perform for me?" Most importantly, infertility needs to be diagnosed and treated by a Physician specialist, not general practitioners, nurses, PA's or medical assistants.

IF ALL ELSE FAILS...
If your fertility journey is meeting too many roadblocks, then you may need to explore other options. Keep in mind, that if you fail to achieve pregnancy naturally, that is NOT the end of the road. I counsel my patients, "Nowadays, we can get almost anyone pregnant, it just depends on what I need to do to achieve the pregnancy". There are many reasons why a woman or man may be infertile and a visit to a good fertility specialist will certainly narrow down or actually pinpoint where the problem lies. Treatment often varies from person to person so don't expect to find the answer on a forum or in a chat room! Blocked fallopian tubes, high FSH levels, abnormal sperm count or low motility, all these and more account for infertility problems in many couples.

A diagnosis by a physician is necessary in order to effectively identify the best course of action for the couple trying to conceive. But, don't let your doctor just put you on Clomid without a good reason. Clomid is NOT a miracle drug. It has a specific purpose, which is to induce ovulation in women that don't ovulate. If you have regular cycles, that is a sign that you are ovulating. That means that the problem is something else and Clomid won't change that. Make sure that the treatment you are receiving is treating a specific problem. Ask you doctor to explain his/her strategy, why they are using the treatment they recommend and what they are treating. Treatment without a specific reason is a waste of time and money, as is treatment without the completion of a complete infertility evaluation. I can't tell you how many patients I have seen who have been on multiple cycles of Clomid or IUI's only to find out that her tubes are blocked!

Above all, stay positive, we are here to help!

Edward Ramirez, MD, FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF

Monterey, California, U.S.A.
Check me out on Facebook and Twitter with me at @montereybayivf