Dr. Susan Caldwell
I Have A Dream...
Every single woman will experience irregular cycles and problems related to her menstrual cycle during her lifetime. This is because, like many systems in our body, the process of healthy ovulation (the primary purpose of the menstrual cycle) takes time (up to 10 years) to mature into a healthy, ordered process. And later in life, after several decades of healthy ovulation, the cycles will naturally become disordered as we eventually stop ovulating sometime after age 35– usually much later into our 40s. This process of degeneration also takes approximately ten years to run its course until the final menstrual cycle ends in the stage of menopause.
What has been your experience when you have brought these problems to the attention of a medical provider? Were you educated on the normal gradual maturation of the process of ovulation in the teen years? It is more common that when women complain about various symptoms of disordered ovulation, doctors don’t educate or reflect on what may be the underlying cause of the problem. Instead, doctors are trained to reflexively offer a one-size-fits-all solution of a version of birth control involving a synthetic hormone that suppresses the natural process of ovulation in favor of a counterfeit monthly withdrawal bleed that mimics a natural period.
We are living through a time of crisis regarding women’s reproductive health. Our traditional medical model of treating disease is failing most patients, but women are significantly harmed. The practice of medicine is geared toward managing symptoms rather than towards working to restore optimal health to our patients. Medical schools teach us how to find the right drug or surgery for the problem but not how to accompany the patient from disease to health. This situation, in general, is bad enough, but the situation is incredibly bleak in women's health. Since the birth control pill began to be prescribed in the 1960s, doctors have used the drug not just to prevent or postpone pregnancy but to “treat” all sorts of symptoms affecting women, including acne, painful periods, and mood disorders. Many of these symptoms stem from a deeper disease – an inability to ovulate healthily.
I was taught in medical school that ovulation was a simple process of releasing an egg from the ovary each month. It either happened, or it didn’t. I learned that it was not necessary for health but an optional function of biology that could easily be turned on or off, like a light switch. I thought of it as I did of any modifiable bodily feature such as hair length or contact lenses – something to agree to or to opt-out of without severe consequences. I now realize that I was seriously mistaken.
Almost every day in the clinic, I meet women who have fallen victim to this faulty paradigm in women’s health. Their cycles reveal to them that they are not ovulating well or not at all. They report to their doctors, but they cannot help them with any other solution than some synthetic hormone that perpetuates the problem of not being able to ovulate. I have been working with these women for years and listening to their stories of feeling dismissed and even harmed by their doctors’ advice. It is heartbreaking to hear what many of them have experienced. The saddest stories are those of women who have been given these hormones for 10 to 20 years without warning of the long-term harm to their bodies and fertility. The birth control pill was initially designed to be taken for only 2-3 years to give women more time between the births of their children. We are now living through an experiment that teaches us what happens when women take birth control for many years.
I see the frightful results of this grand experiment every day in my office as I hear the stories of so many women who have agreed to this treatment plan. They stop their birth control and are left with highly disordered menstrual cycles and many symptoms that are difficult to live with. Many of them desire fertility and are horrified to learn that years of birth control have crippled their ability to ovulate naturally. At this point, they are referred to fertility clinics where they are offered artificial reproductive technologies like in-vitro fertilization (IVF) as their only option to have a baby.
This is such a common scenario for women today. This is my story. With each of these women, I create a space for her to share her anger, grief, and disappointment in how she was treated. And how she agreed to this treatment. I am quick to extend forgiveness and mercy to the OBGYNs who have offered this treatment, knowing that they are only following the treatment protocols taught to be “standard of care”. I explain to them that by taking birth control, they were not simply flipping a switch and turning off the process of ovulation until they were ready to have a baby. If only it were so simple.
Ovulation is not an optional function of our bodies. Ovulation is necessary for a woman to be optimally healthy. She can survive without ovulation, to be sure, but she cannot thrive without ovulation. You can learn more here from Dr. Lara Briden
The primary function of birth control is to prevent ovulation, but that’s just the beginning. Birth control diminishes the entire reproductive system, known as the HPO axis.
During the first decade of menstrual cycles, the brain, ovaries, and uterus learn how to work together as a healthy system – the endpoint being regular, healthy ovulation. Each month, starting around 12 years old, a girl’s brain begins to send messages (hormones) to the ovaries. The ovaries become responsive to those messages and eventually learn to respond by ovulating. During ovulation, essential hormones are produced – estradiol and progesterone – these hormones are crucial to the development and maturation of the inner lining of the uterus (endometrium). Every month, the endometrium “learns” how to grow a healthy lining during the first phase (proliferative phase) of the menstrual cycle under the direction of estradiol, followed by the second phase (secretory phase) that depends mainly on the hormone progesterone.
The uterine lining is a dynamic organ that depends on cyclic, monthly growth and shedding to remain healthy. When a woman is on birth control, her natural estradiol and progesterone production is suppressed, and her lining remains thin and stagnant (she does not benefit from ovulation hormones). A thin, stagnant lining is not healthy and cannot support a healthy pregnancy. Again, it takes time for the uterine lining to become adept at building up and shedding as directed by the ovulation hormones. When a woman is on birth control hormones for years or decades, this development process cannot occur. Many women experience the pain of infertility and miscarriage as a result. Unfortunately, “treatments” such as IVF do not work to nurture the endometrial lining to become receptive to implantation.
This is like how we learn to walk or talk as young children. It takes years for these systems to function optimally under healthy circumstances. The same is true for a woman’s ability to ovulate. Using the example of a toddler having trouble walking, imagine that the doctor recommended keeping the child in a wheelchair or other suppressive treatment instead of offering other more restorative treatment such as physical therapy or surgery. The child would have almost no chance of gaining the ability to walk or run efficiently.
I believe it is possible to change the trajectory of women’s health for the better. What will it take? Here are some of my thoughts:
1. We as a culture, beginning with women themselves, need to start to appreciate that healthy women are women who ovulate, and ovulation is a sign of health.
2. Women should learn to identify and think of healthy ovulation as a sign of health – similar blood pressure, healthy skin, or other more easily visible health markers. This will usually involve finding a teacher or health coach to help her know the signs of ovulation.
3. Medical professionals should begin to restrict their prescribing of birth control and stop regarding these harmful chemicals as a kind of “treatment” while recognizing that they are endocrine disruptors (i.e., poison for our reproductive system).
4. We need many more medical professionals to become proficient in nurturing women's HPO axis so they can achieve optimal health. This may mean that this work should be done by a specialty other than OBGYNs (who are incredibly overwhelmed with responsibilities).
I will address the “how” of this “nurturing ovulation” process in a future blog post. In the meantime, I’d love to hear your ideas about how we can work together to improve this area of women’s health.