Day 21 No More
Nora Jane Pope, ND
Fertility Awareness is also gaining popularity with teens and single women who want to go off “the Pill.” Among teen prescriptions for the Pill, 17% are for PMS, acne, and dysmenorrhea.It is my hope that naturopathic physicians will become a driving force in teaching body knowledge and fertility literacy, thus rendering obsolete the prescription of the oral contraceptive pill (OCP) for menstrual discomfort. As part of my approach to women’s health, I invite my patients to integrate menstrual cycle charting and fertility awareness. Charting one’s cycle helps identify days of both fertility and infertility, which helps couples naturally regulate their fertility. Charting also helps predict hormonal triggers for PMS and seizures, and point to patterns associated with PCOS, endometriosis, and miscarriage.
Naturopathic philosophy blends itself seamlessly with fertility awareness, which appeals to couples that want to naturally regulate family planning without using chemical contraception.1,2 As more OCP side effects come to light, patients want information on other ways to balance hormones.
Since 2002, 4 waves of patients have integrated cycle charting into our treatment plan: 1) women with seizures;
2) couples in their 40s (and then couples in their 30s) struggling to conceive3;
3) breastfeeding or childless couples couples wanting to postpone their next pregnancy4,5; and 4) single young women who are stopping the OCP and want to cure their PMS, acne, and dysmenorrhea without suppressing hormones. Working with this last group is especially satisfying, since their goals are so consistent with our naturopathic guiding principles.
Charting reveals so much clinical information that it can become the patient’s road map for timing blood tests, ultrasounds, and even prescriptions and treatments. The woman’s chart becomes a tool for assessment, diagnosis, treatment, and then monitoring health.
How Does Charting Work?
I teach women how to chart their cycles by making observations as they wipe throughout the day. At night, they record on their Cycle Chart what they feel (sensation); what they see on the toilet paper (observation); and whether the mucus can stretch (“finger test”). The fertile days, or “cervical fluid days,” are days when the woman’s cervix discharges sperm-friendly mucus that is rich in fructose and glucose and which is alkaline in nature. This cervical fluid is biochemically identical to seminal fluid.
The discovery that specific types of cervical fluid correlate to the precise timing of fertility was elucidated by 2 Australian physicians, John and Evelyn Billings. Fertile cervical fluid is produced in response to rising blood estrogen levels. The key factor in determining whether a woman’s cervical fluid is fertile is its sensation. When wiping it off, the sensation is slippery. The last day of this slippery fluid is called the Peak Day and correlates highly with ovulation and the highest blood estrogen levels. The day after the Peak Day, the cervical fluid is no longer slippery, and has much resistance. This sensation is so easily detected that even blind women can determine their fertility.
I love seeing in my practice how cycle charting increases communication between spouses — how it nourishes the mental, emotional, and spiritual side of a couple’s sex life. Charting is a family planning system in which the woman doesn’t bear sole responsibility. I’ve seen how charting creates true intimacy for couples. Couples who chart together have a very low divorce rate.
Charting is a proven method for achieving pregnancy on days of shared fertility, or postponing pregnancy on days of the woman’s infertility.
When pregnancy does occur, charting has obstetrical benefits: Identifying conception (the days surrounding the Peak Day) results in a more accurate “due date,” hence less need to induce labor. Charting also facilitates earlier detection of Group B Strep infection, which presents as a light, watery discharge. Through early treatment of infection, charting can reveal the need for antimicrobial treatment, thereby preventing pregnancy loss due to infection-induced premature contractions.
Charting as a Diagnostic Tool for Infertility
After 2 full months of charting, hormonal imbalances are vividly revealed. I am trained in a particular fertility-care system,7 which uses the following protocols:
For days of bleeding, a red stamp is placed on the chart. Some cultures refer to these days as “Red Flow.” For dry days, a green stamp is placed on the chart.
For cervical fluid days (sometimes called “White Flow”), a white sticker featuring a baby is placed on the chart.
For the Peak Day, the letter “P” is written directly on the sticker. The subsequent 3 days are considered fertile. The numbers 1, 2, and 3 are written on the stickers. A consistent number of “Post-Peak” days (9-16 days) are then given green stickers.
A healthy chart features 5 days of bleeding, followed by a variable number of dry days, followed by 5-7 days of sperm-friendly cervical fluid, followed by the luteal phase (consistent from cycle to cycle). The range can be 9-16 days, depending on the number of days until a woman’s next period. A healthy luteal phase only varies by 3-4 days from cycle to cycle.
Typically, it takes 2 full months of charting before a woman can confidently identify her Peak Day. At this point the chart becomes a road map for assessing the root cause of her infertility.
Day 21 No More
The usual protocol is to order blood work on Day 21 for luteal-phase function. This is based on the assumption that ovulation always occurs on Day 14. When you consider that only 13% of cycles have a Day-14 ovulation, one can appreciate the unreliability of testing on this day.
Using the Peak Day, charting clearly identifies the end of the follicular phase. Post-peak days represent the true luteal phase, based on the woman’s individual physiology. Blood work is done on “Peak Day +7,” not on Day 21.
I like to order post-Peak blood work on Peak +1, +3, +5, +7, +9, and +11. A healthy cycle will have a crescendo-decrescendo pattern in the levels of both progesterone and estrogen.
The next step, after 3 months of charting, is to order an estrogen blood-work series, beginning on the mucus days on Peak -5, -3, and -1, and around the Peak. Again, you want to see a crescendo-decrescendo pattern. A follicular ultrasound series will also use the mucus days as a timing strategy.
Charting for Seizures
My first wave of patients consisted of women with unexplained seizures. I suspected a hormonal trigger. They reported symptoms of PMS. Some had a history of miscarriages, while others were unable to conceive.
After 2 months of charting, they observed premenstrual brown bleeding (PMBB) or tail-end brown bleeding (TEBB). These observations have been shown to reveal low progesterone in the post-peak phase, and low estrogen in the pre-peak phase. Low progesterone can be a trigger for seizures in some women.
Both infertility and seizures respond very well to classical homeopathy, botanical medicine, acupuncture, diet, clinical nutrition, and lifestyle counseling. Some women benefit from some bioidentical HRT. To restore hormone balance and fertility, some women may need pharmaceutical support in the areas of endorphin regulation and insulin sensitivity.
Going Off the OCP
Over the last 2 years, I’ve seen in a shift in attitude towards the OCP. More women in their 20s are getting off the OCP, and after 2 months of charting, they observed several signs of low progesterone or sub-fertility. Such signs can include: a menstrual bleed of < 5 days, < 5 days of sperm-friendly, fertile cervical fluid; a variable post-peak phase from cycle to cycle; PMBB at the end of their cycles; and TEBB.
More women are also experiencing a prolonged pre-phase, with cervical fluid stopping and starting — a classic PCOS presentation. Other cycles reveal a prolonged post-peak phase, which can occur with luteinized unruptured follicle (LUF) syndrome.
All of these infertility signals are suppressed by the OCP.
Lately, I have been teaching this information to teenagers and young women with developmental delays. Some miss a lot of school due to PMS and dysmenorrhea.
Teenagers feel very empowered when they observe their “White Flow.” They know that their PMS can start in the luteal phase, sometimes due to low progesterone. Diet modification and post-peak B vitamins help resolve many PMS symptoms.
Charting as an Alternative to the OCP
What started as an interest in fertility awareness has turned into a philosophical meditation on the cultural benefits of listening to fertility signals. The OCP prevents women from fully restoring their health; it also prevents the clinician from properly investigating the root cause of hormonal dysfunction.
Note the growing body of research linking conditions and OCPs:
- Drug-induced nutrient deficiencies
- No protection from sexually-transmitted infections; also a potential increased susceptibility to susceptibility to HPV8
- Pregnancy due to higher failure rates than reported9
- An increased risk of breast cancer10; in 2005 the World Health Organization added the OCP to its list of carcinogens11
- Risk of embolism and stroke12
- Death (in 2013, 23 Canadian women died who were using a leading estrogen/progestogen-containing OCP13)
- Anecdotal evidence of nausea
- Decreased libido16
- Decreased fertility due to lower ovarian reserve, especially when the users were teenagers17
- Multiple sclerosis18
- Bone loss and osteopenia,21 especially when the users were teenagers
- Finally, there is an environmental toll, as fish populations become sterile due to excessive estrogens from sewage.22
Paternalism vs Partnership
A particular study examining patient consultations for contraception fascinated me: “While 41 percent of [female patients] ranked questions about safety as one of their top three concerns, only 20 percent of the doctors thought discussing safety was a top priority.”23,24
A cultural consequence of the Pill is a paternalistic attitude that expects women to be constantly sexually available. Safety often takes a back seat during doctor-patient interactions.
Female patients want safe family-planning options and safe hormone-balancing options. As naturopathic physicians, we are in the enviable position of being team players with our patients. We understand our patients’ desire to be active participants in achieving their health goals.
Charting as a Spiritual Bridge Between the Sexes
In my practice, I have witnessed the following dynamics:
In a fertile couple that wants to temporarily impose infertility with the OCP, the woman can become a sex object; she is expected to deliver sex on demand
In an infertile couple that wants to temporarily impose fertility, the man can become a sex object; he is expected to deliver sex on demand
As adults, we regularly postpone all kinds of pleasures. I submit that couples that choose to postpone sexual intercourse in order to postpone pregnancy achieve a higher level of intimacy.
If you’re ever in a situation where one of your female patients is considering the OCP for suppressing uncomfortable hormonal symptoms, please consider integrating cycle charting into your practice.
Nora Jane Pope, ND, is a graduate of McGill University and the Canadian College of Naturopathic Medicine. Since 1994, she’s been a user and advocate of Fertility Awareness and Cycle Charting. Since 2001, she’s treated adults and children with seizures; men and women with hormonal imbalances; Marfan’s syndrome; and chronic conditions. In her practice, she uses classical homeopathy, botanical medicine, acupuncture, clinical nutrition, and lifestyle counseling. She integrates the Creighton Model FertilityCare™ Charting System in her practice. Dr Pope harnesses drug-herb and drug-nutrient interactions to increase the efficacy of her treatments. In her spare time, she enjoys travel, tennis, the Lindy Hop, Belgian beer and merlot from Bordeaux, France. She is fluent in French.
- Northrup C. Women’s Bodies, Women’s Wisdom. New York, NY: Bantam; 2010.
- Freundl G, Frank P, Bauer S, Doring G. Demographic study on the study of natural family planning behavior of the german population: the importance of natural methods. Int J Fertil. 1988;33 Suppl:54-58.
- Hilgers TW, Kaly KD, Prebil AM, Hilgers SK. Cumulative pregnancy rates in patients with apparently normal fertility-focused intercourse. J Reprod Med. 1992;37(10):864-866.
- Hilgers TW. The Statistical Evaluation of Natural Methods of Family Planning, Intl Rev of Natural Family Planning, vol. 8, no.3 (Fall 1984), pp.226-64.
- Doud J. Use-effectiveness of the Creighton Model of NFP, vol.9, no.54 (1985).
- Introductory lecture, Billings Ovulation Method, Natural Family Planning Association, Toronto, November 14, 2003.
- CREIGHTON MODEL FertilityCare™ System. Available at: http://www.creightonmodel.com/. Accessed November 5, 2014.
- de Villiers EM. Relationship between steroid hormone contraceptives and HPV, cervical intraepithelial neoplasia and cervical carcinoma. Int J Cancer. 2003;103(6):705-708.
- Infographic: Contraception is Highly Effective. June 5, 2013. Guttmacher Institute Web site. https://www.guttmacher.org/media/inthenews/2013/06/05/index.html. Accessed November 5, 2014.
- Beaber EF, Buist DS, Barlow WE, et al. Recent oral contraceptive use by formulation and breast cancer risk among women 20 to 49 years of age. Cancer Res. 2014;74(15):4078-4089.
- Agents Classified by the IARC Monographs, Volumes 1-111. International Agency for Research on Cancer. IARC Web site. http://monographs.iarc.fr/ENG/Classification/ClassificationsGroupOrder.pdf. Accessed November 5, 2014.
- Pymar HC, Creinin MD. The Risks of Oral Contraceptive Pills. Semin Reprod Med. 2001;19(4). Available at Medscape: http://www.medscape.com/viewarticle/421027_2. Accessed November 12, 2014.
- Yaz, Yasmin Birth Control Pills Linked to 23 Deaths. June 11, 2013. Science Daily Web site. http://www.sciencedaily.com/videos/579311.htm. Accessed November 12, 2014.
- Grant EC, et al. Effect of oral contraceptives on depressive mood changes and on endometrial monoamine oxidase and phosphatases. Br Med J. 1968 Sep 28;3(5621):777-80.
- Gahr M, Freudenmann RW, Connemann BJ, et al, et al. Rapid relapse in depression following initialization of oral contraception with ethinyl estradiol and chlormadinone acetate. Gen Hosp Psychiatry. 2014;36(2):230.
- Hitti M. Halting Oral Contraceptives: Effects Linger. May 19, 2005. Web MD Web site. http://www.webmd.com/sex/birth-control/news/20050519/halting-oral-contraceptives-effects-linger. Accessed November 12, 2014.
- European Society of Human Reproductive and Embryology. Future reproductive lifespan may be lessened in oral contraceptive users: Lower measures of ovarian reserves. July 1, 2014. Science Daily Web site: http://www.sciencedaily.com/releases/2014/07/140701091448.htm. Accessed November 5, 2014.
- D’hooghe MB, Haentjens P, Nagels G, et al. Menarche, oral contraceptives, pregnancy and progression of disability in relapsing onset and progressive onset multiple sclerosis. J Neurol. 2012;259(5):855-861.
- Baron-Faust R. Some Birth Control Pills Pose Gallstone Risk. April 20, 2011. MedPage Today Web site. http://www.medpagetoday.com/OBGYN/GeneralOBGYN/26030. Accessed November 12, 2014.
- Aggarwal RS, Mishra VV, Aggarwal SV. Oral contraceptive pills: A risk factor for retinal vascular occlusion in in-vitro fertilization patients. J Hum Reprod Sci. 2013;6(1):79-81.
- Lopez LM, Grimes DA, Schulz KF, et al. Steroidal contraceptives: effect on bone fractures in women. Cochrane Database Syst Rev. 2014 Jun 24;6:CD006033.
- Nash JP, Kime DE, Van der Ven LT, et al. Long-term exposure to environmental concentrations of the pharmaceutical ethynylestradiol causes reproductive failure in fish. Environ Health Perspect. 2004;112(17):1725-1733.
- Singh M. Doctors Don’t Know What Women Want to Know About Birth Control. June 10, 2014. National Public Radio Web site. http://www.npr.org/blogs/health/2014/06/10/320641019/doctors-dont-know-what-women-want-to-know-about-birth-control. Accessed November 5, 2014.
- Donnelly KZ, Foster TC, Thompson R. What matters most? The content and concordance of patients’ and providers’ information priorities for contraceptive decision making. Contraception. 2014;90(3):280-287.