Join Dr. Carrie Bedient (Fertility Center of Las Vegas), Dr. Susan Hudson (Texas Fertility Center), and Dr. Abby Eblen (Nashville Fertility Center) as they welcome their special guest Erika Johnston-MacAnanny from Shady Grove Fertility in Richmond for a candid and informative conversation about what’s really going on with your period. Erika breaks down what’s considered “normal” in terms of cycle length and dives into what heavy or scant bleeding might be telling you about your health. From anatomical issues like fibroids and polyps to hormonal causes such as polycystic ovary syndrome (PCOS) or hypothalamic amenorrhea (common in elite athletes), this episode covers it all. Erika also shares insight on how IUDs and uterine scar tissue can affect your flow. The doctors also tackle some common myths—like whether a regular period always means you’re fertile—and explore what it could mean if your once-regular cycle suddenly shortens. Whether you’re just curious or actively trying to understand your fertility, you won’t want to miss this essential episode… period.
Episode Transcript:
Susan Hudson (00:00)
You’re listening to the Fertility Docs Uncensored podcast, featuring insight on all things fertility from some of the top rated doctors around America. Whether you’re struggling to conceive or just planning for your future family, we’re here to guide you every step of the way.
Susan Hudson MD (00:21)
This podcast is sponsored by ReceptivaDx. ReceptivaDx is a powerful test used to help detect inflammatory conditions on the uterine lining, most commonly associated with endometriosis and may be the cause of failed implantation or recurrent pregnancy loss. Take advantage by learning more about this condition at receptivadx.com and how you can get tested and treated, providing a new pathway to achieving a successful pregnancy. ReceptivaDx, because the journey is worth it.
Susan Hudson (00:51)
Hello everyone, this is Dr. Susan Hudson from Texas Fertility Center with another episode of Fertility Docs Uncensored. I am here with my amazing, audacious co-host, Dr. Carrie Bedient from Fertility Center of Las Vegas and Dr. Abby Eblen from Nashville Fertility Center. And we are so excited. I have a long time friend that I have known for too many years that we will not discuss.
Carrie Bedient, MD (01:05)
Hi!
Abby Eblen MD (01:08)
Hey everybody.
Susan Hudson (01:18)
Dr. Erika Johnston from Shady Grove in Richmond, Virginia. And we’re going to dive into a subject later with her, but we were talking before we got started that she loves a certain area of sports and it mainly involves a racket in a very small room.
Abby Eblen MD (01:39)
And a dirty little secret.
Erika Johnston-MacAnanny, MD (01:41)
It’s a dirty secret. No, indeed. So I’ve been playing squash for a lot of years. And so squash kind of like racquetball. So you can play, usually play with one other person. You can actually play it in pairs too. And that’s a blast. But yeah, it was just a way to keep it and…Stay sane and it’s just a great way to sweat it out after a long day.
Susan Hudson (02:06)
How do racquetball and squash differ?
Erika Johnston-MacAnanny, MD (02:07)
Mm-hmm. So racquetball, the ball’s a lot bouncier. So I have a hard time tracking it because it’ll go off four different things. But squash, it’s super fun. The racket’s a little bit longer, which is great because I’m a shorty. So it’s nice that you have a little bit more reach. And then the ball, it doesn’t bounce as much. So it kind of dies. Bounce is less than a tennis ball.
So you really are doing like a lot of lunging, which is great for strengthening and leg strength and cardio. Mm-hmm. I know. But the funniest part is that especially the young people can really pick it up well. And we have a lot of courts locally in Richmond. And of course, during pandemic, who wanted to be in a glass box with medical providers? So you had to pick someone that you lived with or that was vaccinated.
But my favorite dirty part of this secret is that there was a young woman that I used to play against when she was 12 and she was just learning and, I’d hit her these beautiful easy balls. But then pandemic, she played with her family and so we didn’t play for a few years and we started playing again. And my goodness, she just wiped the court with me. Was so good. So it’s humbling as well. It’s very humbling.
Abby Eblen MD (03:15)
Hahaha!
Carrie Bedient, MD (03:18)
So when I was in college, I used to play racquetball to ⁓ burn off steam, pre-med, too tightly wound, not much has changed. And so there was one summer that I had stayed over and I was working in the lab, because of course, as a pre-med, trying to get lab experience, trying to get published, running the whole game. And my preceptor, my lab director was, to put it mildly, not a nice human being.
And I really despise this man and so I would go play racquetball and one day I was so mad at him I drew his face on my racquetball. I smashed the crap out of it. Well I went up to the the front wall which of course is this huge white wall that’s like two stories high whatever turns out the image had imprinted all over the wall. All over the wall. And so I very quietly picked up my ball and got out of the gym and was sad that my artistic abilities happened to be really pretty on point that day. And I quit that job not that long after.
I don’t think I ever got found out, but if I did, serves him right.
Abby Eblen MD (04:20)
Now Carrie, that’s definitely a dirty little secret. You didn’t tell us about your dirty little secret.
Or maybe you just have so many, they just come out every now and then.
Susan Hudson (04:28)
You never know when one’s going to come up.
Carrie Bedient, MD (04:31)
Keep you guessing.
Susan Hudson MD (04:33)
Starting a family is one of life’s greatest adventures, but sometimes the path to parenthood isn’t as straightforward as expected. Shady Grove Fertility is there to guide hopeful parents every step of the way, offering compassionate care and advanced fertility treatments to help make parenthood possible. With their exclusive 100 % refund program for IVF and flexible monthly payment options, Shady Grove Fertility makes treatment more accessible.
Visit ShadyGroveFertility.com to schedule a consultation and take the first step, because the adventure of a lifetime starts at Shady Grove Fertility.
Susan Hudson (05:07)
All right, guys, how about a question? Okay, our question today is, hi Fertility Docs. Thanks so much for your podcast. You’ve provided so much to my journey. Thank you for listening. I’m a 28 year old female diagnosed with PCOS, HCG and saline sono normal. Been trying to conceive for a year, first with timed intercourse with Clomid, then two failed IUI cycles before moving on to where they are now with IVF. Their egg retrieval yielded 19 eggs, 10 fertilized, four made it to blast.
Did a Menopur then Lupron trigger. All PGT-A tested three euploid girls and one low mosaic trisomy 21 boy. My question is, what are y’all’s thoughts about transferring a low mosaic? Does the chromosome it occurs on matter? Should we transfer the low mosaic trisomy 21 first since this is the youngest, healthiest I’ll ever be to give him his best chance? Thank you.
Carrie Bedient, MD (06:00)
So I think that this is, there’s like at least two, if not three questions buried in this one. Cause one is, you transfer the low mosaic. The next one is how does the chromosome impact the low mosaic? And then the third is do you transfer the least likely embryo first? And so, to pick one little corner of that, transferring low mosaics has gotten more and more ground recently, especially as more are coming out that hey these can make you know happy healthy babies. They are at lower rates than if you are transferring a completely euploid embryo but if you get a healthy kid you get a healthy kid and that typically is low mosaics with single chromosome abnormalities as opposed to two three four chromosomes being detected. The issue here is that chromosome 21 and an extra chromosome 21 is what is considered to be Down syndrome and so I would be really hesitant to transfer this one mostly because I would be worried that that child would be affected. And it’s one thing to give this embryo the biggest shot at implanting and going forward. It is a completely separate question as to are you ready to deal with the medical components that may come with that because children affected by Down syndrome are affected by many other things as well, including abnormal connections between the esophagus and the trachea, other gut problems where it may be blocked, significant heart abnormality, predisposition to certain cancers, things like that that are far beyond just an intellectual impairment. And so that’s a much different, much bigger question. What do you guys think?
Susan Hudson (07:34)
Okay, I can say in our clinic, we don’t transfer any mosaics that are trisomy 18, 13, 21. And I think that is what you’re going to find in a lot of clinics. I know there are some clinics that would let you transfer, but also don’t be surprised if your clinic says, I’m sorry, we can’t. And so I think trying to find someone who’s willing to transfer the mosaic unless they happen to be open to it at your clinic, which would be a great opportunity. The concern is that most of the time if you transfer a mosaic under certain technologies, that the most likely outcome are no pregnancy, miscarriage or normal healthy baby.
There’s relatively low risk of actually being born with that chromosomal abnormality. However, because this is a chromosomal abnormality that is tied to higher live birth rates, that’s why a lot of clinics tend to have those policies. Different states have different laws. Sometimes physicians can actually get sued for intentionally bringing a child into the world that we knew had a higher risk of being abnormal. And so that ties into a hot ethical, moral debate that I don’t think that there’s a right or wrong answer. It’s just depending on what you want. You may have some more challenges
Carrie Bedient, MD (08:42)
Wrongful life.
Susan Hudson (09:03)
in getting a transfer to happen. Now, I understand what you’re trying to say, you’re the youngest, the healthiest you’re ever gonna be. And if you find in your heart that you’re like, I want to give this embryo the best chance and I have every intention, no matter what I need to go to do where that we’re going to transfer it. I mean, there is something to be said about, having that embryo transferred first. I’ve actually had somebody who it was not a trisomy 21 mosaic, it was a mosaic of some other random chromosome that they wanted to transfer their mosaic first intentionally. That is not what any genetic counselor or any of us regularly do. We generally wanna transfer the embryos that have the best chance first and then work our way down the line.
And so there’s a lot in that, but that’s exactly why I wanted to make sure we talked about this question.
Abby Eblen MD (10:00)
Well, I get the sense too that maybe she wants a boy, maybe because that’s the only boy, but I get the sense that maybe they’re really interested in having a boy. At our clinic, we would be willing to do it with appropriate counseling. We have transferred embryos and there isn’t wrongful life in Tennessee. And I actually have at least two people that I know of that have had children with Down syndrome, one of them passed away. And she said, if I had another Down syndrome pregnancy or embryo, I would transfer it. I would want another Down syndrome child.
I think it depends on your perspective on how you feel about that aspect of it as well. I think you could argue that if you transferred the embryo that had the least chance of being, I mean, aside from the Down syndrome part of it, but say it’s just a mosaic embryo, it probably does have the least chance of working. So the advantage I would think of transferring that one first would be, after you’ve transferred the other three euploid embryos, you wouldn’t have one left going well…we have three kids now, maybe two kids now. Do we really want to transfer that one? What do we want to do with it? If it’s at least likely to work, the argument could be let’s transfer that first. If it doesn’t work, then we’ll go to the euphoid girls at that point.
Susan Hudson (11:03)
What do think Erika?
Erika Johnston-MacAnanny, MD (11:04)
I think these are all great points. I think counseling is so essential in this situation, so she understands all the different pathways. I think to that end too, I’d want to understand her intention of if it is confirmed to not be a euploid fetus, but rather be a trisomy 21 fetus. I want to understand her perception of what her her reproductive plan there was, such that if she was electing to terminate the pregnancy, would also want to make certain that she was counseled well about some potential impact on the health of her endometrium as she goes to proceed with subsequent transfers. Sadly, we’ve all seen, myself included, patients who’ve had D&Cs for different reasons, but for pregnancy termination that have caused damage to their uterus such that it limits their ability to use her remaining embryos. So think that would be an additional step in counseling that I’d want to walk her through.
Abby Eblen MD (11:59)
Yeah, good point.
Susan Hudson (12:01)
Absolutely. Very good. Well, thank you for submitting that question. It’s something that we haven’t really talked about. And that’s really why we went to dive into these questions each week. So we are going to turn to our main topic. And our topic today that we’re going to dive into is the menstrual cycle and how it really plays into fertility.
So Erika, tell us a little bit about the menstrual cycle.
Erika Johnston-MacAnanny, MD (12:30)
I’m really excited to be here and talk about this topic because even though at face value, I think it sounds like such a basic thing. We’re not talking about amazing assisted reproductive technologies and genetic screening and those kinds of things that we all love talking about all day to our patients. It is such a core important issue to what we do every day to serve our patients.
One of things I just wanted to start with talking about is just how do we take a menstrual history from our patients? One thing, and I’ll be curious if you feel this way too, but I always perceive that the patient who’s coming in filling out their electronic medical history or their paperwork, that they perhaps feel pressured to write what they think I want to hear instead of what’s really happening with their bodies.
I’ll see it all the time where perhaps someone’s history, when we dig into it a little bit more, is different when we get into a conversation. And it’s so much more informative. And so I think my first comment would be that all of us, I’ll speak for myself, but I suspect we’re all on the same page. There’s no shame in not having all the data. We can talk through it. There’s no shame in not having a…perfect 28 day cycle. We don’t know that woman, right? So we really want to understand what the truth is. And sometimes it’s okay to not perfectly track everything too. We can talk through trends. That’s okay.
One of the things just to start, is when did period start for a patient? So, this called menarche for our patients. And there again, too, sometimes people don’t have a true exact age, but kind of a ballpark. But that’s a really helpful and insightful piece of information.
Susan Hudson (14:06)
So it’s important to know when you go see your doctor that they’re gonna ask you, when did you start having periods when you were younger? And you’re right. Some people know exactly and then other people it’s like, it was when everybody else was.
Erika Johnston-MacAnanny, MD (14:15)
Yes.
Abby Eblen MD (14:22)
Or they put me on a birth control because it was all messed up and I have no idea.
Erika Johnston-MacAnanny, MD (14:25)
Yes.
And that’s okay too. Cause that’s really informative. Yeah. And, and so I would say from our perspective, we definitely have some ages where we worry, wow, did some things happen, really young, less than third grade perhaps where patients started having, menstruation or early signs of, pubic hair or breast development where they were actually seeing a specialist. So that’s a really important piece for us.
Premature signs of puberty. Was that treated medically or was it just a normal variant? Was there a workup done? And sometimes people still have their family members in their life. I’ll ask them to pause and reach out to a family member to get more information. But you’re exactly right, Abby. Oftentimes patients, by the time they’ve seen us, they’ve also had…a good amount of time where they were using contraceptive, where they really didn’t have a sense of what was happening naturally, but it was rather masked by medications. So that’s important to differentiate what medications they were on. But really, since the onset of their period, I like to dig into the tempo of their period. How often are they having menstrual periods?
And there again, if they’re just reporting, and a patient’s perception obviously is so important. Sometimes people will say, my period’s very irregular. Tell me more about what you mean by that. they say, sometimes. Yes, yes. Yes, exactly. And so really, what I’m looking for is, it monthly-ish?
Are there skipped months? Are there skipped years? Because that’s certainly very informative and comparing and contrasting when they’re on medication versus when they’re off medication. So trying to understand the influence of medication versus what their body’s doing when they’re off of it.
Abby Eblen MD (16:12)
It’s important too to specifically ask them, which I know you’ll probably get to this about birth control, because more than once in my career the patient will say, oh yeah, regular periods, and you assume that they’re not on birth control and they’re trying to get pregnant, and then my nurse will go and she’ll like, did you know she was on birth control? I’m like, no, I didn’t know that. So that’s important to know.
Susan Hudson MD (16:30)
Exciting news from Fertility Docs Uncensored! Our long-awaited book, The IVF Blueprint, is now available on Amazon. Go now to pre-order your copy to learn everything you need to know about IVF, egg freezing, and embryo transfer.
Susan Hudson (16:44)
So what’s an important thing that we always talk about when we’re asking them how often they’re having their periods and they get really caught up on this, on that, what’s the first day of my period?
Erika Johnston-MacAnanny, MD (16:56)
I know. Yeah, no, that’s great. ideally, if someone has a menstrual period that happens spontaneously, if we have to define it, we’ll ask someone to say when the first day of full flow is, when’s the first time they need to use a pad or a tampon or a menstrual cup or, some kind of menstrual underwear that they would be otherwise staining, their underwear.
But Susan, to your point, you’re exactly right. So many of our patients will say, oh, good gracious, this is a hard question, because I’ll have spotting, spotting, spotting, then heavy flow, but then spotting again, but then heavy flow again. And so certainly that’s pertinent when we’re thinking about things either hormonally or structurally. And so there again, I want patients to really say those challenges, because I’ll make notations of them and think about some investigations to follow instead of feeling like they only have to give a half-baked answer. Yeah.
Susan Hudson (17:48)
Absolutely.
Carrie Bedient, MD (17:48)
And when we’re asking about, how many days is your cycle? And there’s always two interpretations of that. One is how many days is your menstrual cycle as a whole, meaning day one through day 25, 28, 31, whatever. And oftentimes people will say, oh yeah, my menstrual cycle is 23 to 24 days apart. And then we ask them in greater detail and say, okay, is that from the first day to what day? And so what are the ways that people can interpret that question and what are we usually looking for in the answer that will help guide us to make our clinical decision making?
Erika Johnston-MacAnanny, MD (18:14)
Yeah, so I think that’s that’s fair. Yeah, the tempo and does it come in an expected time?
Carrie Bedient, MD (18:34)
And is it the first day of, the first day of bleeding to the next first day of bleeding as opposed to the end of bleeding, the last day of bleeding to the end?
Susan Hudson (18:41)
Everybody always thinks it’s last day to first day.
Erika Johnston-MacAnanny, MD (18:46)
Yeah.
Carrie Bedient, MD (18:46)
I get a lot of that too.
Susan Hudson (18:47)
Anytime they put 21 days, I’m like, okay, 21, are we really having starting our period every three weeks, which that does happen to some people? Or is it that’s when you stop bleeding and that’s when you get your next period.
Carrie Bedient, MD (18:56)
Mm-hmm.
Yeah. And the same thing with, a bleeding cycle that lasts for 10 to 12 days. Are you really bleeding fully that entire time or is it five days of that stupid spotting that won’t go away but that is dark brown and old versus are you getting a significant amount of bright red bleeding that indicates active bleeding? And so those are some of the differentiating questions that we’re looking at because it helps us to know how to interpret somebody’s cycle.
Susan Hudson (19:28)
So Erika, you mentioned that there can be hormonal and there can be structural things that play into fertility that can be reflected in the menstrual cycle. So let’s break those down a little bit. So let’s start with the structural things. So what are some structural problems or challenges that we may be able to figure out? Maybe this is an issue based on what’s happening with a menstrual cycle.
Erika Johnston-MacAnanny, MD (19:33)
Mm-hmm.
Yeah, great question. So two things I like to think about when I’m talking to patients. One is, are they having more frequent bleeding than monthly bleeding? So are they having, medically we call it intermenstrual bleeding, right? So that’s one kind of oddball thing to think about from a structural evaluation. Second is they’re having monthly bleeding, but it is…now heavy is tricky, right? Because everyone’s heavy is different. I always think of one of my patients that I had who said, no, no, we just have heavy periods in my family. And she had described the situation where she was actually at a family funeral and was bleeding so heavily that she was thankful she was in a dark suit because she was able to kind of shimmy to the restroom because she was bleeding down her legs. But she said, no, no, but that’s my family. We have heavy menstrual periods.
Well, as it turned out, well, she and her sister had the same structural challenge, which in this case was actually a benign uterine fibroid, so an overgrowth of the muscle wall of the uterus. But in her case, it was actually central in her uterus. So we call it a submucosal position, but that was affecting her flow being very heavy.
So the heaviness is definitely pertinent and there certainly are some other structural causes for heavy flow. Certainly we want to think about other things in those cases. Many of my patients suffer from endometriosis, so uterine lining that implants within the peritoneal cavity. We all see patients that have diagnosed endometriosis.
But an extension of that that can cause heaviness of menstrual flow is adenomyosis. And that’s where actually the endometrium tends to grow within the muscle wall. And the description of this is always very illustrative to me where we describe the uterus as boggy. So that squishy, full, congested uterus and…And all those terms really describe it well when you actually see these uteruses surgically and also makes so much sense why these women have such heavy menstrual flow to the point where many of us, I’m sure, shared patients that need to be transfused or have other challenges where they’re anemic and having chronic challenges with the heaviness of their flow. So heavy definitely being two common causes for things I think about structurally.
Susan Hudson (22:08)
As a marker of heaviness, something that I often ask patients is, are you ever having to do two of something? Are you having to use two items to control your flow? Or are you having to use overnight pads as your go-to? Those things are not normal and those really need to be more fully evaluated. Other things that can cause really heavy bleeding, structurally polyps.
Erika Johnston-MacAnanny, MD (22:10)
Yes, great. Great question.
Susan Hudson (22:35)
We’ve got a lot of people who have risk factors for polyps, who come through fertility treatment, people who don’t have regular menstrual periods, so have those irregular periods. Because they don’t clean house every month, they structurally have an increased risk of getting those polyps. Also, women who have some extra weight, fat tissue actually produces a form of estrogen.
And the uterus is not picky, it’s like gimme, gimme, gimme, and those individuals also have an increased risk of polyps. So, I mean, I can say that I probably do two to four polypectomies a week.
Erika Johnston-MacAnanny, MD (23:16)
Yeah, they’re sneaky, the polyps too. And when I try and help patients envision them, I always liken them to skin tags because I think of, for me, if my seatbelt crosses my neck, sometimes I’ll get little skin tags there. And so I always think of them as little skin tags inside the uterus. Because that’s what they look like. When we’re doing hysteroscopy to treat and remove them. Yeah, but I was thinking about the patient’s question at the start of the podcast. So definitely agree, patients that have diagnosed with irregular cycles, I see polyps at higher incidence in those women for sure.
Susan Hudson (23:47)
Yeah. And segueing into that, things like PCOS, hormonal reasons that periods can be irregular.
Erika Johnston-MacAnanny, MD (23:55)
Mm-hmm. Yeah, so I had the pleasure of taking care of the North Carolina Courage Women’s MLS Soccer Team for some time. And those women, my goodness, they’re just so inspirational and amazing athletes. They do their health questionnaire, and you say, do you exercise? And they say, yeah. And they said, no, no, no, your half day of training is like any normal human’s full week.
So, yeah, so one common cause that I’ll see of irregular cycles are related to, from a hormonal standpoint, are that something is inhibiting the way that the brain communicates with the ovary. So in our patients who are elite athletes, like those amazing women, and many of our patients train very intensively, and we wanna support that.
But sometimes that level of training will inhibit the communication between the brain and the ovaries. And so we used to call it different things like runner’s triad, but medically we call it hypothalamic amenorrhea or hypogonadotropic hypogonadism. So that will cause prolonged or absent cycles in the extreme situation.
The thing to rule out in those situations, of course, though, in patients for whom their period goes away, is the worst case scenario that we also all see where the anterior pituitary is perfectly intact, the brain is sending it signals, but unfortunately, the ovary doesn’t have any answer back. And so in our patients who unfortunately are in a category of diminished ovarian reserve or premature ovarian insufficiency, and in those cases, the…hormone levels show us that the brain actually is working overtime, it’s almost yelling, screaming at the ovary, but the ovary unfortunately can’t answer back and bring to ovulation in regular or predictable fashion. So in those cases, hypergonadotrophic hypogonadism.
Susan Hudson (25:46)
Do you want to talk a little bit about PCOS as a hormonal reason periods can be a little irregular?
Erika Johnston-MacAnanny, MD (25:49)
Yeah. So the more common situation is exactly this. So many of my patients have PCOS. And I think the communication there’s kind of interesting. So I like to talk to my patients a lot about understanding how the brain talks to the ovary and PCOS. Because what we all see in our patients that have PCOS is that, in fact, the signal’s intact. When we do blood draw, we see that area in the brain that is central and controls ovulation.
It’s definitely speaking, there’s definitely a findable signal, a detectable signal, but it’s a ratio issue. So typically in our patients that have more predictable regular cycles, the two hormones that act as duo are partners in crime, our follicle stimulating hormone and our luteinizing hormone. They work together to signal to the ovary to ovulate, but normally the FSH level is higher than the LH level. That’s what we see when patients have predictable cycles. But in our patients that have PCOS or PCOS type morphology, because it is a bit of a spectrum, those women typically have an LH level that’s much higher than their FSH level. And it’s so perplexing to my patients too, because many of them dutifully are doing ovulation predictor kits and looking for urinary luteinizing hormone. They say, yeah, the stick says I’m ovulating. Well, actually the stick is just telling us that you have a high level of luteinizing hormone. So it can be a reason for false positive. But it’s exactly that challenge with the ratio that confuses the ovary. So the ovary is unable to really get to maturity. And get to the point where you’re actually able to predictably release an egg from the ovary.
The good news is there’s great medications to fix it, but first we have to affirm that that’s what’s happening. So in a lot of those patients, they’ll have these kind of jags where sometimes they’ll have a regular period, very commonly right after they’re coming off of birth control pill. But then it really spaces out to the extent that they’ll even skip months, skip several months. Sometimes patients say, well, gosh, I haven’t even had a period for a whole year.
And depending on what they’re hoping for, as teens, sometimes they say, yes, I haven’t had a period in a year. But obviously, when they’re trying to conceive, it’s more problematic. And so the very common pattern that we see in PCOS.
Abby Eblen MD (27:56)
Can you mention something that’s not hormonal but is a little bit more esoteric but we do see it and that is how scar tissue plays a role in having irregular periods?
Erika Johnston-MacAnanny, MD (28:14)
Yeah, I was thinking of what Susan had said, do you need two things to handle your flow? I think so many of my patients, really by the time I see them, they’ve really tried to be good historians and kind of track their flow. Apps are great for this, because most of our patients are busy working professional women. And so at least it lets them kind of real time track things and track the duration of their flow.
But oftentimes I’ll see patients who have had some kind of event happen in their uterus. So perhaps they had an IUD, perhaps they had an early miscarriage and needed to have a D&C surgical procedure for removal of pregnancy tissue. They had a polyp or a fibroid removed hysteroscopically and that necessitated surgery.
And so in those women, most commonly, there’s not a surgical consequence where it’s problematic or changes their period. But if a patient reports a change, right, just like two of anything is not good, I like that rule, ⁓ A change is definitely something that merits investigation. So when my patient says to me, I used to be able to use regular tampons and I needed a regular tampon, sometimes I leak through, but now my period is very scant, just a little bit of spotting or I’ll have cramping but really not see much on the toilet tissue when I’m using the restroom. That change is really concerning for me for development of scar tissue. So historically we used to call it Asherman’s syndrome and now uterine synechiae is more the term to be used. But that’s definitely a high risk situation for uterine scarring.
Susan Hudson (29:48)
We all have patients come in to us and they’re new patients and they’re like, I am healthy, I exercise, I’m doing all the right things, I’m taking my prenatal vitamins and my periods have always been normal. And they feel very reassured that there’s nothing wrong with them because they have regular menstrual periods that…happen like clockwork, they’re not too heavy, not too light. What would you say to someone who came to see you like that?
Erika Johnston-MacAnanny, MD (30:19)
Yeah, I think it’s a great start, but I would definitely say we have to be a little more comprehensive in the lens. But you bring up such a good point. Because while that’s a great start, I do think that oftentimes I’ll talk to patients for whom it’s a false reassurance as well, where they say, well, of course, my tubes must be open because my periods are regular. And I understand where that misinformation comes from.
But sometimes it’s shocking, so I’m thrilled we’re talking about it today to patients that absolutely there can be tubal abnormalities and still because the bleeding’s actually coming from the central portion of the uterus, not the fallopian tubes, that that may be a cause of infertility for them. The endometrium may be just fine, but it may actually be a tubal factor. And in the same way, I definitely have had patients who…presume that because their cycle is regular and predictable, they must be ovulating. But in fact, they’re having intermenstrual bleeding, or breakthrough bleeding, or anovulatory bleeding because they’re lining, I call it an avalanche, right, so you’re using two of things. The bleeding has thickened so much, or the endometrium, sorry, has thickened so much and pieces flake off, in an unpredictable manner. But if someone’s trying to track and that’s happening intermittently, they may misperceive it as an ovulatory menstrual cycle when in fact more investigation is needed. I would say to that patient, good start, but let’s not make the assumption that everything’s okay because of that. We really do want to do some more investigation together to get to the root cause.
Susan Hudson (31:58)
And just because you’re having regular menstrual periods doesn’t mean that ovarian aging isn’t happening. Women go on to have periods monthly often until they go through menopause and average age of menopause is 51. And so, there’s a long time that a lot of people have periods that hormonal, ovarian aging is happening. And I always think of it when I have the people who have historically had PCOS or polycystic ovarian syndrome and they haven’t started taking new supplements. They haven’t had weight loss. And they’re like, wow, over the last two or three years, my periods have just automatically become normal and they’ve been never been normal before. And now they’re in their upper thirties, early forties. And I’m personally having a little heart palpitation cause I’m like, Wow, you’ve fallen into where the rest of us are. And so, there are lots of important things we can get from a menstrual period. There’s lots of good history. But there’s not a right or wrong answer. And what we really need is to know exactly what’s happening for you.
Abby Eblen MD (33:08)
Well on the flip side, what would you say to a woman in her late 30s who says, you know, my periods have been 28 days, but now in the last couple years they’re more like 23 days apart.
Erika Johnston-MacAnanny, MD (33:17)
Yeah. My antenna would be up. So it always worries me when patients are having shortened intervals in their cycles. That worries me particularly for early ovarian aging. So in a woman who’s sharing that reproductive history, I would definitely want to do some ovarian reserve assessment. My favorite is AMH. We all love that hormone level. It’s the truth teller.
And I love for our patients, it’s convenient. They can go any day in their cycle. It doesn’t matter where they are. They can go that day and get it drawn. It’s not gonna be fasting. All these things. And it’s very reliable. It doesn’t fluctuate a whole lot month to month. So it really is helpful. But I would be concerned about something like that.
I like to also confirm it with a second evaluation and not just hang my hat on just one number alone. Not a second AMH, but rather I like to look at it a different way. So I find it helpful to also do an internal vaginal ultrasound to look at an antral follicle count to make certain that those two data points are giving us the same themes. I was thinking about what you were saying though about the…the regular menstrual periods not predicting your ovarian reserve. Building on that, I was also thinking of our patients that have their menstrual periods starting later, which is many women, particularly very athletic women or women that are very physically active. And I think one thing maybe to dispel is this idea of kind of a deferred menopause in those situations.
Yeah, so I’ll have patients that present perhaps at 44, but they thought they had more time because their menstrual period didn’t start until they were 16 or 17. And so they were doing backwards math and thinking, oh, that average age of menopause doesn’t apply to me. So unfortunately, it still does.
Carrie Bedient, MD (35:02)
Or if they have been on birth control their entire life and they’re like, I haven’t been ovulating, don’t I have more eggs? The logic sounds great, but unfortunately the reality doesn’t hold and those eggs go away whether or not they’re releasing.
Erika Johnston-MacAnanny, MD (35:07)
Mm-hmm. Mm-hmm.
Yeah. And during pregnancy too, I had a patient last month, she was really disappointed that she had had a successful pregnancy with treatment and came back to further expand her family. And she was very disappointed about the decline in her egg reserve during that time, because in her mind, she thought pregnancy helped her to save the eggs because she wasn’t ovulating during that time. And unfortunately, that’s not the case.
Susan Hudson (35:40)
Time is never our friend, unfortunately.
Abby Eblen MD (35:42)
Clock keeps ticking no matter what.
Erika Johnston-MacAnanny, MD (35:44)
Physiology is tricky for us. One thing that we didn’t talk about was painful menstrual periods. So I was thinking that might be helpful too for those patients that are wondering what amount of pain is normal. And sadly, patients that are dismissed by their doctors as just not being tough enough to get through their menstrual periods.
So this is something I talk about to patients all the time. Your menstrual period really shouldn’t take you out of work or take you out of school for several days. That’s not a normal amount of pain. And when a patient relates that kind of history to me, that it’s not just cramping or tolerable with ibuprofen or a heating pad, it definitely worries me for other conditions like endometriosis or adenomyosis that we had mentioned earlier.
So it’s definitely something where I’d want to start with a transvaginal ultrasound to look for more severe signs of endometriosis, which while a benign condition, certainly we see in many of our patients in more advanced cases can cause a lot of adhesions in the pelvis. And if it grows within the ovary, decline in the ovarian reserve, affect fallopian tube function and implantation.
Susan Hudson (36:50)
Yeah, you were mentioning that and as I was thinking about it and I knew you were going to start talking about endometriosis. Interesting thing about endometriosis is the severity of endometriosis actually does not relate to, we think about endometriosis when we hear pain, okay? But just because you don’t have pain does not mean you don’t have endometriosis. And I think a theme of what we’ve talked about today is normal is good, but normal does not necessarily mean great.
And so if everything’s stone cold normal, it doesn’t mean we don’t have a hormonal problem. It doesn’t mean we don’t have a structural problem. It doesn’t mean we don’t have something that’s lurking like endometriosis. If you do have something that’s abnormal, then we definitely want to pay attention to it. But we can’t rest on our laurels just because somebody has a cyclic 28 day period that doesn’t phase them.
Erika Johnston-MacAnanny, MD (37:29)
Yeah, well said.
Carrie Bedient, MD (37:44)
Trust but verify in everything.
Erika Johnston-MacAnanny, MD (37:46)
Yeah. And data is powerful. So many of our investigations are relatively non-invasive and it doesn’t tether your patient to having to jump into treatment. It just gives them good information about their own physiology. And that’s powerful. To help educate her or her partner about different treatment options is really wonderful.
Susan Hudson (38:04)
Absolutely. Very good. Well, I think we’ve talked a lot about periods and, really encompassed how the period reflects problems and challenges that we see in infertility. And thank you so much for joining us, Erika. It’s always great to see you.
Erika Johnston-MacAnanny, MD (38:19)
I really appreciate being here and this podcast is amazing. Thank you for all that you all do to help patients be more informed and come to their visits with amazing questions. So I really appreciate all the work that you do.
Carrie Bedient, MD (38:31)
Thank you.
Susan Hudson (38:31)
Thank you so much. To our audience, thank you so much for listening and subscribe to Apple Podcast to have next Tuesday’s episode pop up automatically for you. And also be sure to subscribe to YouTube. That really helps us spread reliable information and help as many people as possible.
Abby Eblen MD (38:32)
Thank you.
Carrie Bedient, MD (38:47)
Visit fertilitydocsuncensored.com to submit questions and sign up for our email list. Keep an eye out for our book being released on September 23rd and you can start to pre-order on Amazon now.
Abby Eblen MD (38:57)
As always, this podcast is intended for entertainment, not a substitute for medical advice from your own physician. Subscribe, sign up for emails, and we’ll talk to you soon. Bye.
Carrie Bedient MD (39:06)
This podcast is sponsored by ReceptivaDx. ReceptivaDx is a powerful test that can help detect inflammatory conditions on the uterine lining that might be preventing you from becoming pregnant or staying pregnant. If you have experienced implantation failure or recurrent pregnancy loss, ask your doctor about ReceptivaDx testing. If found, uterine inflammation can be treated, providing a new pathway to achieving a successful pregnancy. ReceptivaDx because the journey is worth it.