Thyroid Issues

The health and function of the thyroid gland is directly related to a woman’s menstrual cycle, her fertility, and her health. The thyroid is a small butterfly-shaped organ that sits in the front of the neck. Small but mighty- it serves as a control center for many critical functions in the body like metabolism, brain function, menstrual cycles, and fertility.  Because the thyroid gland is part of our hormonal system, the thyroid interacts with every other hormonal system in the body (ovaries, adrenals, pituitary, etc.) for a woman’s optimal reproductive health. When a woman is having difficulty getting pregnant, evaluation of her thyroid for the optimal  function must always be considered. Thyroid problems come in two forms; hypothyroidism (low thyroid function) and hyperthyroidism (excessive thyroid function). 

Hypothyroidism

Hypothyroidism is a common, undetected factor for menstrual cycle and fertility problems. Thyroid problems are accompanied by an imbalance between estrogen and progesterone levels which leads to irregular cycles and fertility issues. Thyroid imbalances also disrupt metabolism and reduce cellular energy, affecting normal ovulation. Moreover,  low thyroid function can also cause:

• Short luteal phase
• Long or short cycles with heavy bleeding and cramps
• Increased insulin sensitivity
• Low-quality cervical fluid
• Low libido
• Increased risk for PCOS, a cause of irregular or anovulatory cycles
• High prolactin levels, which can suppress ovulation. 
• Infertility

It is estimated that one in 8 women has thyroid disease and 50% of them are unaware that they have it- hence many women go undiagnosed. The symptoms of thyroid dysfunction can be vague and may be missed until a woman presents with infertility when she is attempting to get pregnant. Hypothyroidism is the most prevalent form of thyroid disease, and greater than 90% of people diagnosed with hypothyroidism have Hashimoto’s disease.  

Hashimoto’s disease

Hashimoto’s thyroiditis is an autoimmune disorder in which the immune system in your body begins to attack your thyroid gland, slowly damaging and destroying it. This damage can lead to a reduction in thyroid hormone levels or hypothyroidism. Women are ten times more likely to have Hashimoto than men making it increasingly important to consider in a women’s’ health and fertility. Hashimoto’s commonly occurs during major shifts in a person’s life- and can often occur after a period of high stress.  Symptoms of hypothyroidism and Hashimoto’s are many and can include the following:

• Irregular or absent menstrual cycle
• Long periods (> 6 days) or short cycles (< 21 days)
• Heavy bleeding during period
• Painful periods
• Early puberty in girls under 10 
• Infertility 
• Miscarriage
• Anxiety
• Fatigue 
• Weight gain or an inability to lose weight
• Depression 
• Irritability
• Memory loss
• Difficulty concentrating 
• Hair loss or dry, brittle hair
• Dry skin
• Difficulty swallowing
• Constipation
• Sensitivity to cold
• Joint and muscle pain
• High cholesterol
• Low resting temperature

Many doctors screen patients for thyroid function with one simple test called a Thyroid-Stimulating Hormone (TSH). If the TSH falls within normal ranges, the thyroid is considered normal and healthy.  However, a complete thyroid evaluation requires TSH testing as well as additional tests of thyroid function including total T4, free T4, free T3, reverse T3, and thyroid antibodies (both thyroglobulin and thyroid peroxidase antibodies). The combination of these tests allows a complete evaluation of thyroid function as well as the diagnosis of Hashimoto’s disease.  

Because optimal thyroid function is critical to the health of the baby as well as the mother, pregnancy will not be possible unless thyroid levels are not only “normal” but are “optimal”. Unfortunately, because thyroid antibodies can fluctuate in Hashimoto’s thyroiditis, a single negative antibody test does not necessarily rule out Hashimoto’s disease or its effect on fertility.  A physician should repeat the antibody testing multiple times in a woman who is having difficulty getting pregnant because of this fluctuation in thyroid antibodies. Optimal thyroid hormone levels are essential for the healthy development of your baby’s brain and many women require thyroid hormone adjustment during the first trimester of pregnancy when thyroid needs often go up by 30-50% for mother and baby.  

Hyperthyroidism

Hyperthyroidism is a condition where an excessive amount of thyroid hormone is made, causing overstimulation of your body which can lead to symptoms such as anxiety, rapid heart rate, bone loss and difficulty getting pregnant. Hyperthyroidism is commonly caused by Graves’s disease- another type of autoimmune thyroid disease affecting the thyroid gland. Unlike hypothyroidism, hyperthyroid individuals typically are aware of this condition because the symptoms of Graves disease are not vague.

Remember! Having the right amount of thyroid hormone for your individual needs is essential to your well-being. Women are more likely than men to develop thyroid problems, and the months after birth are an especially high risk for thyroid problems to surface.  If you’ve been having trouble getting pregnant,  have irregular periods, think you are not ovulating, or have had a miscarriage, it is important to have your thyroid function checked BEFORE you get pregnant to make sure your levels are optimal to conceive and maintain a healthy pregnancy.  If you feel unusually blue in the year after the birth of your baby, or at any time, and especially if you have any of the above symptoms, get tested for thyroid problems!

Polycystic Ovarian Syndrome (PCOS)

PCOS affects about 10% of women and is not a problem that starts in the ovaries. It is a syndrome that impacts your entire body and is caused by an imbalance and overproduction of hormones including insulin and male hormones. This imbalance leads to the production of immature follicles that rarely release eggs. Because normal ovulation does not occur in these women, they often have difficulty getting pregnant. PCOS is a common cause of female infertility and is the most common cause of infertility in women who do not ovulate normally or have regular menstrual cycles. PCOS is still a topic of confusion and disagreement in the medical community because of its presents with a variety of conditions that vary from woman to woman. Common symptoms include:

• Irregular or long (>35 days) cycles that rarely result in ovulation
• Limited cervical fluid for long periods of time
• High-quality cervical fluid with or without ovulation for long periods of time
• Infertility
• Excessive body or facial hair
• Male pattern hair loss 
• Acne
• Difficulty losing weight and/or obesity-related to insulin excesses. 

Some clinical symptoms checked with ultrasound include:

• Enlarged white ovaries that appear to have a ‘string of pearls’ on the surface due to immature follicles that don’t reach maturity to release and egg. 
• Elevated testosterone and LH levels with LH produced in excess of FSH (opposite the normal ratio).  
• When ovulation occurs it’s often abnormal (abnormal egg and corpus luteum). 
• Elevated insulin levels with excess weight gain and inability to lose weight. 

Besides the common clinical symptoms of PCOS, women with this condition have a high risk of developing long-term health problems, such as insulin resistance, metabolic syndrome, high blood pressure, diabetes type 2, heart disease, endometrial cancer, breast cancer, and ovarian cancer (from unopposed estrogen).

How To Diagnose?

There is believed to be a genetic component to PCOS and although women develop the condition in their teens, they are typically not diagnosed until their 20’s or 30’s. Women with PCOS usually have 2 out of three of the following symptoms:

• Irregular long (>35 days) cycles
• Increased male hormones causing an excess of body of facial hair, acne or male pattern baldness
• The ‘string of pearls’ on the ovaries determined by ultrasound 

The good news is that there is a new diagnostic test to help evaluate for PCOS, the anti mullerian hormone (AMH) test. AMH measures the number of follicles present and is often considered an accurate marker for PCOS (there are an excessive number of follicles and this level will be high) along with high fasting insulin levels, high free and total testosterone levels, and high DHEA sulfate levels.

Integrated Medical Treatment

Before you venture into medications or medical procedure, you should try to control PCOS with natural methods which include:

• Exercise to  try to achieve and maintain an ideal body weight (body fat in the mid 20%)
• Focus on a low-carbohydrate, low-glycemic diet
• Combine carbs with fat and protein to balance blood sugar
• Select foods with more fiber and less sugar
• Space carbohydrate-heavy foods throughout the day to avoid dramatic blood sugar increases
• Minimize foods that trigger cravings
• Stay hydrated and limit caffeine
• Choose monounsaturated & omega 3 fats over saturated & trans fats
• Supplement with calcium (2-3 pills 400 mg daily) and if trying to conceive:  multivitamin with 400mcg of folic acid
• Supplement with d- chiro- inositol (see below)

Traditional Medical Treatments

• Birth control pills may regulate the irregular bleeding associated with PCOS, but it doesn’t resolve the underlying cause of PCOS
• Metformin (Glucophage) helps insulin work more efficiently thus lowering levels of insulin and allowing weight loss and reduction of males hormone levels associated with PCOS
• d- chiro- inositol (DCI) helps insulin work more efficiently, improves ovulatory function while decreasing androgen levels and high blood pressure 
• Cyclical Progesterone therapy is believed to help balance the excess of male hormones which cause delayed ovulation and ovarian imbalances.

• Ovulatory drugs stimulate ovulation in women that do not ovulate on their own and increase the chance of conception. There are two main drugs which support ovulation:
  • Clomiphene citrate (Clomid) is taken for five days either from cycle days 3 through 7, or from day 5 through 9 at a dose of one tablet (50mg) daily. If the patient does not ovulate on this dose, progesterone can be given to start a period and a 100mg or 150 mg dose can be tried. The average day that ovulation occurs is about 8 to 10 days after completing a 5-day course of Clomid. Remember also that Clomid can lead to poor cervical fluid and endometrial lining and quality due to its antiestrogenic effect! 

• Letrozole (Femara) can suppress estrogen levels which will increase the output of FSH (follicle-stimulating hormone) from the brain. In women with PCOS, the increase in FSH hormone can result in the development of a mature follicle in the ovary and ovulation of an egg. The drug can also stimulate the release of multiple eggs which can increase the chances for pregnancy. The most common dose is 2.5 mg per day typically taken for 5 days, starting on the 3rd to 5th day of your menstrual cycle. 

Concerns A 2005 FDA report on Femara reported a possible higher incidence of birth defects based on animal studies. That is why many doctors will not prescribe letrozole. However, a 2006 study on 911 newborns showed that there was no difference in birth defects between clomiphene citrate and letrozole groups. Similar results were shown in a Cohrane review study including 7935 women! Moreover, a 2014 study on 623 children demonstrated that birth defects were similar among women who conceived naturally, took CC or letrozole. Finally, a 2014 study on 750 women with PCOS not only resulted that there was no significant difference in birth defects between clomiphene citrate and letrozole groups, but also that letrozole had higher live-birth and ovulation rates compared to clomid.

• Gonadotropin therapy is a second-line therapy if Clomid and Glucophage are not successful. There is a high risk of ovarian hyperstimulation.
• Ovarian drilling and ovarian wedge resection reduces male hormone levels which can be useful for women who don’t ovulate with Clomid or Metformin. Because serious side effects can occur (adhesions preventing pregnancy), this should be performed by physicians with experience doing this procedure

• If you’re experiencing irregular cycles, especially very long cycles, you should seek help from your physician. PCOS is associated with long-term health risks!

If ovulation is achieved with PCOS some women consider egg harvesting and freezing when they are younger to increase the likelihood of conceiving and delivering a child at an older age.

Endometriosis

Women with this condition have tissue from the uterine lining that implants itself in places other than the uterus. The reproductive hormones in a woman’s body are believed to increase the growth of endometriosis when it occurs. This can cause a wide variety of symptoms including:

• Intense menstrual cramps
• Painful intercourse 
• Infertility 
• Excessive bleeding during menses
• Chronic pelvic or low back pain
• Spotting in between periods 
• Gut pain
• Fatigue or low fever
• Painful urination or bowel movements during your menstrual periods
• Diarrhea, constipation, bloating, nausea, dizziness, or headaches during periods
• Low resistance to infection

How To Diagnose?

The diagnosis of endometriosis is generally quite difficult. In combination with the symptoms above, if you notice these fertility issues, you should be tested.

• A luteal phase that is normal in length but shows low body temperatures indicating lower than normal progesterone levels during the luteal phase.
• Short cycles (<27 days) with long periods (>8 days).
• Almost no days of wet cervical fluid or even dry days during the cycle.

The “golden standard” is laparoscopy (microscopic examination of the tissue). A “near-contact” laparoscopy is best because tiny endometrial cells can often only be seen at a greatly magnified level. Women with endometriosis may want to consider trying to conceive earlier vs later in their life because this condition is difficult to treat and outcomes of treatment are unpredictable.

How To Treat?

There are a few available treatments for endometriosis, but unfortunately, remission is rarely permanent after medical treatment and it should always be personalized because of the number of variables associated with endometriosis.

• Nonsteroidal anti-inflammatory drugs can reduce pain but have no effect on reducing the endometriosis itself. 

• Hormonal birth control can reduce the production of hormones in a woman’s body preventing ovulation and pregnancy, and thus the growth of endometriosis. Birth control pills can also decrease the bleeding that may cause pain. Logically, birth control pills can be used by women with endometriosis pre or post-pregnancy but cannot be used while a woman is trying to get pregnant. 

• Gonadotropin releasing hormone agonists. This treatment reduces a woman’s reproductive hormones essentially putting a woman into menopause while taking them. Examples of these medications include nafarelin (Synarel), leuprolide (Lupron), goserelin (Zoladex), or danazol (Danocrine). Because this treatment essentially creates menopause, all of the symptoms of menopause can occur with this treatment- hot flashes, night sweats, vaginal dryness, sleep disturbance, and decreased libido. This treatment cannot be used by a woman trying to get pregnant. 

• Laparoscopic Surgery. This should be considered when the above measures have failed and symptoms are unrelenting and severe. Treatment to destroy endometriosis may be performed during laparoscopy by a physician skilled in this procedure to lessen the risks of scarring. This procedure should be performed before ovulation in a woman’s cycle if at all possible as this is believed to lessen the chance of recurrence of endometriosis after treatment.

Excessive Prolactin (Hyperprolactinemia)

While women are breastfeeding, the prolactin hormone is released,  which suppresses follicle-stimulating hormone (FSH) and luteal hormone (LH) both of which are vital for ovulation. When ovulation is suppressed, reproductive hormone levels are low and women have minimal or no fertile cervical fluid. Women who constantly breastfeed could go for long periods of time without ovulating. Nature knows best- it prevents future pregnancy and it allows the mother to focus on the nourishment and care of her newborn child before conceiving again while she is breastfeeding.  In rare cases, a woman can have a small and usually benign tumor of the pituitary which produces prolactin- the same hormone produced while breastfeeding. It is possible for these women to have irregular or no cycles as well as difficulty getting pregnant. Checking prolactin levels should be part of the evaluation for all women having difficulty getting pregnant.

Avoid Female Surgery  

One of the quickest ways to decrease fertility is to have female surgery which can disrupt the health and ability of the ovaries to produce healthy eggs. If female surgery is needed, it should be performed by an experienced physician with the protection of the outer shell of the ovaries where mature eggs are released.

Primary Ovarian Insufficiency (POI)

POI or Premature Menopause is a condition in which lower than normal estrogen production can mimic perimenopause with irregular cycles, hot flashes, vaginal dryness, and painful intercourse. POI is a serious disorder that should be addressed with estrogen-progestin therapy to avoid further health problems including osteoporosis and heart disease. With this endocrine condition, women with POI are unlikely to get pregnant naturally. With the support of integrative therapies, women are at times again to regain healthy ovarian function which may allow pregnancy to occur.  Traditional physicians will often recommend donor eggs for women with this condition when they want to get pregnant.

Ovarian Cysts

Ovarian cysts usually don’t cause a serious health risk, and in most cases, they resolve themselves. If they cause pain due to swelling, rupturing, or bleeding, surgery may be required. However, surgery should be a last resort as it can affect fertility due to scarring.

Functional cysts are a result of a normally functioning cycle gone slightly off course. These may occur one time, or occur often and include:

Follicular Cyst 

This type of cyst is caused by a follicle surrounding the egg that continues to grow, but instead of rupturing to release the egg it continues to enlarge with the egg still inside – in turn, causing anovulation. When charting, your body may still produce the cervical fluid necessary to conceive, but you will not see the temperature shift that usually happens with ovulation. Follicular cysts usually resolve on their own by day 5 of your next cycle. When follicular cysts are painful, they can be treated with a progesterone injection which will lead to a menstrual period starting within 3-6 days. 

Luteinized Unruptured Follicle (LUF) 

This cyst is caused by a normal sequence of ovulatory events that come to a halt when the egg remains stuck in the follicle that is supposed to release it. With charting, LUF can be deceptive because fertile-quality cervical fluid is produced and is accompanied by the temperature shift that accompanies ovulation. LUF can lead some women to believe they’re pregnant with a delay in bleeding. Taking an HCG blood test will help to clarify the situation when the test returns a negative result. Just as with Follicular Cysts, they usually resolve on their own by day 5 of your next cycle. If it does not resolve,  it can be treated with a progesterone injection.

Corpus Luteum Cyst (CL)

This kind of cyst is caused by the normal formation of a corpus luteum following ovulation. However,  instead of the corpus luteum degenerating within 12-16 days as it normally does, it begins to seal off and fill with excess fluid or blood, causing a cyst. With charting, this type of cyst will lead to fertile-quality cervical fluid and is often still accompanied by the temperature shift that accompanies ovulation.  A CL cyst, however, may delay your period, which may not come until the cyst resolves itself. In case you got pregnant, the cyst will resolve on its own within the first 3 months of pregnancy.