The Problem With the Day 21 Progesterone Test (Episode 643)

Full Transcript: Episode 643

Lisa Hendrickson-Jack:

This is the Fertility Friday Podcast, episode number 643.

In today’s episode, we are going to be diving into the luteal phase. We’re going to be talking about luteal phase deficiency, whether it makes sense to be testing women on day 21 of their cycle, and what some of the research tells us and why that conflicts with some of the information that we know from cycle charting.

In case you’re new here, I am Lisa Hendrickson-Jack. I’ve been teaching women to chart their cycles for well over 20 years. And in fact, I literally wrote the book on cycle charting, my first book, The Fifth Vital Sign. And today we’re going to be looking at this perspective from that standpoint. What can we learn about the luteal phase when we’re actually looking at the menstrual cycle, looking at patterns versus simply looking at a spot test that is done, I would say, randomly on day 21 of the cycle.

First things first, what is the luteal phase? Luteal phase is another word for the second half of the cycle. In a healthy cycle, the first day of the cycle is the first day of a woman’s true bleed. Even if she had a few days of spotting leading up to that, when she actually has her true bleed, that’s going to be the first day of her cycle.

Then once her period comes to an end in a typical healthy cycle, she may have a couple of dry days. Dry days are just simply days that she isn’t observing cervical fluid until she starts to actually see her cervical fluid emerge. And she will see that cervical fluid typically for anywhere from about two to seven days in a healthy cycle, at which point she will ovulate. The cervical fluid will dry up for the most part, and then she will enter into that luteal phase, which in a healthy cycle should last anywhere from about 12 to 14 days on average.

Now, what’s really interesting with cycle charting is it is not a spot cycle day 21 blood draw. When we are able to track the menstrual cycle, if you are a women’s health practitioner and you’re working with clients, when you are able to support your clients to track what’s happening in the menstrual cycle, you are getting kind of a day-to-day, cycle-to-cycle understanding of what’s happening. And you can start to see patterns.

When you’re working with clients, the luteal phase, I mean, like I said, healthy luteal phase is anywhere from 12 to 14 days, but luteal phases I’ve seen with clients can be as short as six or seven days. And the argument there, the reason why there’s a whole debate in the literature about what is luteal phase deficiency and could this be linked to infertility, is because we also know how long it would take a fertilized egg to implant.

If a woman has ovulated and she was trying to conceive and the egg is fertilized, we know that it takes anywhere from about 12 to 14 days before that fertilized egg is going to make its way through the fallopian tubes and actually move into the uterine cavity where it will then implant. And logically, if your luteal phase is seven days or eight days or even nine days, meaning that the lining is starting to shed anywhere from seven, eight, nine days after you’ve ovulated, then that shedding of the uterine lining that’s taking place is taking place around the same time as the egg is supposed to be fertilizing. That would pose a pretty significant problem to allow the egg to implant.

This is essentially what the argument is. When we’re taking a look, when you have women who are charting their cycles and they’re tracking and they’re starting to confirm ovulation and they’re observing that whether it’s spotting is happening earlier, they’re having increased PMS symptoms or whatever the case, then this is the argument that this is not great for fertility, not great for conception. And it’s something that we should be looking at.

Now, a recent study came out in the American Society for Reproductive Medicine, and it’s entitled Diagnosis and Treatment of Luteal Phase Deficiency, a committee opinion. What’s really interesting in this paper is they’re basically questioning, and I’ve seen many papers like this, questioning the validity of this concept of luteal phase deficiency, and essentially saying that there’s no evidence for it. We can’t really prove that it causes infertility.

From the standpoint I can, after reading a lot of papers, I feel like they’re basically saying that we can’t really prove specifically that this is causing infertility based on this particular study, based on this particular blood draw. I mean, when we’re looking at studies, they are having to test that blood level of progesterone on a specific day of the cycle, typically day 21. Whether or not that’s related to ovulation is another question.

And interestingly, the researchers in this case are not convinced that the luteal phase or the potential for luteal phase deficiency has anything to do with fertility challenges. Now, interestingly, in this paper, the researchers are coming to the conclusion that it’s hard to diagnose, and they’re just kind of blanket saying that there’s no evidence that there’s an association between the luteal phase deficiency and infertility.

And how are they trying to diagnose? Well, they talk about identifying menstrual cycle length, though I don’t always see a very clear mode of diagnosis. Often the studies are looking at the LH levels, so they’re kind of looking at when the LH levels rise. That’s a fairly common way of measuring it. They may be doing progesterone testing, and typically that involves one test at some point in what they’re saying is midluteal. But that generally involves doing one test around day 21 of the cycle, which is presumed to be about midluteal.

That’s presumed to be about a week or so after ovulation, which would, if that was true, it would represent midluteal. But because many of these studies, and just the average woman who’s being given a progesterone test on day 21 of the cycle, is typically not tracking anything to do with her cycle. Ovulation can vary significantly. I don’t know how doing this test randomly without confirming ovulation first would really give a true indication of what’s happening in terms of her progesterone level. And furthermore, progesterone levels can fluctuate even throughout the day.

This kind of idea that we’re just going to do a spot test and it’s going to give us all this information I think in and of itself is a bit flawed. And another suggested approach is an endometrial biopsy, actually doing a biopsy to somehow determine if this person has luteal phase deficiency.

The challenges outlined then by these researchers are that it’s difficult to diagnose. There’s not really a clear way for them to figure out if the luteal phase is actually deficient. And due to then this kind of soup of research that they have with different types of testing and this kind of inherent difficulty of identifying it, according to them, they’re not really able to come to much of a conclusion as to whether or not it makes a difference, as to whether or not there’s a correlation between this supposed condition and fertility challenges.

And ultimately, if we’re looking at a bunch of different studies that are trying to look at this in different ways, if we’re not really understanding how the cycle works and we’re just kind of arbitrarily giving women tests on day 21 of the cycle without confirming or even identifying if ovulation took place, then naturally you’re not going to get compelling results.

What do you do if you are a women’s health practitioner and you’re trying to support your clients, you’re trying to understand this phenomenon? As soon as you open that floodgate and start supporting women with menstrual cycle charting, as soon as you start having women track their basal body temperature, track their cervical position and identify ovulation in the cycle, you are inevitably going to start seeing a variety of lengths of luteal phase. And in today’s world with the stress that we have and all the different challenges that we see, you’re inevitably going to see some short luteal phases.

The interesting thing to me is that when you’re working with women who are trying to conceive, there’s exactly zero women that are going to be satisfied with having kind of like a subpar cycle. They’re wanting to understand how to optimize it. They’re wanting to improve it. They’re wanting to improve their progesterone production, balance their hormones. They’re wanting to have a cycle that actually falls within normal parameters.

Even if we can’t show in this research that there’s a direct link that they can prove through these different means that a short luteal phase will cause infertility or will prevent pregnancy, even if it’s hard for the researchers to kind of show that definitively, when you work with women who are consistently having short luteal phases, that in and of itself is associated with a variety of other unfavorable symptoms.

Even if we just look at quality of life, if we just look at her experience, she’s much more likely to have PMS symptoms, much more likely to show potentially symptoms of estrogen dominance, including heavy periods related to this kind of imbalance of estrogen to progesterone. And by definition, if she’s starting her period seven or eight days after ovulation, it is less likely that fertilized egg is actually going to have a place to implant because that is happening. This bleeding is happening before the implantation would even be taking place.

I would argue that I would not agree with the researchers that there’s no way to identify the luteal phase defect, as they call it, the short luteal phase. I think that’s silly. Obviously, from the perspective of creating research studies and trials and if you’re wanting to blind some of the participants, it makes it hard if you can’t really do a blind study of charting your cycle because it’s a very involved process. It’s not as simple as putting different medications in kind of neutral packaging or something like that.

I do recognize that there are some inherent challenges with cycle tracking, but to say that there’s no way to identify luteal phase deficiency is kind of silly. And to say that there would be no way to organize a study on this is also kind of silly because we can implement fertility awareness tracking methods. You can implement LH testing in addition to it. You could implement basal body temperature testing to at least better triangulate what’s happening with the luteal phase.

I think the main challenge for practitioners who are working with women and even kind of starting to jump into the cycle tracking realm is, first of all, a lack of confidence. If you yourself have some charting experience, but you never really took training or never really worked with an instructor, then you may be able to kind of figure it out for your own cycle. But when you’re working with clients who are experiencing incredibly short luteal phases, pre-menstrual spotting or other types of abnormal bleeding, experiencing abnormal mucus patterns or anything that is not quite just textbook cycle unfolding, then it becomes a little bit more challenging.

The first step to even identify what is even going on, to be confident that what you’re seeing really does meet that definition, to be confident in identifying how long that luteal phase is and what to do about it. And then furthermore, what do you do? How do you support your clients to lengthen that luteal phase?

Interestingly, these researchers are kind of arguing that there’s not really a way for us to test it. They’re saying that we can’t really find a direct link to infertility, and therefore they can’t really justify doing anything about it. To me, this just shows the consistent issue that we have in our culture, in our standard medical system, where we don’t really know what to do with women’s issues. We don’t really know what to do when women are having hormonal challenges, when things are awry.

We don’t even understand how the menstrual cycle works. I mean, we’re still testing progesterone on day 21 when that has often absolutely nothing to do with when she actually ovulated and is not even producing a consistently accurate result. The issue really is that we just don’t have enough knowledge, education, or interest to figure out what’s happening within the female body.

And the answers are right there. When we add charting to the mix, when we have a standardized charting methodology and a framework for which to understand the menstrual cycle through that lens, the lens that the menstrual cycle is a vital sign, and to really be able to track what’s happening and to compare that and to know whether these cycle abnormalities, what they’re related to, to know what type of conditions that could be causing it and how to support women.

If we don’t have that background, then it makes it very difficult for us to support clients. But fortunately, it doesn’t have to be that way. Fortunately, there are standardized ways to track these things. There are standardized ways to track cervical fluid, to track basal body temperature, to get a lot of clarity in terms of identifying if ovulation is happening at all and if it is happening to identify when it is, to be quite clear on how long that luteal phase is.

And also, as we implement various strategies to support menstrual health, it is also possible to track a woman’s progress as she improves her progesterone production and as luteal phase length increases. The irony is that so many women struggle with issues with luteal phase length, and there’s actually a fairly straightforward solution to this problem. And what our clients really need is a practitioner who is confident and skilled and knowledgeable in this specific area.

This paper is the gift that keeps on giving. They identify what they call idiopathic luteal phase deficiency, they say there’s no underlying identifiable cause. They’re basically saying it’s not real. They’re saying we can’t really figure out how to identify it. Therefore, it’s unidentifiable. We don’t really know what causes it. We don’t even think it’s real.

This paper is like the crumb of the crumb in terms of gaslighting because it’s basically saying like this isn’t even real. It’s not even a real thing. Meanwhile, you have women who are literally tracking their ovulation, their mucus, their temperature, their cervical position, and they’re fully identifying it. They’re fully looking at their cycle and saying, look, my luteal phase was seven days and I don’t feel very good. I have this raging PMS and something just really feels off.

And instead of looking into it and actually figuring out how to sort it out, we are just going to say, well, we can’t really track it. This is where we’re at. This is definitely where we’re at in terms of our knowledge of women’s health issues.

One of the arguments that I’ve been making for many years is that this is one of the big issues. Even highly trained medical professionals are not getting an adequate education in matters of menstrual cycle health, fertility awareness, cycle charting. This modality, even though it’s gotten a lot more attention lately, even though there’s a lot more people talking about it, a lot more people teaching it, a lot more people learning it, the average woman and even average women’s health professional has not received any training in cycle charting, advanced menstrual cycle tracking, advanced chart interpretation.

And this is leading to papers like this one being released and basically perpetuating this idea that we just have no way of knowing even something as simple as being able to identify luteal phase deficiency.

Now, interestingly, and I feel like in this paper, the researchers are talking out of both sides of their mouth, but interestingly, on the one hand, it’s kind of like, we don’t really have a way to diagnose it consistently. We don’t really know if we can prove that it’s like a real condition and we don’t really know if it’s linked to infertility.

But they’re also saying that there are some proposed treatments for this condition that doesn’t really exist and we can’t really identify it. It’s like, again, we’re talking about both sides here.

One of the proposed solutions is ovarian stimulation, which is interesting. We have a luteal phase deficiency and let’s give women drugs to support ovulation. Now, there is a reason for that if we have a stronger follicular development and a stronger ovulation. Because the ovarian follicle, after it ruptures and ovulation takes place, it does turn into the corpus luteum. And the corpus luteum is what produces progesterone.

And the health of that corpus luteum is highly correlated to, well, I should say the health of the ovarian follicle is highly correlated to then the health of the corpus luteum. Because essentially one is transforming into another to produce the hormones that are necessary. When we are seeing a short luteal phase, it is showing a bit of a defect in the corpus luteum. It is showing that it’s not really able to progress and develop to the full extent, and the progesterone that it is putting out is insufficient.

Another proposed solution, unsurprisingly, is progesterone. Giving women progesterone. And there’s a lot of research showing that if women are having a variety of different symptoms, whether it be related to PMS, whether it even be related to luteal phase defects that are associated with miscarriage, progesterone administration can significantly reduce the risk of miscarriage.

And again, when I see things like this, and this is why I’m always talking about these kinds of papers on the podcast, when I see papers like this, it just kind of reinforces what I’ve been saying for many years, that there’s a big issue. There’s an issue in terms of how even medical professionals are trained. Without having this baseline understanding of how the menstrual cycle works, it’s like we just can’t put things together properly.

Even though you have all the different pieces of this situation in this paper, the researchers can’t manage to put it together because they just can’t figure it out. They’re just like, well, we did the blood test and it didn’t do anything. It didn’t show us a consistent pattern. We did this endometrial biopsy. Like, we just don’t know what to do. And we don’t really think it’s real then because our faulty measuring methods are not giving us answers. And therefore, we’re just going to conclude that it’s just in your head and you’ve imagined it. Even though we know that it’s a real thing and it’s been talked about for decades.

Bottom line, there is a way to understand what is happening in the luteal phase and it doesn’t require a random blood draw on day 21 of the cycle. If you are a practitioner who works with women and you’re wanting to understand what’s happening with their hormones, cycle tracking is arguably one of the fastest and most efficient ways to get that insight.

And it’s not the same as a blood draw because you’re not getting the insight just once. You’re not getting the insight just this one day randomly at a random time. You’re able to see patterns. You’re able to actually see how the menstrual cycle unfolds, the pre-ovulatory and post-ovulatory phases of the cycle. And beyond just this one random blood draw, we’re able to see patterns in that luteal phase.

We’re able to see if you have your clients and they’re tracking their cycle, cycle over cycle, you’re able to see what the luteal phase was doing several months in a row and you start to be able to actually see what the correlations are.

You may have a client who had a huge spike in exercise, and that’s associated with a shortening of the luteal phase or some additional spotting. You may have a client that had a really rough and stressful cycle, and you saw that it interfered with either ovulation or the second half of the cycle. You may have a client who decided to try a new diet, working with a dietician who’s giving her a calorie deficit so that she can lose weight. And that is associated with what’s happening in the luteal phase.

Charting gives you insight into what’s going on in real time, but it also shows you how a variety of different factors, some of which you wouldn’t have even considered, are impacting the cycle.

And of course, this is exactly what we teach our practitioners in our Fertility Awareness Mastery Mentorship Program. This is what we are doing. This is essentially our bread and butter. Not only just providing random data points like these researchers are doing in this paper, but providing a framework for how to instruct your clients to chart, a systematic way to actually note these fertile signs so that you can then go on to interpret them, and also protocols to support your clients to identify and improve these conditions. It is not rocket science, but it certainly is an important and useful practice that is clearly needed, especially when we see papers like this.

If now you are curious, and I piqued your curiosity on this paper, feel free to head over to fertilityfriday.com, find this podcast episode. We will have in the show notes page the paper itself. You can take a look at it.

If you’ve seen these trends as a women’s health practitioner, you’ve seen clients struggle with issues like this with a short luteal phase and then being kind of told by the doctors that it’s not a real thing or being just given an arbitrary day 21 requisition form that is not necessarily in any type of relation with when they actually ovulated, then you already understand what I’m talking about.

We’ve created several resources to help you in your journey to really better understand the menstrual cycle and start mastering this process with clients. One of our top resources is our ebook, How to Interpret Virtually Any Chart Your Client Throws at You. Head over to fertilityfriday.com slash chart for details. And for more information about our Fertility Awareness Mastery Mentorship where we train our practitioners the art of advanced chart interpretation, head over to the Fertility Awareness Institute, fertilityawarenessinstitute.com, and you’ll find details about our programs there.

With that said, I hope you have a wonderful week, weekend, whenever you are tuning into the show. And of course, as always, until next time, be well and happy charting.