CD 1 (cycle day one) is the first day of the menstrual period. The actual definition of which day is designated as “day 1” can vary from source to source. Generally it is the first day of significant menstrual bleeding, not just spotting. If the period begins in the evening or during the night, from about 6pm-midnight, “day 1” is considered to be the following day.
During menstruation, the endometrial lining of the uterus is shed. A quick drop in progesterone usually precedes the beginning of the period, and on CD 1 both the estrogen and progesterone levels are relatively low. From a Chinese medicine point of view, with the loss of blood during menstruation, the Ren and Chong mai gradually empty, and by the time the menses is over the Ren and Chong, Kidney yin and Liver blood, are at their lowest in the cycle.
Problems during the menstrual period are most commonly indicative of problems with qi and blood flow, while problems that occur or are worse towards the end of the menses are generally associated with blood deficiency.
Supporting fertility during the menstrual phase focuses on clearing any stagnation that may impede the quality and movement of qi and blood in the following cycle. Clearing blood stasis facilitates the complete discharge of menstrual blood so that the new endometrial lining can grow on a smooth, clean base.
The follicular phase begins on CD 1 of the menstrual cycle when new follicles, containing eggs, begin their growth. However clinically, we generally begin support of this phase after the major menstrual blood flow is over, usually around day 4.
During the follicular phase, the hypothalamus and the pituitary interact, stimulating the pituitary to release FSH (follicle stimulating hormone) that in turn stimulates the maturation of the ovarian follicles. One of these follicles will grow to become the largest, or dominant follicle, and will release its egg at ovulation.
The regeneration of the endometrium, or uterine lining, begins about 2 days after the onset of menstruation, even though menstrual bleeding still continues. This process includes tissue repair of the uterus where the lining has shed as well as the development of estrogen and progesterone receptors in the new tissue. Estrogen is the dominant hormone during this phase, and as the levels gradually rise, proliferation of the endometrium and its dense vascular network is stimulated. It also causes the cervix to produce cervical fluid.
From a Chinese medical perspective, follicle development is a yin process, dependent on yin, blood and essence. In the follicular phase, the Ren and Chong mai are filling and the yin and blood are building as the follicles grow. Any tendency to yin and/or blood deficiency should be supported during this time as when these deficiencies affect fertility they may manifest with poor follicular development, thin endometrial lining, or decreased cervical mucus.
Secondarily, heat may be a problem during this phase as it easily causes damage to the yin, and can lead to follicles that mature too rapidly resulting in poor egg quality, early ovulation and the shortening of the entire menstrual cycle. Patients with fertility problems frequently experience a great deal of stress when month after month they are unable to conceive. In these cases, heat from stagnation may disturb the steady building of yin and blood, and is often seen in upward spikes in the basal body temperature.
When the main developing follicle becomes large enough and estrogen reaches a certain level, ovulation will occur. Prior to ovulation, the hypothalamus and pituitary gland again play a major role as LH (luteinizing hormone) is released. This causes the “LH surge” which occurs about 24 hours prior to ovulation and is detected by an ovulation predictor kit.
In a normal, healthy ovulation, the basal body temperature chart will show a quick rise in temperature with the LH surge, and temperatures will then stay relatively high throughout the second half of the cycle. This is indicative of the quick change from yin dominance in the follicular phase to yang dominance in the luteal phase. Ovulation itself depends on the yin and blood being at their fullest, and the ensuing transformation of full yin to yang.
Yin at its fullest corresponds to the secretion of ovulatory cervical mucus and follicle growth at its peak. As it changes to yang, activity and movement are expressed as the dominant egg bursts forth from the follicle. This process of ovulation is dependent on the strength and fullness of yin, the ability to mobilize yang, and the movement of qi and blood to facilitate transition.
Specific treatment strategies in this stage are applied when ovulation is early, delayed, or poor in general. This may be seen in long cycles, in basal body temperature charts that are not biphasic, or when ovulation predictor tests show no clear ovulation. Some ovulatory problems such as polycystic ovary syndrome (PCOS) and amenorrhea may be more complicated and treatment throughout the cycle is needed.
The Heart is also involved in ovulation through the activity of the Bao mai, the collateral connecting the Heart to the ovaries and uterus. The Bao mai is one of the pathways by which the action of the Heart qi and blood descend to the reproductive organs, keeping them nourished and facilitating movement. The health of the Heart and Liver are key energies in the activity and vitality of transitions affecting the reproductive system. Ovulation and the transition to the luteal phase of the cycle may also be inhibited by stagnation of qi, blood and/or phlegm. Pain at ovulation or inability to ovulate in a timely manner may be an indication of problems with this transitional movement.
After the egg is released at ovulation, the sperm and egg travel to meet in the fallopian tubes, where a successful sperm will penetrate and fertilize the egg. The egg must be fertilized in the fallopian tubes within about 12 hours of ovulation, then it continues moving to the uterus to implant in the endometrial lining. Implantation begins about 5-7 days after ovulation. The necessity of healthy yang to support movement and activity in this phase is clear.
After ovulation, the corpus luteum is formed at the site on the ovary wall where the follicle released its egg. This gland secretes progesterone keeping the endometrium rich in hormones and nutrients and maintaining a healthy environment for implantation. Progesterone is the key hormone in the luteal phase of the cycle and is evident in the higher basal body temperatures during this time.
The luteal phase is dominated by qi and yang, but is also dependent on a good foundation of yin and blood. In order for implantation to occur, the uterine lining must be healthy and “receptive”. The endometrium must be thick, moist, and rich in blood and nutrients, a very yin environment in which the fertilized egg burrows until it is completely buried by the end of the cycle. Support in this phase generally begins with vitalizing the yang and qi, as well as the foundation or root of the yang, the yin and blood.
Problems in the luteal phase may been seen in significant drops in basal body temperatures in the second half of the cycle, in progesterone insufficiency, problems with implantation, and the tendency to miscarriage. Although pre-menstrual stagnation is not itself generally an indicator of an infertility problem, it may well compound the difficulty, therefore balancing and circulating the Liver qi may be employed as a secondary treatment principle.