Menstrual Phase

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.

Follicular Phase

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.

Ovulatory Phase

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.

Luteal Phase

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.