Have you ever heard of the HPO axis? What about ovulatory dysfunction?
Before I started studying women’s health, I certainly had not heard of either.
HPO axis stands for the hypothalamus-pituitary-ovarian axis and it is responsible for the hormones and neurotransmitters that signal for ovulation to happen.
And ovulatory dysfunction is what happens when the HPO axis isn't working as it should. Because, when the communication between these organs breaks down, ovulation won’t happen.
How to know if you're ovulating
But before we get into the nitty gritty of HPO axis dysfunction. We first need to ask – are you ovulating?
And PS- just because you have a period does not mean that you are ovulating. Here are a few ways you can tell if you’re ovulating.
Use basal body temperatures to track for a temperature shift post ovulation.
Ask your doctor to do a progesterone lab test 5-7 days after you suspect you’ve ovulated or about 7 days before you expect your next period.
Use at home progesterone test strips, such as Proov.
So, if you are ovulating – great! That means your HPO axis is up and running. Yay!
If you are not ovulating, that means it’s time to do some investigating about where the communication breakdown is happening.
Types of Ovulatory Dysfunction
Like I said above, not ovulating is called “ovulatory dysfunction” and according to the WHO, there are three main categories of ovulatory dysfunction related to the HPO axis.
Here I am going to break down the 3 categories of dysfunction (plus a bonus reason you might not be ovulating at the end!). And give you some idea of what testing might help you get to the right diagnosis and how each condition is treated.
Ok, so here are the 3 categories of ovulatory dysfunction according to the WHO:
Hypothalamic Pituitary Failure
Eugonadal Ovulatory Dysfunction
Ovarian Failure
Let’s break them down.
First, hypothalamic pituitary failure (HPF). This accounts for about 10% of ovulatory dysfunction and is largely caused by genetic, congenital issues or from some kind of trauma (like a hemorrhage, for example).
With HPF, there is some kind of communication failure between the hypothalamus and pituitary gland. So the ovaries never get any kind of messaging that ovulation should happen.
Women with HPF likely had delayed puberty or currently have no cycle whatsoever. Investigating this type of ovulatory dysfunction usually includes checking labs such as FSH, LH, and estradiol. If HPF is suspected, it might also mean an MRI to take a look at the pituitary gland.
Unfortunately, there really aren’t any diet or lifestyle interventions to improve HPF and will require some kind of medical management.
Next up, eugonadal ovulatory dysfunction. This is the most common type of ovulatory dysfunction, with about 85% coming from this category. This type of ovulatory dysfunction is caused by issues with endocrine messengers, which ultimately stop or delay ovulation.
Here are the most common conditions that fall within this category:
PCOS - for most women with this condition, blood sugar dysregulation and high insulin levels ultimately lead to irregular or skipped ovulation.
Hypothyroidism - they thyroid hormone is crucial for a healthy cycle and a sluggish thyroid can slow or stop your cycle. Evaluation of the thyroid requires a FULL thyroid panel and working with a practitioner who can interpret labs in a way that relates to your menstrual cycle.
Hypothalamic Amenorrhea - this is when a stress (either physical or emotional) causes the hypothalamus to get off line and stop sending out signals that lead to ovulation. Undereating, low body fat, and over exercising are the most common stresses that lead to this condition. if undereating, low body fat, or over exercising are the cause for HA, increasing calorie intake, body fat, or reducing exercise will kickstart your cycle.
Obesity - This one is tricky because excess weight can stop ovulation because of the hormonal activity of adipose (fat) cells. That being said, I think it is also important to point out that dieting is not the best approach to overcome this… because, see above (hypothalamic amenorrhea). A well-rounded and nourishing eating routine will help significantly more than any single "diet".
High prolactin levels - prolactin is high in breastfeeding women, but when it is high outside of breastfeeding, it can put the kibosh on ovulation (for the same reason women don’t ovulate when exclusively breastfeeding). When prolactin is high outside of breastfeeding, there are several causes that can be examined by your doctor. And various treatment options including medication or potentially surgery.
And the third and final category of ovulatory dysfunction is called primary ovarian insufficiency (POI) or failure (POF). And like the like implies, this is when the ovaries are offline and not properly functioning. About 5% of ovulatory dysfunction is caused by this category.
POI often has auto immunity at its root, though other conditions such as Turner syndrome/ other genetic conditions or toxic exposure can also be the cause.
Typically, your doctor will run certain tests to determine if POI/ POF is the reason you aren’t ovulating. This usually includes FSH, estradiol, AMH, and antral follicle count.
Because auto immunity is often at the root of POI, it’s important that I bring up gut health – which is often associated with autoimmunity.
There is lots of new research showing that improving gut health can help to reverse all kinds of autoimmune conditions, including POI! This is super exciting stuff and means that if you learn this is the reason you aren’t ovulating regularly, working with a skilled gut health practitioner might be just the ticket to help you conceive naturally.
And as promised – there is another possible reason you aren’t ovulating regularly or at all. And it is called Post Birth Control Syndrome (PBCS).
PBSC, obviously, can happen after you stop taking birth control. It includes a slew of symptoms such as missing/ irregular periods, heavy periods, crazy PMS, acne, headaches, hair loss, etc…
The good news, the cause of hormonal imbalance is temporary and typically resolves after some time. Though, focusing on diet and lifestyle changes can help to speed the process and get you bad to a regular cycle (and optimal fertility!).
Citations:
Mikhael, Sasha et al. “Hypothalamic-Pituitary-Ovarian Axis Disorders Impacting Female Fertility.” Biomedicines vol. 7,1 5. 4 Jan. 2019, doi:10.3390/biomedicines7010005
Wu, Jiaman et al. “Association between premature ovarian insufficiency and gut microbiota.” BMC pregnancy and childbirth vol. 21,1 418. 5 Jun. 2021, doi:10.1186/s12884-021-03855-w
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