Every woman knows that there is a “monthly appointment” to monitor when you want to put a baby in the pipeline.

They were once, in many cultures, the object of mistrust and fear. Today, the hormonal mechanisms underlying menstruation are well known and, despite the many prejudices that still circulate on the subject, we accept them for what they are: a physiological phenomenon, sometimes annoying, but which reflects the good general and reproductive health of women in child-bearing age. But there are many doubts for those seeking pregnancy: is regular menstruation a sign of fertility? Should we correct any irregularities when we want a baby? Can altering the physiological cycle with a hormonal contraceptive harm health or future reproductive capacity? Does the return of menstruation after the birth of a child marks the resumption of fertility? Since when is a contraceptive necessary? Here are the answers of the experts.

Regularity of the cycle and fertility: a certain combination?

“Menstruation is defined as regular if it occurs every 28 days, more or less three days,” says Alessandra Graziottin, director of the Centre for Gynaecology and Medical Sexology at the San Raffaele Hospital in Resnati, Milan. “A regular menstrual cycle is a sign of a woman’s good health and is a reasonable indicator of fertility. I say reasonable and certainly not, because there are factors independent of menstrual regularity that can hinder conception. For example, the occlusion of the fallopian tubes, or an ovarian reserve that for various reasons is reduced. In general, however, a woman who has precise menstruation can rely on her reproductive capacity.

However, there may occasionally be a “jump” due to illness, high fever and debilitation, a period of physical or mental stress, as a result of a sudden loss of weight. “If these are isolated episodes, there is no reason to worry,” explains the gynaecologist. “On the contrary, if the cycle tends to shorten or progressively lengthen without apparent causes and this trend persists over time, it is a sign that something is wrong with the ovarian function”.

Another frequent cause of menstrual irregularities is anaemia. “Many people suffer from it, often without knowing it,” observes the gynaecologist. “To diagnose it, you need blood count, sideremia and ferritin. With the administration of iron, the problem is solved.

The shortest normal cycle due to progesterone deficiency is also common. The hormone dosage in the blood is used to determine this. “The therapy to regularize the cycle is the administration of natural progesterone for 12 days a month,” explains the expert.

What should I do if I plan to become pregnant?

“We must first ascertain the cause of the irregularity,” says the expert. “It would be a mistake to try to correct the defect without understanding its origin. The shortening or lengthening of the cycle can be, for example, a sign of the imminent depletion of the ovarian reserve. “It can happen at any age,” says Graziottin. “1% of women go into menopause before the age of 45. To check if this is the reason for the irregularity, the blood dosage of FSH and anti mullerian hormone (AMH) is needed. If the examination shows that the menopause is actually approaching and the woman is willing to have a child, my advice is to seek it as soon as possible, or to resort to cryopreservation of oocytes.

What is the difference for those who take the pill?

Hormonal contraceptives – not only the pill but also the transdermal patch and vaginal ring – alter the physiological hormonal mechanism of fertility by blocking ovulation. “Since menstruation is the final phase of this physiological process, the woman who takes a contraceptive estroprogestinic or pure progestin, has no menstruation,” explains Angelo Cagnacci, Director of Obstetric and Gynecological Clinic of Udine, who has written a document on this subject for the Italian Society of Contraception. “The periodic bleeding that occurs at the monthly suspension of contraception is induced by the sudden drop in the level of progesterone, which is no longer taken. Often the bleeding from suspension has different characteristics from those of physiological menstruation: the blood flow is more modest, the duration is limited and the symptoms related to premenstrual syndrome, such as swelling of the abdomen, headache and general inflammation are reduced. If hormonal contraceptive is taken without suspension, as is normally done for pure progestin and as can also be done with estro progestin, periodic bleeding is completely absent. “Some women do not like this complete disappearance of pseudo-menstruation, which appears to them to be unnatural,” notes Cagnacci. “I would like to reassure them: the usefulness of menstruation is linked solely to fertility. If they are not looking for a pregnancy, they can do without menstruation. At one time it was believed that periodic blood loss had the function of purifying the body of toxins. Today we know that this is not the case. According to a study we have carried out among Italian women, 65-70% find their period annoying and unpleasant. Hormonal contraceptives, therefore, can deprive them of the discomfort without damage to health, unless specific contraindications assessed by the doctor.

The contraceptive action of the pill, patch or vaginal ring is reversible. When the woman decides to stop taking the pill to look for a pregnancy, her physiological cycle begins to work again. “Normally it resumes immediately, the month after the suspension,” says the gynecologist. “And so too is the reproductive capacity restored. In a small percentage of cases, it can happen that it takes a few months for a regular recovery. If, on the other hand, the cycle reappears late, or becomes irregular, it is a sign that some other factor interferes with the function of the ovaries. It is possible that the ovarian reserve is close to exhaustion and that the signs of perimenopause have been masked previously by the use of contraceptives, or that a recent weight loss quite important has altered the hormonal balance.

What happens after a pregnancy?

During the waiting period, menstruation is interrupted, but after the birth of the baby, with the return to normal hormone levels, the cycle also resumes. “The head doctor, i.e. the first menstruation after childbirth, usually occurs no earlier than 40 days after the birth of the baby, but it can take up to 6 months if the new mother breast-feeds, because the prolactin that the mother’s body secretes during the lactation period inhibits ovulation,” explains Alessandra Graziottin. “Be careful, however, not to trust the contraceptive action of breastfeeding. The first ovulation can occur at any time, even before the head of the family presents itself, so it is prudent for the woman to use a contraceptive. If she breast-feeds, she cannot use estro progestin, but she can use a condom or pure progestin. No fear for the latter: its intake does not alter the quality of breast milk and does not interfere with the development of the newborn.

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