Women's Health Community

Dear zoozoo: We are so grieved to hear about the loss of your baby this summer. At 17 weeks that must have been even harder----women begin to really identify with being a mother.

It sounds like you were put on intermittent Prometrium to see if a flow can be "kick started" (as opposed to Prometrium given constantly every day). Hope I am tracking you correctly.

As you may have read, the most common cause of a missed period is not having ovulated that cycle. In a normal cycle, estrogen is produced all month. Estrogen is responsible for building up the lining of your uterus so you have something to shed each month.

In a normal cycle, progesterone production increases following ovulation. Progesterone "stabilizes" the uterine lining in preparation for a possible implantation of a new pregnancy. If you are not pregnant that month the levels of estrogen and progesterone fall, triggering the release of the uterine lining—your period.

So, if you do not ovulate, the estrogen build up of the lining continues, but without the usual ovulation associated progesterone. Thus, the hormone levels don't decline, and the lining stays up inside the uterus—your missed period(s).

If you have been several months without a period, a gynecologist may give you some progesterone in a pill form (eg Provera 10 mg for 5 days or Prometrium 400mg). Within 48-72 hours after stopping the progesterone your "progesterone blood level" will fall, triggering the release of the lining that has been building up. Many women report that these periods are very heavy-- as though several months of lining are shed.

Causes for not ovulating are multifold: thyroid problems, pituitary problems, ovarian cysts, physical stressors (eg sudden increases in exercise, crash dieting), emotional stressors (problems with partners,finances), increased body weight, anorexia, rotating shifts at work, etc. You certainly have had a stress in the form of the pregnancy loss.

There is a second, less common cause for not having a period. In some women the estrogen levels become very low. The levels are so low that no uterine lining is available to be shed. When these women are given the progesterone pills to take, no flow occurs after the medication is finished. This tells the GYN that the woman is not making enough estrogen to produce a thickened uterine lining.

Some causes for not making enough estrogen can include: premature menopause/premature ovarian failure (POF), elevated prolactin level from the pituitary gland, severe stress impacting the hypothalamus.

In your very specific case there are two other POSSIBLE causes for your absent periods. One is hormonal, the other a physical problem with the uterus.
1. After longer use of birth control pills (or daily progesterone pills) the lining of the uterus can get so thinned out that there is nothing much to shed when the progesterone pills are stopped. In this scenario, after time away from progesterone, the lining will grow back so there is more available to be shed.
2. Where there has been a D&C or other instrumentation inside the uterus sometimes the lining has been scraped away. In this instance, even with adequate estrogen blood levels, there is no base layer of lining tissue left to regrow and shed. Over time lining will regrow, but this is a more concerning condition compared to a hormonal issue. The medical name for this is "Asherman's Syndrome."

So what to do. PLEASE follow up with your OB/GYN. You can ask them about Asherman's Syndrome vs POF. There are tests for these. They may tell you that you lining is too thinned out--or that stress has impacted the hypothalamus.
Keep at it; you are asking the right questions!

If you'd be so kind, write us back and let us know how things are going. We will be wondering. Moreover, your experience may benefit another woman in the future who finds your post via Google search.

In Sympathy for Your Loss,
Jane

I had my fsh prolactin and my estradiol checked all came back good but... my estradiol was very very high it was 1440.00 the dr did a HCG level it came back less then one i am not pregnant. I am very worried and i am also having a sonohystogram on the 8th of february. if you have ever heard of this please let me know ..

Dear zoozoo: Normal FSH suggests premature ovarian failure not the cause; normal prolactin suggests no pituitary tumor. With a very elevated estradiol one would rule out:

1. Molar pregnancy--this is not your culprit as the blood HCG was very low.

2. Estrogen producing tumor--this is very uncommon, and if suspected would mandate additional imaging.

3. Some other substance cross reacting with the lab test (or a lab error)--if this is suspected the test can be repeated.

4. Increased amounts of male hormones ("androgens") from the theca layer of the ovary and/or from the adrenal glands which the body then converts into estrogens---usually the woman will have other signs of increased male hormones such as unwanted hair growth, acne, etc.

5. Blood test taken at the time of a normal estradiol peak (eg right prior to ovulation).

zoozoo, it is also important to know what unit of measure is being used with your estradiol level. There are two ways to measure estradiol. A normal estradiol is 20-400 picograms/milliliter but 70-1500 is a normal estradiol if it is being read using picomol/liters. Keep following up with your OB/GYN. If a repeat estradiol remains very elevated they can refer you to a reproductive endocrinologist.

Yours,
Jane