Fertility Awareness (FA) is a method that allows a woman to understand when she is fertile or infertile during her menstrual cycle by tracking changes in the cervical mucus, vaginal sensation, the cervix, and basal body temperature. These changes are influenced by fluctuations in hormones that occur during the menstrual cycle with estrogen being dominant in the first half of the cycle and progesterone being dominant in the second half of the cycle. Understanding what is happening during the menstrual cycle gives women a lot of information about their health and empowers them to make the best decisions for their health.
At Health Blossoms, I often recommend Fertility Awareness for women and couples who are trying to get pregnant; for women with cycle irregularity; for women with various concerns related to hormonal imbalance, i.e., dysmenorrhea, PCOS, luteal phase defect etc.; for women coming off of the pill; for women who want to understand what’s happening during their cycle and what this may indicate about their health; and for teen girls as an introduction to learning more about menstrual cycles and their health. I review the data collected throughout the menstrual cycle with my patients and show them what it may mean about their fertility, ovulation, hormone balance, and overall health. Based on this information, I am able to recommend nutrients, herbs, lifestyle changes, exercise, or other therapies to optimize the patient’s health and fertility goals.
What happens during an optimal menstrual cycle? Let’s review!
The menstrual cycle length is typically 28-30 days but may vary in length for various reasons that may be better understood by charting changes during the cycle. The first day of bleeding up to the last day before another period is the menstrual cycle. Menstruation, menses, bleeding, or the period, is defined by the shedding of the uterine lining and indicates the beginning of a new cycle. The first day of bleeding is Day 1 of the menstrual cycle. Spotting before the flow starts is not considered Day 1. Menses typically lasts 4-6 days. Ideally with 3-4 days of moderate blood flow and 1-2 days of light flow.
The follicular phase includes menstruation, the development of a new follicle and the building up of a new uterine lining. The follicular phase typically lasts from Day 1 -14. An immature egg develops inside a sac or follicle under the influence of pituitary hormones. As the follicle develops it releases estrogen. During this phase the estrogen levels start off low and increase dramatically to stimulate a surge in LH levels and ultimately ovulation.
The effects of estrogen in the follicular phase support fertility:
- Estrogen builds up a new uterine lining after the old lining is shed.
- Down regulates the thyroid for a cooler body temperature.
- Gradually increases cervical mucus production. The cervical mucus nourishes the sperm and may keep the sperm alive for up to 5 days.
- Changes the quality of the mucus from tacky to slippery. These changes may be confirmed with ferning of saliva on a microscope.
- Softens the cervix, lifts the cervix in the vaginal canal, and opens the os of the cervix.
- Stimulates the LH surge for ovulation.
Ovulation results from the follicle breaking open and releasing the egg. The egg is captured by the fimbriae of the fallopian tube. The egg is viable for 12-24 hours after ovulation. The egg hangs out in the outer third portion of the fallopian tube where it may be fertilized by sperm.
After ovulation, the follicle that released the egg becomes the corpus luteum and begins producing progesterone. The second half of the cycle is called the Luteal Phase and lasts from day 15-28. Progesterone continues to build up and maintain the uterine lining in preparation for implantation of an embryo. If fertilization and implantation do not occur, the egg and corpus luteum dissolve and the uterine lining is shed with the next menses.
The effects of progesterone in the luteal phase prepare for pregnancy:
- Progesterone maintains the uterine lining and increases the vasculature to support implantation and a growing baby.
- Stops the production of cervical mucus.
- Up regulates the thyroid for a warmer body temperature.
- Firms up the cervix, lowers the cervix in the vaginal canal, and closes the os.
- Stimulates the glandular breast tissue.
The amount, quality of, and appearance of cervical mucus changes throughout the cycle under the influence of estrogen and progesterone. After menses, the quality of the cervical mucus typically goes from dry to tacky to creamy and finally to slippery leading up to ovulation.
How to check for cervical mucus:
- Check morning, mid day, and before bed
- Wipe the vaginal opening with a clean tissue
- Feel the tissue to check if any mucus is there
- Examine the mucus for the quantity, quality and appearance. Hold the mucus between the index finger and thumb and then open the index and thumb.
- Tacky mucus is like glue and sticks to the index finger and thumb.
- Creamy mucus is like lotion with a smooth texture and may stretch a little between the index finger and thumb but breaks easily.
- Slippery mucus is like egg white and stretches between the index finger and thumb to about 2-3 inches without breaking.
FERTILE SIGN: the presence of cervical mucus is an indication of fertility. The cervical mucus may keep the sperm alive for up to 5 days. The change of the mucus from creamy to slippery indicates ovulation has happened or is about to happen. The slippery mucus is ideal for allowing the sperm to swim towards the egg in the fallopian tube.
INFERTILE SIGN: No mucus.
The vaginal sensation typically follows along with the changes in cervical mucus. The sensation of dryness or wetness of the inner vaginal lips may be noticed even before checking for mucus.
FERTILE SIGN: wet sensation.
INFERTILE SIGN: dry sensation.
How to check for the position of the cervix:
- After menstruation and any spotting has stopped, check once per day, ideally after a shower
- In a squatting position, insert the middle finger into the vagina and feel for the quality, position, and opening of the cervix
Post menses: the cervix feels firm like the tip of the nose, to the left or right and low to midway in the vaginal canal, with a closed os
Around ovulation: the cervix feels soft like the inside of the cheek, central and high, with an opened os
After ovulation: the cervix feels firm, to the left or right and mid way to low, with a closed os
A soft, high, and open cervix is ideal for fertility and receptive to sperm.
A firm, low, and closed cervix.
How to check basal body temperature:
- Check your temperature in the morning before you get out of bed
- Check the same time each morning for comparison
From Day 1-14, the temperature is lower due to estrogen. Estrogen down regulates the thyroid gland. The temperature ideally ranges from the mid 97s to the high 97s.
After ovulation, the temperature is higher due to progesterone. Progesterone up regulates the thyroid gland. The temperature ideally ranges from the low 98s to the mid 98s.
The basal body temperature will vary depending on what time of the morning it is taken. With cooler temperatures expected with early morning and warmer temperatures in the later morning. This is why it is important to take the temperature at the same time each morning and to record the time for proper interpretation.
The basal body temperature may increase due to an infection with a fever, alcohol intake the night before, or if the temperature is taken later than usual.
FERTILE SIGN: A dip in temperature indicates that ovulation is about to happen and confirmed by a spike in temperature with temperatures that remain high in the second half of the cycle.
INFERTILE SIGN: Temperatures that don’t shift from 97s in the follicular phase to the 98s in luteal phase may indicate ovulation did not occur.
If the temperatures are not at least 97.5, this may indicate a thyroid issue.
As estrogen levels build, it increases the chloride in the cervical mucus and the saliva. As the chloride increases, it causes the saliva to have a ferning pattern. To view the ferning pattern, wipe saliva on the lens of a hand held microscope, allow it to dry and then view this with light. The Fertile-Focus is a convenient hand held microscope. When the estrogen levels have built up just prior to ovulation, a strong ferning pattern will be seen. This is an indication that ovulation may happen within the next 1-2 days.
Checking saliva for a ferning pattern is not traditionally part of fertility awareness. I may recommend that a patient check for ferning if the typical signs of fertility are not obvious or they have irregular and unpredictable cycles.
FERTILE SIGN: Distinct ferning pattern a few days before ovulation.
INFERTILE SIGN: Lack of a distinct ferning pattern.
The main changes I recommend patients to chart are the cervical mucus and basal body temperature. I will suggest charting vaginal sensation, cervix position and ferning if enough information is not learned from cervical mucus and basal body temperature.
To understand how hormones may be influencing other things women may experience during their cycle, I often recommend charting other information as follows. These recommendations are often individualized to the patient.
Other information to chart:
Desire for sex
Ovulation Predictor Kit results
Difficulty falling asleep
Therapies, ie, massage, acupuncture, ATMAT®, self care, foot reflexology chiropractic etc.
How to chart:
Using a paper chart, mark the first day of menses as Day 1 and log the changes in cervical mucus, vaginal sensation, cervix, temperature, and ferning pattern throughout the cycle. With this information identify your fertile signs and the peak days for fertility. The peak days for fertility are 1-2 days prior to ovulation. The peak days are the best days to have intercourse if you are trying to get pregnant.
You may also use a fertility app like Kindara that is based on the fertility method.
The best options for a thermometer are a Geratherm thermometer or the Wink thermometer that syncs with the Kindara app.