Signs of insufficiency of the luteal phase. Modern view on luteal (progesterone) insufficiency

One of the reasons for the violation of the monthly cycle and infertility is the insufficiency of the luteal phase. With this pathology, the formation of the corpus luteum is disrupted and progesterone deficiency occurs.

Main Causes and Treatments for Luteal Phase Insufficiency

Luteal phase deficiency (LFP) is a pathology of the menstrual cycle, in which the function of the corpus luteum is impaired. As a result, the production of progesterone decreases, which leads to infertility and premature termination of pregnancy.

Normally, the monthly cycle is divided in half by ovulation. In the first half of the cycle, estrogen dominates. The second phase begins from the moment of ovulation, the follicle bursts, and in its place a temporary hormonal organ, the corpus luteum, is formed.

The corpus luteum produces progesterone, a constant concentration of which is necessary for the normal course of pregnancy. Progesterone prepares the endometrium of the uterus, affects the process of implantation of the fetal egg, ensures the development and carrying of pregnancy.

The third phase of the monthly cycle is called the luteal, it lasts from 12 days to two weeks. Violation of the proper functioning of the corpus luteum, which leads to insufficient production of progesterone, is called insufficiency of the luteal phase of the cycle.

The reasons

Depending on the balance of hormones, the disease is of two types:

hypoprogesterone;
hyperestrogenic.

In the first case, the corpus luteum is not formed, of insufficient size, and in the second phase of the cycle, a progesterone deficiency is formed. Because of this, the endometrium develops poorly, its thickness is less than 10 mm.

In the hyperestrogenic type, the corpus luteum develops normally, the level of progesterone decreases insignificantly, and the thickness of the endometrium is sufficient - more than 12 mm. But a woman produces an excess of estrogen. Although normally their concentration should be significantly reduced, since they act opposite to progesterone.

failure of the central regulation of hormones;
severe stress;
tumors of the reproductive system;
overweight or its deficiency;
endocrine diseases;
physical stress;
inflammation of the uterine appendages;
polycystic ovaries.

The process of formation of sex hormones is regulated centrally by the hypothalamus and pituitary gland. Incorrect central regulation disrupts the maturation of follicles, the formation of the corpus luteum and the production of progesterone. Such a failure occurs due to traumatic brain injuries, neuroinfections, severe stress, mental illness.

Violation of the general hormonal background in endocrine diseases also causes a lack of normal levels of sex hormones. The primary cause is thyroid disease.

Inflammatory and oncological diseases of the reproductive system disrupt the normal formation and functioning of the corpus luteum, the process of ovulation and attachment of the fetal egg. These include tumors of the uterus, polycystic ovary syndrome, inflammation of the uterine appendages.

Excessive physical activity is one of the significant causes of the pathology of the menstrual cycle, especially at a young age. Therefore, NLF often develops in women who perform heavy physical work, athletes.

Excessive fluctuations in weight lead to this violation of the monthly cycle. For example, strong and rapid weight loss as a result of exhausting diets.

Symptoms

When a woman has luteal phase insufficiency, symptoms appear:

failure of the menstrual cycle;
termination of pregnancy;
infertility.

Violation of the monthly cycle is manifested in a change in its normal duration. Menses become irregular, painful, poor or profuse. Scarce ones appear.

Spontaneous abortion usually occurs in the first three months of the term. Repeated miscarriages make pregnancy impossible. Reduced concentration of progesterone makes it impossible for the normal process of implantation of the egg in the uterus. Which leads to infertility. Patients with corpus luteum hypofunction are usually underweight.

Diagnostics

At the appointment, the gynecologist, first of all, carefully collects an anamnesis, finds out the presence of menstrual disorders, the painful nature of menstruation, the inability to become pregnant or recurrent miscarriages, the patient's lifestyle. The doctor conducts a general and gynecological examination. It is important to determine concomitant diseases, whether a woman is taking any medications (especially hormonal ones).

It is necessary to find out the cause of underweight. Whether it is permanent or the woman has suffered a sharp weight loss. To find out the duration of the second phase of the cycle, you need to count the days from the moment of ovulation to the onset of menstruation.

To do this, you can use the old method - determining the basal temperature. Since progesterone causes an increase in body temperature, after ovulation and from the moment the corpus luteum functions, it will increase.

In addition to ovulation itself, this method can determine the progesterone deficiency of the second phase of the monthly cycle. A more modern way to determine ovulation day is to use special tests that are freely sold in a pharmacy. NLF is confirmed when the second stage of the cycle becomes shorter than 12 days.

From standard laboratory methods, a woman takes blood for general and biochemical analysis. For the diagnosis of NLF, the concentration of hormones is determined: luteinizing (LH), follicle-stimulating FSH, progesterone, prolactin, thyroid gland.

If you suspect the presence of tumors, inflammatory processes, ultrasound diagnostics, MRI are used. A biopsy is performed to clarify the type of neoplasm. To diagnose the condition of the endometrium, hysteroscopy is used - a modern endoscopic examination of the uterine cavity.

Treatment

The therapy should be complex, aimed at both treating the causes of NLF and general strengthening of the body by various methods.

Treatment must begin with the underlying disease that caused the violation of the luteal phase. In inflammatory processes, antibiotics, anti-inflammatory drugs, immunostimulants and immunomodulators, vitamins are used.

The main method of therapy is the replenishment and normalization of progesterone levels. For this, a woman is prescribed progesterone-containing hormonal preparations (, Duphaston).

In addition to replenishing the progesterone deficiency, it is necessary to eliminate the excess of estrogens, which are antagonist hormones: antiestrogen drugs are prescribed.

With insufficient development of follicles, a woman is prescribed treatment with follitropins - drugs that enhance the process of ovulation and maturation of the follicle. The preparations are used in the form of solutions for injections, tablets and suppositories.

Actively use physiotherapy treatment. An effective method is intravaginal phonophoresis. For women who are underweight or overweight, it is important to bring it back to normal.

Spa treatment and acupuncture are also used to improve ovarian function. To normalize the psycho-emotional state, it may be necessary to consult a psychologist, psychotherapist and prescribe sedatives.

Conclusion

NLF is a serious pathology, which is one of the causes of infertility. The appearance of characteristic symptoms is the reason for the obligatory consultation of a gynecologist.

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Hello, I was very surprised when I got to this site, all the questions that tormented me during my 33 years of life I found here. I got my period at the age of 14. December 15th. Menstruation at the beginning came about 1.5 months later. Well, we haven't gotten around to it yet. In the summer, six months after the first arrival of menstruation, we went to the mountains and I got my period. Despite the fact that I had my period, I swam in the reservoir. After arriving home, the periods did not stop as usual, the daubing continued for three weeks. I told my mother about this and she took me to a pediatric gynecologist. She prescribed me rigevidon and told me to drink for three months. I drank it for three months. During the reception menustralnopodobnoe bleeding was. After the termination, there were also two months of menstruation. Then the menstruation stopped and did not come. I went to the gynecologist, she prescribed vitamins for me, but nothing helped. A year has passed. I got pneumonia. They started injecting me with gintomycin and I drank licorice root. After three weeks came monthly which was not a year. Then the next ones came five months later. And so I began to have a chronic cycle disorder. The longest period from cycle to cycle was 4 months. At the age of 24, after completing her master's degree, she got married. After 8 months, she began treatment for infertility. I went to a private clinic to see a doctor who was recommended by friends. They diagnosed polycystic disease, prescribed Diana-35, mastodinone drops for 6 months. After 6 months, clostilbigit was prescribed to stimulate ovulation. Ovulation came, but closer to menstruation, an acute stomach began, abdominal pain, an ultrasound showed a corpus luteum cyst (hyperstimulation), she prescribed ciprolet and some other pills. Then she said that she needed to do a laparoscopy. I refused. I went to the institute of gynecology. There, the doctor again prescribed the contraceptive Novinet for me and told me to drink for three months. I asked why should I drink a contraceptive if I want to get pregnant. She said that there will be a rebound effect, the rested ovaries will begin to work actively. I drank the news. Then I was sent for insemination. The uzistka said that she did not see the maturing follicle. And the doctor said that it had already burst and, with non-existent ovulation, I was insimilated with my husband's sperm. But the obvious result did not occur. After some time I went to another gynecologist. She said that I have erosion and that I need to press it, that the infection sticks to this sore and because of this the spermatozoon dies. They cauterized, the patency of the tubes was, but there was adnexitis, an adhesive process. We started making a dropper with metrogil and ultraviolet. Then they prescribed dostinex for 8 months, siofor, l thyroxine and after it iodine balance. I drank for 3 months there was no menstruation. Measured basil. Well, then they added proginova and duphaston to all this. But there was no result. Ovulation did not occur. The follicle reached 9-11 mm and began to regress back. I took Dostinex for about a year. Tired of everything and gave up. Then, after some time, again began to suffer what to do. There were no periods for two or three months, and as soon as I had a drink of chamomile for 5 days, they came. I went to doctors and sat on the Internet. I thought I would never get pregnant. Because I had this chronic illness. Then I went to the Institute of Gynecology as the head of the polyclinic at the Institute. There, after an incorrect treatment, the follicular cyst again started to work, and even after taking duphaston, there was no menstruation. The doctor said it was necessary to do an operation, twist the cyst, look at the tubes. Come on Monday for surgery (was Saturday). I speak and as analyses. She speaks and analyzes we will draw. I said nothing. Came home five days drank chamomile. Menstruation came, at the end I went for an ultrasound, they said that there was no cyst. With that, I said that I would never go to the doctor again. If the manager himself said that she would draw tests for the operation, this is nonsense. She began to douse herself with cold water, drank black cumin oil, red palm oil, began to drink zinc, healer's herbs, wear massage insoles, drank chamomile, licorice. After a month, she found a gel-like transparent liquid on her panties and realized that ovulation had occurred. The next month, ovulation occurred on the 21st day, we lived with my husband and I became pregnant .. How did I know this? Because with a chronic violation of menstruation, it is difficult to know. I spent millions of pregnancy tests. Closer to my period, I had to lift two heavy boxes. After a while, the daubing began and I thought that my period had come and got upset and told my husband that I could no longer endure all this. He supported me and said that everything will be fine with us. But after anointing for two days, the daubing stopped. I was surprised and did a test, and a faint red second strip was not long in coming. Three days later I repeated the test and the strip was already pronounced. I didn't believe it. Six years of my torment after marriage gave its result. But after some time the temperature dropped and the daub began. I started taking zinc as it helps my own production of progesterone. She quit her job and lay upside down. The daubing stopped, toxicosis began and everything is like in pregnant women. I was afraid to share the ultrasound. The ultrasound was done on the 4th month, as they said they would not take it into account without an ultrasound. A healthy, beautiful girl was born. Since both my husband and I took zinc, it turned out to be a real hybrid, the face of the eyes are my eyebrows, and the figure from the neck to the tips of my dad's toes. My daughter is now 2.9 years old. I fed her for two years. During breastfeeding, no, there were no periods. And after the termination, they do not want to come again. I want to get pregnant again, this problem of not a regular cycle and anovulation befell me. The follicle regresses after 10-12 mm. What to do, how to be again. Since I did a lot of things at the same time, I don’t know what exactly helped me get pregnant. It seems like I'm doing everything I did again, but so far there is no result. Therefore, I will again fight for the right to become a mother for the second time.

The normal menstrual cycle consists of two phases. The first, follicular, lasts from the first day of menstruation to ovulation. At this time, estrogen dominates. The second phase is called the luteal phase and it lasts about 14 days after the release of the egg into the fallopian tube. Immediately after this, the follicle bursts and a corpus luteum forms in its place, which produces progesterone. It ensures the implantation of the zygote and contributes to the normal course of pregnancy. A malfunction of the corpus luteum, which leads to insufficient production of progesterone, is called luteal insufficiency.

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Symptoms of Phase 2 Deficiency

This pathological condition is manifested by the following symptoms:

1. Various disorders in the menstrual cycle:

cycle irregularity. It sometimes becomes less than 21 days, then there is a delay;
copious bleeding with clots during menstruation;
spotting that lasts less than 3 days.

2. Spontaneous abortion, especially in the first trimester.
3. Infertility - the absence of the onset of conception within a year of regular (ie, 2-3 times a week) sexual life.

Causes of pathology

There are three main types of causes due to which violations occur in the second phase of the cycle. These are functional, organic and iatrogenic:

1. Functional - associated with pathologies in the work of the reproductive and other organs that affect the cycle. These include:

Savage syndrome (resistant ovary syndrome) - a pathology in which the ovaries stop producing hormones;
ovarian hyperinhibition syndrome - suppression of ovarian function due to the use of drugs that affect their stimulation. As a result, menstrual flow is absent;
polycystic ovaries - a disease in which the ovaries produce a large number of follicles;
ovarian exhaustion - cessation of menstrual flow due to ovarian failure before 40 years;
thyroid diseases - hypothyroidism (insufficient production of hormones) and hyperthyroidism (excessive production of hormones);
hyperprolactinemia - a pathology in which the level of prolactin is elevated;
pituitary hypogonadism - reduced production of hormones in the pituitary gland, which affects the functioning of the gonads.

2. Organic causes are associated with impaired functioning of organs in combination with changes in their structure. Such pathologies contribute to the development of disorders in the functioning of the ovaries and other organs. These include:

Asherman's syndrome - the formation of synechia inside the uterus;
endometriosis - the formation of the uterine mucosa outside its limits;
adenomyosis - germination of the endometrium in the muscle layer;
fibroids - a benign neoplasm located in muscle tissue;
proliferation of the endometrium or endometriosis;
polyps - benign formations located in the endometrium;
malignant tumors of the endometrium and ovaries;
inflammation of the inner layer of the uterus;
fatty degeneration of the liver (steatosis) - replacement of normal liver cells with adipose tissue;
cirrhosis of the liver - the replacement of healthy tissue with connective cells, as a result of which the structure and functions of the organ change;
hepatitis - a viral disease of the liver;
traumatic brain injury.

3. Iatrogenic causes occur after therapeutic measures. These include:

curettage of the uterus for diagnostic or therapeutic purposes;
abortion.

There may be other causes of luteal insufficiency:

underweight - lack of calories in food;
sudden weight loss due to diet;
stress, depression;
change of climate and time zone;
drug use;
strong physical activity.

Diagnosis of the disease

If symptoms of luteal phase insufficiency (LFP) are detected, it is necessary to visit a gynecologist to determine the cause of this pathology. At the appointment, the doctor will conduct a general and gynecological examination, collect information for anamnesis, find out what medications the woman is taking.

To determine the length of the second phase, the gynecologist will advise you to measure the basal temperature every morning - normally, progesterone increases the temperature. Instead of measuring it, you can use ovulation tests, which are sold in pharmacies. The diagnosis of phase 2 insufficiency is confirmed if, after these methods, it is found that it lasts less than 12 days.

The doctor will prescribe various tests:

general and biochemical blood test;
blood for sex hormones and thyroid hormones;
coagulogram (clotting analysis).

If a tumor or inflammation is suspected, the patient will be referred for an MRI, ultrasound and biopsy. For information about the state of the endometrium, hysteroscopy is used (an examination of the uterine cavity performed endoscopically).

Treatment of second phase failure

Treatment of this pathology should be complex and only conservative. For this use:

1. First of all, the cause of the pathology is treated. If it is an inflammatory process, then antibiotic therapy is used. If the cause of the insufficiency of the second phase was stress or depression, then sedatives are prescribed.
2. An important role is played by the replenishment of progesterone. For this purpose, preparations containing this hormone are prescribed - Utrozhestan or Duphaston. In addition to these drugs, injections or suppositories with progesterone can be prescribed. If the cause of the disruption in the production of the hormone was the improper functioning of the corpus luteum, then the problem will be solved with the help of progesterone-containing drugs.
3. To eliminate excess estrogen, which is an antagonist, antiestrogen drugs are prescribed - Tamoxifen, Raloxifene.
4. For sufficient development of the follicle, it is recommended to take follitropins. These are drugs used to enhance the process of ovulation and the maturation of the follicle. Such funds are available in the form of injections, suppositories and tablets.
5. Physiotherapy treatment is also effective. One of these methods is intravaginal phonophoresis. With the help of it, the drug is injected into the deep layers by means of ultrasound.
6. Some doctors prescribe hCG injections to stimulate the corpus luteum and increase progesterone. Usually injections are given after conception to maintain the corpus luteum.
7. To improve the general condition, sanatorium treatment, taking vitamins is recommended.

Folk recipes in the treatment of the disease

In some cases, with the permission of the attending gynecologist, traditional medicine recipes can be used:

Dried raspberry leaf tea. Grind dry leaves, take 2 tablespoons and brew in 500 ml of boiling water. Insist for half an hour, strain and drink the resulting broth throughout the day in small sips.
Grind plantain seeds, take 1 tsp. and 1 tbsp. l. ordinary cuffs, brew a glass of boiling water. Allow the decoction to cool, strain and take 15 ml in the morning, afternoon and evening.
1 st. l. herbs adonis brew in a glass of boiling water. Wrap for 2 hours, strain. Drink instead of tea 3 times a day.
3 art. l. ramishia lopsided pour half a liter of boiling water and leave the decoction in a thermos all night. The resulting remedy to drink 150 ml 3 times a day an hour after a meal.

It should be remembered that folk remedies are used only as an aid. In no case should you refuse the main treatment with the help of medications.

Try to avoid stress.

Luteal phase deficiency is a fairly serious disease. Without treatment, it leads to infertility, menstrual irregularities, cancer of the reproductive organs, etc. Therefore, in case of any deviations in health, it is necessary to consult a doctor.

Studies show that in women with normal reproductive function, there are large fluctuations in the production of progesterone from cycle to cycle, and the concentration in the blood serum in different cycles is completely different. Progesterone in non-pregnant women is produced in a pulsatile manner, reflecting the pulsatile production of LH.
Its level fluctuates every 90 minutes and can increase up to 8 times the minimum level. Therefore, a one-time determination of progesterone does not reflect the true picture of the level of progesterone and is of no practical importance.
Capturing the peak of progesterone with one measurement is not easy, and even impossible. It's like picking one frame from a movie and trying to judge what the movie is about, how it starts and how it ends.
To make a diagnosis of luteal insufficiency, serial progesterone levels must be determined for a minimum of three menstrual cycles, taking into account other signs of this condition. Many conditions and diseases in which luteal insufficiency can be observed require adjustment and treatment, and not prescribing progesterone and thus effectively "kicking" the woman and creating a false belief in her that the prescribed progesterone will help her become pregnant and endure the pregnancy.

How ethical is it to prescribe progesterone in situations where luteal insufficiency is the result of other diseases that need to be treated or conditions that need to be corrected?

For example, if a woman is underweight, and because of this, long menstrual cycles, often with impaired ovulation, how ethical is it to prescribe her progesterone (duphaston) ostensibly to treat luteal insufficiency, instead of explaining to a woman the importance of adipose tissue in the participation of sex hormone metabolism, conception and bearing offspring? How ethical is it to prescribe progesterone to women who are nervous about any trifle and do not understand that stress exacerbates their problems with conceiving and bearing a child, instead of recommending a consultation with a psychotherapist or an anti-stress program? How ethical is it to prescribe progesterone for elevated prolactin levels without finding out the causes of hyperprolactinemia and without determining the presence or absence of ovulation?

So, it is important to understand this truth: one can speak about the insufficiency of the luteal phase only when this second phase is present. This means that the cycle must be ovulatory - one of the important diagnostic criteria for the diagnosis of luteal insufficiency.

Progesterone phase deficiency is an extremely rare diagnosis and is not recognized by many progressive physicians. This attitude of doctors is explained by the fact that if the first phase takes place naturally and ends with ovulation, then it is unlikely that the second phase will proceed with disturbances. After all, the second phase significantly depends on the quality of the first phase.

Insufficiency of the luteal phase or corpus luteum is most often spoken of in the context of ovarian insufficiency, primary or secondary, when the menstrual cycles and the maturation of germ cells are impaired. In an isolated variant, when there is a violation of the luteinization of the follicle and the corpus luteum becomes inferior, progesterone deficiency is extremely rare.

Also, the function of the corpus luteum of pregnancy is completely incorrectly assessed. The peculiarity of the functioning of the corpus luteum of pregnancy is that with normal implantation, which is possible in the presence of a healthy fetal egg, hCG stimulates the production of progesterone by the corpus luteum. If the fetal egg is defective, implantation is disrupted and the amount of hCG is low, which automatically drowns out the work of the corpus luteum.

If ovulation has occurred, that is, the maturation of the egg, then this speaks in favor of the normal first phase (otherwise ovulation would not have occurred) most often. Ovulation disorders are more common than violations of the formation of the corpus luteum, since the corpus luteum is still the same mature follicle that goes through new stages of development (qualitative change).

It is assumed that the reason for the violation of the formation of the corpus luteum and its insufficiency lies in the violation of a healthy proportion between follicle-stimulating hormone (FSH) and lutein hormone (LH), which are involved in the regulation of the corpus luteum. This disproportion can be caused not only by a violation of the production of FSH or LH, but also by the negative influence of other hormones - prolactin, thyroid hormones, less often than others. A sharp increase in LH before ovulation is an important signal for the future transformation of the follicle into the corpus luteum.
Insufficiency of the luteal phase can be observed in perfectly healthy women, but leading a certain lifestyle, which drastically affects their reproductive function. So, for example, in women who run and run 35-50 km per week, luteal phase deficiency is observed, which will manifest itself as a normal level of progesterone and even a normal duration of the second phase in most cases. Studies have shown that two types of luteal insufficiency occur in women involved in intense sports, one of which is associated with a violation of the absorption of progesterone, and the other with a violation of the relationship between LH and the production of progesterone.

In lactating women, luteal phase deficiency is often observed, manifested by short menstrual cycles, which is partly due to the action of prolactin, as well as a violation of the LH-progesterone relationship.

But there is another reason for the occurrence of luteal insufficiency, which is not related to the function of the corpus luteum (and it can be normal) - this is a breakdown at the level of the endometrium: a lack of estrogen and progesterone receptors, or an imbalance in their number, or a defect in the receptors, which can have a different nature of occurrence, but often congenital. Such a mechanism for the occurrence of progesterone deficiency is often observed with repeated spontaneous miscarriages that occur due to inadequate preparation of the endometrium for the adoption of the fetal egg.

Another mechanism for the development of luteal insufficiency is explained by an increased level of oxidative processes in the tissues of the uterus, that is, a state of intracellular stress (oxidative stress). Insufficiency of the luteal phase in the presence of hormonal disorders from the thyroid gland also occurs in a number of women, and this type of dysfunction of the corpus luteum cannot be compensated by progesterone alone. It is always necessary to eliminate hormonal breakdowns from other organs.

Women with primary luteal insufficiency, which is associated with the work of the corpus luteum, always have ovulation, that is, the maturation of the germ cell.

In anovulatory cycles, progesterone levels are always the same, although low for the second phase, but since there are no phases in anovulatory cycles, the diagnosis of progesterone deficiency is not made in such cases.

Given that a decrease in progesterone in the second phase of the normal cycle, after its peak on the 7th day after ovulation, leads to the appearance of menstruation, then the lack of progesterone, that is, its low level, will lead to spotting appearing before 28 days. In violation of the corpus luteum function, menstrual cycles are always short, and the second phase usually does not exceed 9-12 days.

Although for many women, menstrual cycles of 21 days may be their physiological norm and do not affect fertility (the ability to conceive and bear children), in women suffering from infertility or recurrent spontaneous miscarriages, a short menstrual cycle should always be alert for progesterone deficiency.

There are no other visible signs of progesterone deficiency. Therefore, often the diagnosis of this condition requires laboratory and other diagnostic tests.

Despite a number of contradictions in the diagnosis of progesterone deficiency, there are still the following diagnostic criteria, which are followed by most doctors in the world:

The presence of ovulation and two phases of the cycle.
Short second phase of the cycle (less than 12 days).
Low progesterone levels 6-8 days after ovulation.
Lack of pulsatile progesterone production.
The absence of a normal reaction of the endometrium to a change in the hormonal level and phase of the cycle.

How to correctly diagnose luteal insufficiency? When is the best time to do it to get reliable results? What diagnostic method should be preferred? These and other questions still do not have clear answers, because there can be a lot of reasons for progesterone deficiency - from a breakdown at the level of its production to the moment it is absorbed by tissues and excreted from the body. This is a long period of biochemical reactions involving hundreds of other substances and structural units, including genes. Even if there is no breakdown in the “production-assimilation-processing-elimination” chain, other factors, both internal and external, can influence this process.

And it is important not just to “find fault” with the indicator of the level of progesterone in the blood (which is most often determined incorrectly), but to analyze each specific case without bias and premature conclusions.

Measurement of basal body temperature for the diagnosis of luteal insufficiency is considered an outdated, inaccurate and unreliable method, therefore it is not used in modern obstetrics. The presence of spontaneous miscarriages in the past is not a criterion for making this diagnosis, but is taken into account as an important additional factor.

Normally, the luteal phase can last from 11 to 16 days, so the middle of the luteal phase and the peaks of hormones may not always coincide.

Features of fluctuations in progesterone levels during the day and different periods of time:

When determining luteal insufficiency, many doctors forget that progesterone is produced not in a constant mode, but in a pulsating one (as a reflection of LH production). This means that the difference between low and high levels constantly fluctuates throughout the cycle and especially during the luteal phase.

The production of luteotropic hormone, which regulates the production of progesterone, depends on hypothalamic-pituitary activity, and during the day, as well as the entire menstrual cycle, LH pulsation can be in different modes:

pulsation with high amplitude (ejection of a large amount of LH without clear time intervals),
appulsation (LH production is negligible),
pulsation in the state of sleep (almost chaotic in frequency and amplitude production of LH,
regular 90-minute uniform pulsation.

How do most doctors diagnose luteal insufficiency? Usually women with irregular long cycles come to the doctor (because many are thin and tall, dieters, nervous and worried about any trifle), and therefore more often anovulatory cycles than ovulatory ones.

Or, for many, ovulation occurs much later than with a 28-day cycle, which is the norm. In other words, in most cases, these are quite healthy young women who simply have not been explained that low weight, too young age and stress are the causes of an irregular cycle most often.

Such women are sent to check the hormonal levels and are required to donate blood for some hormones at the beginning of the cycle, and for progesterone - on the 21st day of the cycle. This number "21" is almost magical. Why on the 21st day of the cycle? Because that's how it's done? Why are other days not suitable for hormone testing? They fit; any day is fine, especially when there is no ovulation.

With an anovulatory cycle, there is neither the first phase nor the second, so tests can be taken on any day, especially since women most often do not know when their next menstruation will come - in a week, two, a month, three months.
So why is everyone so obsessed with day 21 (less often day 22 or 23)? Because in the normal 28-day ovulatory cycle of healthy women, progesterone peaks on this day.

However, a cycle of 21 days, and 26 days, and 30 days, and even 35 days, and in some women even 40 days, is also considered normal if it is accompanied by ovulation. In women with cycles longer than the classic 28 days, the rupture of the follicle does not occur on the "traditional" 14th day of the cycle, but much later. This is not "delayed" ovulation, this is their (women's) normal ovulation.
With a 28-day cycle, a rise in progesterone levels is observed on the 7th day after ovulation, which is the 21st day of the cycle. And if a woman ovulates earlier or later, not on the 14th day, then when can we expect an increase in progesterone levels? All on the same 7th day after ovulation. What day of the cycle it will be - it is important to learn how to count correctly. Therefore, if a woman ovulates on the 21st day with a 35-36-day cycle, then the rise in progesterone will be observed on the 21+7=28th day of the cycle.

Unfortunately, most women do not know about this specific rise in progesterone, but it is unfortunate that doctors do not know either. So it turns out that they send a woman to check hormones, usually estrogens are in an excellent norm, and progesterone on the 21st day of the cycle is “low”. And according to this one result of the analysis, a diagnosis is immediately issued - insufficiency of the luteal phase.

Determination of the reaction of the endometrium to progesterone:
Ideal in the diagnosis of luteal insufficiency would be to compare progesterone levels on different days of the second phase with changes in the endometrium, because the logical conclusion suggests itself: if the level of progesterone is low, then the secretory changes in the endometrium will be disturbed (weakly pronounced) too.

But what a disappointment it was when a large number of doctors who studied the histological structure of the endometrium obtained by biopsy on different days of the luteal phase compared the results.

It turned out that with a low level of progesterone, there may be a normal development of the endometrium, and vice versa, with a normal level of progesterone, there may be a bad endometrium. It also turned out that in healthy women, progesterone can be low, but they will become pregnant and carry a pregnancy without problems. Progesterone levels may be low in some cycles and normal in others, but this does not affect reproduction. In some cycles of a healthy woman, there may be a good endometrium, and in others, a bad one. All these are physiological norms.

Thus, determining the level of progesterone, even in its dynamics, and endometrial biopsy, even in different cycles, are not reliable methods for diagnosing luteal phase deficiency.

Modern view on luteal insufficiency:

Let us summarize the above in the form of a modern view of progressive doctors on the state of progesterone deficiency.

1. Primary insufficiency of the luteal phase manifests itself as a violation of the production of progesterone by the corpus luteum or an inadequate response of the endometrium to progesterone.
2. Insufficiency of the luteal phase is manifested by a shortening of the second phase of the cycle, and not by its lengthening. The normal duration of the luteal phase is 12-16 days (average 14 days). With insufficiency of the luteal phase, its duration is from 3 to 10 days (average 9 days).
3. In the vast majority of cases, a low level of progesterone during anovulatory cycles is a natural manifestation of a violation of the ovulation process and insufficiency of the first phase. Menstrual cycles are most often long (more than 35-40 days).
4. Anovulatory cycles do not have phases, so the diagnosis of luteal phase insufficiency in such cases is not made.
5. In women with low weight (thin), the first phase is prolonged, often anovulatory cycles, usually more than 35-40 days, which is a physiological response to low body weight and lack of adipose tissue involved in the absorption and metabolism of sex hormones. In such women, the level of oxygen and energy starvation of tissues, including the ovaries, is higher compared to women with normal body weight.

6. Although a normal level of progesterone is important for the development of pregnancy, most often abortion occurs not due to a lack of progesterone, but for the following reasons: defective conception (defective ovum), late implantation (also often due to a defect in the ovum).

7. Insufficiency of the luteal phase, when the level of progesterone is below normal levels, is observed as a physiological self-defense reaction that prevents the processes of reproduction (and therefore the implantation of a possible product of conception) under the following conditions of a woman: starvation, anorexia, bulimia, eating disorders, rapid weight loss, intense sports, heavy physical activity, stress, obesity, aging (older age), in the postpartum period.

8. Periodically, luteal phase deficiency can occur in normal menstrual cycles.

9. Insufficiency of the luteal phase is observed as a secondary sign in the following diseases: polycystic ovary syndrome, endometriosis, hyperprolactinemia, thyroid disease, after stimulation and induction of ovulation, with a number of metabolic disorders.

10. Luteal insufficiency can be manifested by a shortening of the second phase, spotting before menstruation, repeated spontaneous miscarriages, and infertility.

It is important to understand that, as an isolated diagnosis, luteal insufficiency is extremely rare. In making a diagnosis, it is necessary to confirm or exclude all of the above conditions that may be involved in the appearance of corpus luteum insufficiency.

Luteal phase deficiency symptoms

Causes of insufficiency of the luteal phase of the menstrual cycle:

1. Dysfunction of the hypothalamic-pituitary system that has arisen after physical and mental stress, trauma, neuroinfection, etc. It has been established that with insufficiency of the luteal phase of the menstrual cycle, the level of FSH is lower than in healthy women.

2. Hyperandrogenism of ovarian, adrenal or mixed genesis.

3. Functional hyperprolactinemia. Insufficiency of the luteal phase of the menstrual cycle can develop as a result of the influence of high concentrations of prolactin on the secretion and release of gonadotropic hormones, as well as inhibition of steroidogenesis in the ovaries. Often in women with insufficiency of the luteal phase of the menstrual cycle, hyperprolactinemia is combined with hyperadrogenemia.

4. A protracted inflammatory process in the uterine appendages.

5. Pathology of the corpus luteum, caused by biochemical changes in the peritoneal fluid (increased content of prostaglandins and their metabolites, macrophages, peroxidase, etc.).

6. Hypo- or hyperthyroidism.

Diagnosis of luteal phase deficiency

When diagnosing NLF, they are based on the clinical manifestations of NLF and additional research methods. The main symptom of NLF may be infertility or scanty spotting 4-5 days before the onset of menstruation. When diagnosing NLF, the following methods are used.

The traditional method is to measure basal body temperature. With normal function of the corpus luteum, the duration of the luteal phase is 11-14 days, regardless of the length of the menstrual cycle. NLF is characterized by a shortening of the second phase of the cycle, and the temperature difference in both phases of the cycle is less than 0.6 degrees. This test is not always objective for judging NLF, since when determining the level of progesterone in the blood plasma and endometrial biopsy, there may be a clear discrepancy between the level of progesterone and the severity of secretory changes in the endometrium.

Evaluation of the level of progesterone in the blood, determination of the excretion of pregnandiol in the urine. The ideal is to determine its level during the second phase of the menstrual cycle 3-5 times. The level of progesterone in blood plasma 9-80 nmol / l and pregnandiol in the urine more than 3 mg / day is an indicator of a satisfactory function of the corpus luteum.

An endometrial biopsy performed 2-3 days before the onset of menstruation reveals insufficient secretory transformation of the endometrium. It is found in half of women with infertility and a typical biphasic rectal temperature and in about 70% of women with an atypical biphasic basal temperature curve. The normal level of blood progesterone in the second phase of the cycle is not a guarantee of a full-fledged secretion phase, since there may be a violation of reception at the level of the endometrium, therefore, in case of infertility, an endometrial biopsy is indicated.

Ultrasound scanning of follicle growth and endometrial thickness in the dynamics of the menstrual cycle suggests NLF.

Laparoscopy performed after ovulation allows you to observe the stigma at the site of the ovulated follicle, although the presence of ovulation does not mean the full function of the corpus luteum.

luteal phase deficiency treatment

Treatment of NLF - insufficiency of the luteal phase of the menstrual cycle can be started according to the type of replacement therapy, namely, to prescribe a progesterone solution in the second phase of the cycle 10 days before the onset of menstruation. Pregnancy was observed in more than 50% of women.

It has been established that norsteroids (norcolut, prelamut, etc.) have a luteolytic effect. Chorionic gonadotropin is preferably administered on the 2nd-4th-6th day of the increase in basal temperature. Earlier and later administration is impractical: early administration may contribute to the luteinization of the non-ovulating follicle, and later may have a luteolytic effect. The introduction of hCG can be combined with the appointment of clomiphene or pergonal, but under the control of the level of estradiol in the blood or ultrasound scanning.

Combined estrogen-progestogen drugs are prescribed for the reboud effect for 2-3 courses.

Clomiphene according to the usual scheme: from the 5th to the 9th day of the cycle, 50 mg, with insufficient effect, the dose can be increased to 100-150 mg / day. Clomiphene from the 5th to the 9th day of the cycle, HCG for 2000-3000 ME 184 Days 2-4-6 of increasing basal temperature. Pergonal in combination with HCG.

With NLF caused by latent hyperprolactinemia and hyperandrogenism, treatment with dexamethasone is recommended - 0.75 mg / day. for 10 days, then 0.5 mg/day, and Parlodel 2.5 mg/day.

There are reports of beneficial effects of NLF therapy with luliberin. There are reports of treatment of NLF with prostaglandin blockers (indomethacin, naprossin).

In conclusion, NLF is a multifactorial pathological condition leading to infertility. Therefore, its treatment is quite difficult, the effectiveness of treatment increases when the cause of NLF is clarified and pathogenetic therapy is carried out.

Prevention consists in the prevention of those pathological conditions that contribute to the development of NLF.