Cervical Health Awareness Month
January 3, 2022
By Courtney Wechsler, MD
Empowering Individuals through Fertility Awareness
Editor’s Note: Two events are central markers of both female health and fertility: the production of fertile cervical mucus and the ovulatory event. Although menstruation is perhaps the most obvious physical sign characterizing the female cycle, without fertile cervical fluid produced by the developing ovarian follicle, the release of an egg (oocyte) and its subsequent fertilization by sperm, there would be no pregnancies. Despite these facts, education about the importance of cervical mucus and ovulation as markers of health is not a significant component of medical training, creating an unfortunate gap in patient education as well.
The FACTS elective in fertility awareness exists to bridge this gap. While on the FACTS elective, Dr. Courtney Wechsler summarized a review by Vigil et al published in 2012, titled, “The Importance of Fertility Awareness in the Assessment of a Woman’s Health.” The brief summary below discusses aspects of the thorough article written by a team of experts in fertility awareness who make a strong case for incorporating fertility awareness as a foundational aspect of women’s health. Readers are encouraged to read the summary below followed by the full article to gain an understanding of the physiologic basis for the future of women’s health.
“Fertility awareness” refers to an individual’s ability to identify the occurrence or absence of ovulation within their menstrual cycles.i The ability to determine the timing of ovulation alongside other bodily changes provides important insight into hormonal shifts occurring throughout the menstrual cycle and can be used to suggest hormonal imbalances, metabolic disturbances, and other reproductive pathologies. Identification of ovulation in conjunction with monitoring of these bodily changes also allows individuals to determine both fertile and infertile times within their menstrual cycles, which enhances personal health awareness and promotes reproductive autonomy.
Hormone Changes Throughout the Menstrual Cycle
Four main hormones have primary effects on the menstrual cycle: follicle-stimulating hormone (FSH), luteinizing hormone (LH), estrogen, and progesterone. These hormones follow a standard pattern in a cyclic fashion, each contributing to various aspects of the menstrual cycle (see image). The menstrual cycle begins with the development and growth of an ovarian follicle (containing an egg) in response to FSH released from the pituitary gland (in the brain). As the follicle enlarges in the ovary, it begins to release estrogen, which causes the endometrium (lining of the uterus) to thicken in preparation for the potential implantation of an embryo.
Once estrogen levels reach a certain threshold, this triggers a steep rise in LH (also released from the pituitary gland), inducing ovulation (the release of the egg from the follicle). The egg then travels from the ovary to the fallopian tube, where it has the chance to become fertilized and result in a pregnancy.
After release of the egg, the empty ovarian follicle shrinks and forms the corpus luteum (“yellow body”), which secretes progesterone. As the ovarian follicle transitions to the corpus luteum, estrogen levels fall and progesterone levels begin to rise. Progesterone’s main effect is to stabilize the endometrium. In the event of a pregnancy, an embryo implants within the endometrium and releases human chorionic gonadotropin (β-hCG). This hormone stimulates the corpus luteum, allowing the continued release of progesterone and the ongoing stabilization of the endometrium to support the pregnancy (this is why there is no menses during pregnancy).
During cycles in which no pregnancy implants within the endometrium (and, thus, no β-hCG is available to sustain the corpus luteum), the corpus luteum continues to involute, and regresses fully within 11-16 days.1 The regression of the corpus luteum causes a decrease in progesterone levels, withdrawing the hormonal stabilization of the endometrium. As a result, the endometrium begins to slough and menses ensues. Because both estrogen and progesterone block the brain’s release of FSH, decreasing levels of these hormones allow the brain to again secrete FSH, thus resetting the cycle.
Cervical Mucus Changes Throughout the Menstrual Cycle
Cervical mucus patterns (observed as vaginal discharge or secretions) also fluctuate in response to menstrual cycle hormone levels and can thus be used as a surrogate indicator of hormonal shifts within the body. In fact, cervical mucus follows a distinct pattern under the influence of estrogen and/or progesterone. This makes it possible to observe and track changes in vaginal secretions to monitor fluctuations in these hormones in a non-invasive way. For example, with increasing levels of estrogen early in the menstrual cycle, cervical mucus becomes thin, watery, slippery, and lubricative. Such thin, watery mucus is ideal for fertilization, as it allows sperm to travel more easily through the cervical canal in its ascent toward a released egg. This mucus type indicates periods of potential fertility.
Following ovulation, with lower levels of estrogen and rising progesterone, cervical mucus becomes thick, tacky, and dry. The switch to this mucus type after “fertile” mucus indicates the approximate timing of ovulation and the transition toward a period of infertility. This thicker mucus is ideal for periods of infertility, as it blocks sperm, bacteria, and other organisms from ascending the cervical canal and entering the uterus, thus aiding in prevention of internal infection during times of infertility or pregnancy.
Monitoring Fertility Throughout the Menstrual Cycle
Understanding these hormone fluctuations and the associated bodily changes that take place throughout the menstrual cycle allows individuals to monitor, chart, and track periods of fertility and infertility. Reviewing daily charted data can help to identify variations among cycles or discover atypical patterns between cycles that may result from increased life stressors, infection, reproductive pathology, or pregnancy. Charted cycles can also be used to tailor pharmacotherapy, whether for symptom relief throughout the menstrual cycle or in targeted treatment of infertility, among others. Tracking cycle changes enables individuals to gain a deeper understanding of their unique physiology, identify personal cycle patterns, and decrease ambiguity in potential periods of fertility versus infertility, ultimately giving them more control over their bodies and reproductive choices.
* The patient’s name was changed to protect her privacy, and permission was granted to use all quotes and information.
 Vigil, P., Blackwell, L. F., & Cortés, M. E. (2012). The Importance of Fertility Awareness in the Assessment of a Woman’s Health a Review. The Linacre Quarterly, 79(4), 426–450. https://doi.org/10.1179/002436312804827109.
ABOUT THE AUTHOR
Courtney Wechsler, MD
Courtney Wechsler, MD wrote this review as a fourth-year medical student at Wright State University Boonshoft School of Medicine in Dayton, OH while on the FACTS elective. She is now an emergency medicine resident at Detroit Receiving Hospital in Detroit, MI. With a dedicated interest in obstetric and gynecologic emergencies, her career goals include improving Ob-Gyn care within the emergency department, from miscarriage management to intimate partner violence and physical abuse survival. She is passionate about inclusivity and empathy for others and is dedicated to advancing racial and reproductive justice within healthcare.