Woman is unique amongst females of all species in that her reproductive capacity ends in middle life. There is a progressive decline of fertility until, at about the age of 45 to 50 years, when perhaps she has another 25 or 30 years of active life ahead of her, she become infertile. The years during which fertility decreases are known as the climacteric (change of life). The term “menopause” is more strictly applied to the cessation of the menstrual bleeds.
Physiological Patterns of the Climacteric may take one of the following forms:
The menstrual bleeds may stop without obvious warning and not begin again. In these circumstances the woman may at first suspect that she is pregnant.
The cycles may become very irregular, with short and long cycles interspersed with cycles of normal length. The amount of bleeding may vary considerably, at times being heavy. The woman will be anxious to be sure that all is well physically and may need reassurance that she will be able to manage her fertility in this newly erratic situation.
Ovulation may now occur infrequently or cease altogether, but episodes of bleeding continue.
The woman may become infertile before ovulation ceases because the cervix no longer responds to the changing hormone levels to produce mucus capable of supporting sperm.
The interval between ovulation and the following menstruation may become shorter, or the hormone levels of the luteal phase be inadequate, rendering the cycle infertile (short or deficient luteal phase).
The number of months or even years between the onset of these changes and the end of fertility cannot be predicted. It is possible that menstruation may cease for months at a time only to be followed by apparently normal fertile cycles. However, as time goes by the woman will recognize an increasing number of indications of infertility.
Practical Application of the Billings Ovulation Method™
It is possible that the woman has come because she and her husband have been following a natural method which relies on the presence of ovulation. She is now confused and as they have been waiting for the confirmation of ovulation, prolonged abstinence is causing them concern. Neither the woman nor her teacher should be disturbed by the absence of the typical mucus pattern of a fertile ovulation. The woman will learn to understand the significance of identifying infertility and gain confidence that she will identify any changes that signify potential fertility. She can learn to recognize her Basic Infertile Pattern and to apply the three Early Day Rules. If cycles have become longer than 35 days the chart may now reveal a combined Basic Infertile Pattern where before the woman had only identified one. She may have dry days, followed by days of unchanging discharge, or a combination of both dry days and days of unchanging discharge. Two weeks of charting, without intercourse and without any bleeding, which reveals a pattern which is unchanging, can be recognized as a Basic Infertile Pattern. The couple will be able to have intercourse on alternate evenings using the second Early Day Rule so long as the pattern continues. They wait without intercourse for the duration of any change from the Basic Infertile Pattern and for a further 3 days after the return of the BIP before resuming intercourse from the fourth evening and thereafter on alternate evenings until there is a further change. Such a change may be a change in sensation felt at the vulva, a change in the visible signs of the mucus or any bleeding.
The teacher should take an adequate history, including the following points:
Number of pregnancies, including miscarriages
Number of surviving children and their ages
Forms of family planning used in the past – chemical contraception is more likely than usual to produce prolonged infertility at this age
When did any irregularity in the length of cycles begin
Has she noticed changes in her menstrual bleeds – reduced or prolonged bleeding, “clots”, etc.
Any episodes of bleeding between one menstruation and the next
Breast changes – where previously she experienced soreness after ovulation, this may now have disappeared or it may be more severe, lasting for several days and even disturbing her sleep
Hot flushes – occurrence, frequency. These typically happen when oestrogen levels are low (during the Basic Infertile Pattern)
Vulval swelling and ovulatory pain - if these have previously been noticed around Peak time they may be absent in some cycles
Changes in the physical characteristics of the mucus
Any medical investigations or treatments
Family history – diabetes, blood pressure/hypertension, high cholesterol
Medications – prescription drugs or naturopathic/herbal preparations
Once a history has been taken the teacher will explain the normal events of the fertile cycle, while stressing that, if a typical ovulatory pattern is not revealed by the charting, the couple will nevertheless be able to apply the Rules of the Billings Ovulation Method™ through an understanding of fertility and infertility.
Guidelines for the Teacher
The teacher will need to allow time and be prepared to listen – as she may be the first person who has shown this woman empathy. She may be feeling unattractive and taken for granted as she ages and her family no longer seem to need her. She may be anxious about the possibility of another pregnancy and therefore not enjoying the conjugal relationship with her husband. Both husband and wife may be feeling the stress of prolonged abstinence. Just being able to talk about these things may help her feel more relaxed.
The teacher should give a simple and clear initial instruction which explains the physiology of the ovulatory cycle but reassures the woman that even if she is not ovulating she will be able to recognize what is happening in her body and be able to identify her increasing infertility. She should begin charting immediately by becoming aware of the sensations at the vulva as she goes about her normal daily activities and recording these on her chart at the end of each day using just one or two words. She should also briefly describe any discharge that she sees, but not touch the discharge or make any internal investigations. The couple is advised to abstain from intercourse and genital contact for two weeks while the initial recording is made.
At the first follow-up appointment, after two weeks of charting, the teacher should go through the chart with the woman, clarifying what the descriptions mean and ensuring that the correct stamp or symbol has been used. If the woman records “dry” does she mean nothing felt, nothing seen? If she has written “wet” on several days, were they all the same or has there been some development – damp, moist, wet, and even slippery? If there are different words used on many days to describe what was seen, were these significant differences or merely slight variations of something that was essentially the same? Is it possible to identify a Basic Infertile Pattern of dryness? Or are there indications that the Basic Infertile Pattern is one of unchanging discharge or even a combined Basic Infertile Pattern? Gradually the teacher will be able to help the woman identify patterns of infertility and potential fertility and, perhaps, a Peak symptom. It may be necessary to mark the count of 1, 2, 3 after days of change or bleeding.Remember that regular bleeding indicates ovarian activity. However, bleeding may not be menstruation.
Once a Basic Infertile Pattern has been established the couple can begin applying the Early Day Rules. Remind them to confine intercourse to the evenings and not on consecutive days. Bleeding cannot be assumed to be menstruation, even if it is regular bleeding. If a Peak has not been identified prior to the bleed, remind her to apply the third Early Day Rule to this bleed as it may be the result of high oestrogens and therefore indicate fertility. If Peak is identified the Peak Rule is applied. Acts of intercourse should be marked on the chart so that the teacher can be sure the couple understands the correct application of the guidelines. If there is evidence of departure from the rules it is important to be sure that the couple has understood and is prepared for the possibility of a pregnancy. It may be necessary to remind them that there are sound, scientific reasons why the rules mean what they say.
Over time it can be expected that the chart of a peri-menopausal woman will reveal evidence of diminishing fertility. Cycles may become long and irregular with only occasional patches of mucus which may or may not be followed by bleeding. If the teacher understands the Continuum of Ovarian Activity (Studies in Human Reproduction, Professor James B Brown) she will be able to explain to the couple the reasons for the cycle variants that are likely to occur before the cessation of all bleeding at the menopause. A peri-menopausal woman also needs to understand that even though she may be ovulating, as indicated by temperature rises or hormonal studies, as a couple they are infertile if her cervix is no longer producing mucus and she is experiencing prolonged BIP interrupted by regular bleeding.
If the woman describes any symptoms that the teacher suspects may be the result of pathology, including prolonged, heavy bleeding, she should be advised to consult her doctor to rule out any abnormalities and check that she is not becoming anaemic. If the results indicate it is just the normal but erratic pattern of waning fertility then the teacher will be able to reassure the woman and her husband that all is well and they can continue to enjoy physical intimacy in peace and harmony. A confident relaxed teacher, who imparts sound knowledge, will ensure a confident and relaxed husband and wife.