Anovulation - No Ovulation - Tests And Causes And What To Do About It

    What is anovulation

    Anovulation refers to a condition in women who do not ovulate, in which no egg is not released from the ovaries. This can lead to menstrual cycle irregularities (no periods or amenorrhea, long or short cycles, or irregular cycles). You need to ovulate if you want to get pregnant, and have regular mentrual cycle, regular menstrual periods or bleeding. Anovulation is the #1 reason of infertility experienced by women with difficulties getting pregnant..

    How Do you know you are not ovulating?

    Women who ovulate regularly have regular periods, usually every 28 (range 21-35) days. Women with with anovulation have very irregular or no period. Monitoring your menstruation as well as ovulation cycle, which includes becoming aware of the signs of ovulation, can help you identify some of the symptoms of anovulation. The most common of these fertility symptoms include the following:

    • irregular basal body temperature (BBT)
    • irregular menstruation
    • reduced PMS symptoms
    • amenorrhea (the absence of a menstrual period)
    • excessive menstrual bleeding
    • oligomenorrhea (light menstruation)

    Experiencing chronic anovulation or avoiding treatment can lead to infertility.

    What Causes Anovulation?

    Anovulation is normal when you breastfeed or you are pregnant. Women taking the birth control pill also do not usually ovulate, but they have regular menstrual cycles. Excessive weights (too much or too little weight) can lead to anovulation as can stress. The #1 cause for anovulation is PCOS (Polycystic Ovarian Syndrome).

    Try to identify why you don't ovulate.

    If you are overweight, losing weight, and if you are underweight gaining weight makes you usually ovulate. In more serious cases of anovulation, fertility drug therapies such as clomiphene and gonadotropin may be recommended to induce ovulation. It is important that any underlying cause of infertility which may result in anovulation be treated. In some cases, an ovarian wedge resection may be performed. This procedure involves the removal of certain parts of the ovaries in order to balance hormone levels. Speak to your doctor or a fertility specialist for information on what is best for you. Being aware of your options can help you make the appropriate decision for your future benefit.

    First step: Do a pregnancy test

    The first step when you miss your period is to do a pregnancy test. If the pregnancy test is repeatedly negative then you are not pregnant and chances are that you missed your regular periods because you did not ovulate.  So the next step is to figure out if you ovulate or not. You are likely to ovulate regularly if you have regular menstrual cycles around 28 or so days.

    You are likey to NOT ovulate (anovulation) or to ovulate irregularly if:

    • If your periods do not come at all with a negative pregnancy test
    • Your periods are more than 35 days apart,
    • You have a lot of spotting with irregular periods
    • Some women have regular periods but are still not ovulating, but this is fairly unusual.

    Step 2: Determine if you ovulate

    There are several ways to determine with enough certainty whether and when you are ovulating.

    Basal Body Thermometer BBT and Natural Family Planning

    The least expensive way is with something called Basal Body Temperature Charts (or BBT's).  You will need a thermometer.  They do make special BBT thermometers, but a digital thermometer will also do.  Do not use the ones that go in your ear.  They can vary depending on how far into your ear you get the probe, and you want a very accurate temperature for this.  Graph for your temperatures, and some of them will even plot them for you.  There are even ap's for that!  First thing in the morning, before you have gotten out of bed or done anything, take your temperature.  Plot it on the graph.  Do this every morning from the first day of your period until the first day of your next period.  If you are ovulating, you will find that your temperatures hover around the same number until about 14 days from your next period.  They will then dip down for a day, go up to a new temperature, and then hover around that new higher temperature until you get your next period.  If you can see that on your graph, then you are ovulating.  The dip is the day you are ovulating.  If you cannot see that, you may not be ovulating.  It can be hard to interpret these some times, so if you don't see what I just described, don't get discouraged.  Try one more method to see if you are ovulating before you decide. 

    Ovulation Predictor Kit OPK

    Another option is to try ovulation predictor tests (OPK).  These look just like the home pregnancy tests you can buy, but they are to determine when you are ovulating instead.  Unfortunately, different brands vary in their accuracy.  If you are finding positive tests with the regular "pee-on-the-stick" kind, then you don't really need the fertility monitor.  If you are not having luck with the stick version, then the monitor may be helpful.  If you find a positive test, then you are almost definitely ovulating, though there are "false positive"OPK tests.  If you get your period 13-16 days after the positive test, then you are definitely ovulating.  If you do not get your period in that time frame (and you are not pregnant), then you may have something called PCOS.  PCOS can give you false-positive ovulation tests.  Ten percent of ovulating women will not get positive ovulation tests, unfortunately.  So if you are having regular cycles but can't find a positive ovulation test, you may still be ovulating. 

    Blood Progesterone Levels

    The ultimate way to determine whether you are ovulating or not is to have your doctor do a blood test to look at your progesterone level.  Progesterone is a hormone that your ovaries make after you ovulate.  The best way to test your progesterone level is to draw the blood about a week before your next period is due.  If your progesterone level is over 3 ng/ml, then you are ovulating.  If your cycles are too irregular to predict when your next one is coming, then it can be drawn 3 weeks or more after your last one.

    Diagnosis of Anovulation

    The main symptoms of women who do not ovulate (anovulation) is having no period (amenorrhea) or having irregular periods or bleeding. Once you know that you don't ovulate, you know how to figure out if you are or are not ovulating.  

    Common causes of anovulation (in the absence of pregnancy)

    • Polycystic Ovary Syndrome (PCOS) (approximately 70% of cases of ovulatory dysfunction). 
    • Hypothalamic amenorrhea, also known as hypogonadotropic hypogonadism (approximately 10% of cases)
    • Hyperprolactinemia (approximately 10% of cases), and
    • Premature ovarian failure, also known as hypergonadotropic hypoestrogenic anovulation (approximately 10% of cases)
    • Breastfeeding
    • Menopause

    There are three distinct parts of the body that contribute to ovulation problems: the hypothalamus, the pituitary gland, and the ovaries.

    1. Hypothalamic problems (GnRH pulses FSH and LH)

    • Polycystic ovary syndrome (PCOS)
    • Prepubertal
    • Strenuous Exercise
    • Certain Diets
    • Stress
    • Low BMI, anorexia, sudden weight loss
    • Chronic or severe illnesses
    • Some drugs (e.g., opiates)

    2. Pituitary causes

    • Hypothyroidism
    • Hyperthyroidism
    • Too much Prolactin. Prolactin may be increased with certain drugs (e.g. major tranquilizers). Any pressure on the gland such as certain tumors (prolactinomas) can also cause a rise in the prolactin hormone (hyperprolactinemia), which in turn can cause problems with ovulation.

    3. Ovarian causes

    • Premature ovarian failure (POF)
    • Ovarian failure = menopause
    • Primary ovarian failure (often a chromosomal problem)
    • Secondary ovarian failure (cause often unknown, but can be due to an autoimmune disorder or caused by chemotherapy, radiotherapy, or surgery. The FSH is usually increased as there is no estrogen or inhibin feedback

    Laboratory Studies for Anovulation

    The very first test to do is a pregnancy test as pregnancy must first be excluded as a cause of not having a period.

    Other laboratory evaluations in patients with anovulation include the following:

    • LH/FSH - FSH is the first test to do as it helps diagnosing premature ovarian failure. The next condition to diagnose is polycystric ovary syndrome or PCOS. LH in combination with FSH, helps establish a diagnosis of PCOS (with LH/FSH ratio >2:1)
    • Ovarian steroid hormones - Estradiol, progesterone (midluteal)
    • TSH - Hypothyroidism
    • Prolactin - Hyperprolactinemia
    • Glucose - Using a 2-hour glucose tolerance test after 75-g glucose load
    • Cortisol with or without ACTH stimulation test - Helps determine presence of adrenal insufficiency
    • Total testosterone/free testosterone - In the presence of hirsutism or virilization, can help distinguish ovarian versus adrenal origin
    • Dehydroepiandrosterone sulfate (DHEAS) - Hirsutism or virilization of adrenal origin
    • 17-Hydroxyprogesterone - CAH
    • Pregnenolone - 17-alpha-hydroxylase deficiency

    Workup for autoimmune disorders may be considered when initial test results are uninformative and may include the following studies:

    • Complete blood count (CBC)
    • Complete metabolic profile - Electrolytes, albumin, renal function tests, liver function tests
    • Antinuclear antibodies
    • Rheumatoid factor
    • Erythrocyte sedimentation rate
    • C-reactive protein
    • Thyroid antibodies

    Other tests may include the following:

    Karyotype - Usually performed in patients younger than 30 years to rule out presence of Y chromosome (frequency of germ cell tumors in patients >30 y is negligible)
    Galactose-1-phosphate - Galactosemia

    Polycystic Ovary Syndrome (PCOS)

    A very common reason for not ovulating is something called PCOS or polycystic ovarian syndrome.  This is a condition where eggs cannot mature enough to be able to ovulate.  These semi-mature eggs produce a lot of testosterone and other male hormones.  These male hormones feed back to the pituitary (the gland in your head that controls your menstrual cycle), and they confuse your pituitary.  Your confused pituitary send out the wrong hormones to the ovaries (too much LH and not enough FSH), and keep your ovaries from being able to ovulate.  This causes more testosterone production and the cycle just gets worse and worse.  All the sacs with the stuck eggs look like cysts on the ovaries, which is why it's called "polycystic".  

    Many but not all women with PCOS usually have other signs of high testosterone levels such as:

    • acne  
    • hair growth on the face, chest, back or belly
    • male-pattern balding

    It is a called a syndrome rather than a disease, because what causes it can vary woman to woman.  One of the main causes is insulin-resistance.  This is a condition where a woman's insulin is not working as well as it should.  It can lead to diabetes, when it gets very bad.  The ovary has insulin receptors.  When it sees too much insulin, it stops ovulating and makes male hormones and therefore PCOS.  Women with this condition often times (about 50% of the time) are overweight, and many also have a family history of adult onset diabetes in her older relatives.  PCOS needs to be diagnosed by your doctor.  He or she will do blood tests and perhaps and ultrasound as well.

    Prematurev ovarian failure (POF)

    Premature ovarian failure (POF) is a loss of ovarian function in younger women, well before menopause. Women with POF have eggs that are less or not capable to become fertilized. POF is among the reasons women have difficulties getting pregnant. It is often diagnosed by finding an elevated FSH test.


    Thyroid Disease

    Both underactive or overactive thyroids can affect ovulation.  Other symptoms of thyroid disease include feeling hot when everyone else is cold or vice versa, unexplained weight gain or loss, hair loss, fatigue, nervousness, or skin changes.  It is diagnosed by blood tests and is easy to treat.


    An uncommon reason for not ovulating is an excess of a hormone called prolactin. Prolactin is the hormone involved in breast feeding, and so many women with high prolactin levels will also have a milky discharge from the breasts too.  Just like breast-feeding women do not get regular periods, women with high prolactin levels who are not breast feeding will do the same. 

    Breastfeeding Moms

    When a mother is breastfeeding a baby, the hormones that trigger ovulation are often suppressed. This is a natural body reaction to giving birth. The body will try to prevent further pregnancy until the baby has stopped nursing and thus the hormonal changes. While ovulation does not cease and women do have the ability to become pregnant immediately after birth in some cases, ovulation problems may occur as long as breast milk is being produced.

    Stress, Exercise, Underweight, Overweight

    Extreme stress or excessive dieting or exercise will also lead to ovulation problems. So can being overweight. Your optimal BMI body mass index should be between 19.5 ad 25.  A woman's body is designed to decrease her fertility if it thinks there isn't enough food around to support a pregnancy or baby or there is too much stress (perhaps predators chasing you?).  So if a woman has very low body fat or a low dietary fat intake or is under extreme stress, she will stop ovulating.  This is common with marathon runners, ballet dancers, women on death row, and body-builders.  It can definitely happen with less extreme cases too.  Decreasing the amount of exercise, increasing calorie and especially fat intake, or changing the stressful situation can reverse the ovulation problems.

    Unknown Causes of Anovulation

    About 10% of women who do not ovulate have no defined reason why they are not ovulating.  It appears that their pituitaries just do not send out the right signals.  There are also other much rarer hormonal causes.  Most of these will have other signs and symptoms that bring that person to the attention of a doctor.

    No matter why you are not ovulating, you need to see a doctor!  If the lining inside the uterus does not shed with a period at least every 6 weeks, it can start to turn abnormal.  It can even turn into cancer, so this is serious!  If you are not ovulating because of extreme stress, exercising, or dieting; then you are also at risk for osteoporosis and bone breakage.  If your prolactin levels are high, then you may have a tumor on your pituitary.  Although these tumors are usually benign, they can permanently affect your vision if they grow too large.  Thyroid disease and PCOS have implications for the rest of your health as well, so go see your doctor.  Most of these conditions are very easy to diagnose and treat, so why not go see someone today?