Why You’re Not Ovulating: LH Surge Problems in Busy Women (Fertility Explained)

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If your period is late… your ovulation feels unpredictable… or your fertility treatments aren’t going as planned—this episode is for you.

Today, we’re breaking down LH surges and ovulation dynamics, especially in busy, high-achieving women. Because ovulation is not just “on or off”—it exists on a spectrum, and even subtle disruptions can impact your ability to conceive.

In this episode, we cover:

• What an LH surge actually does (and why it matters)

• How stress, sleep, and lifestyle can suppress ovulation

• Why your cycle may be delayed—even with negative pregnancy tests

• The connection between LH, luteal phase quality, and implantation

• How age and hormonal shifts impact ovulation quality

• The overlap between hypothalamic amenorrhea (HA) and PCOS

• Signs your LH surge may be weak, delayed, or suboptimal

• Why “regular cycles” don’t always mean optimal fertility

If you’ve ever felt confused by your cycle—or like your body isn’t doing what it’s “supposed to”—this episode will give you clarity, validation, and a path forward.

Fertility is not one single problem—it’s a series of small factors working together. And the good news? Many of them are modifiable.

Transcript

Hello, my loves, and welcome back to the Love and Science podcast. Today, we're going to talk about
LH surges and ovulation dynamics, especially in busy women, because we know that the menstrual
cycle is not just a series of events, but it's actually a choreography. It is a dance. We talked
about this in the last episode where the follicular phase sets the stage for the LH surge, which
sets the stage for the luteal phase. And there can be many points along the way. where maybe things
do still happen, but they can definitely be suboptimal. And so again, physiology is not an all or
none event. I was taught in my training that ovulation was an all or none event, but through a
little deeper dive, through my mentors and fellowship, and also a lot of the reading that I've done
since then in my clinical experience, I've learned that there's a whole range of how things can
present in terms of suboptimal ovulation, LH surges, and the downstream effects of that.
So just to start the conversation, who here listening has ever expected their period at a certain
point in time on a certain date and it didn't come? And you're checking pregnancy tests,
they're negative. The next day comes no period. The next day comes no period. You know that your
REI is waiting for you to call because that's going to set the stage for your next phase of
treatment, but the darn period is not coming and it's making you enraged and mad and confused and
frustrated. I have a whole other podcast episode on this when the period doesn't come, because I
think that the neural circuitry surrounding this phenomenon, it goes straight to the amygdala, it
goes straight to the hippocampus, it goes to all the fear centers, and we truly, it can make us
crazy people. I've gone through this myself. And there's some predictability that we rely on,
well, at least this is working, or at least this is my sign that I can move forward, even if the
last treatment didn't work. But when that doesn't happen, especially in the face of negative
pregnancy tests, it can be like truly it can cause people to go crazy. And I don't say that
lightly. It truly is like one of those things where maybe on paper, it doesn't make sense, but the
emotional weight of it is really important to call out. Okay. So what are a few situations in which
LH surges can be not optimal? One of them is stress. And why is this from a biological perspective?
We know that during stressful times, it is not good for us to reproduce. This is like biological
and this has happened for millennia, right? So if we are living in a famine or if we are living and
we're being hunted, right? By a predator, like it is not good for us to reproduce during those
times. It's very expensive to be pregnant. It's very, you know, energetically expensive to be
breastfeeding. And it's also... vulnerable to be taking care of a newborn. And so all those things
make it such that biologically, there was a survival advantage to the people who did not have an
effective LH surge when there are times of stress and that that could resume when that stressful
insult or situation was released. And so interestingly, like, you know, people might say,
okay, well, I was studying for my boards and for some reason, my period didn't come that month, or
maybe something super stressful in your life happens. a parent dies or you have a move across the
country and that tends to throw things off. We see this all the time. And, you know, I just want to
call out that this is a biological response that is actually fairly protective for our species.
But when we are trying to move things forward on the fertility journey, it can be really, really
stressful. And so that's one thing that can throw things off. And, you know, as a reminder, we
talked a little bit about reproductive physiology, menstrual cycle physiology in the last episode.
But there's this whole region of neurons in the arcuate nucleus in the hypothalamus.
And I was actually, I'm grateful that the lab that my mentor in fellowship shared lab space with,
Sue Mentor, she dedicated her life to studying this population of KNDY. They call them candy
neurons, you know, in the hypothalamic arcuate nucleus. And they function as the master pulse
generator for the GNRH and LH release. which obviously controls mammalian reproduction. And so
those neurons, they can be differentially affected by different inputs,
different blocking signals, different environments. And it's really, really fascinating research if
you want to do like a deeper dive into it. But the point is that stress is one of those blockers
where when we are stressed, it shuts down the typical negative feedback to positive feedback switch
from the estrogen. on that pulse generator. And then what happens is that doesn't happen,
or maybe it happens, but it's a very weak signal. And we don't ovulate or maybe even that
follicular phase is drawn out to the point where maybe we ovulate later once that stressful
stimulus is removed. And then the cycle ends up being a lot longer than we would have expected.
And so stress is one of the main drivers for an incomplete or a suboptimal or even absent LH surge.
Age is also really important here. We've looked at follicular dynamics of older women and older
women do seem to have a less than optimal LH surge at times. And so, you know, we've heard of like
perimenopausal women who have these like luteal long, like, you know, like, like out of phase,
um, you know, times when they had abnormal hearing bleeding. We also can have these like very
prolonged follicular phases as well. But it's not just like a light switch happens,
right? We've talked about this. It's not like all of a sudden you're 25 and then you're 45 or 50
and there's that sort of change that happens in the 40s. We know that the reproductive changes that
can affect fertility happen 10 to 15 years before the final menstrual period. And so there can be
these subtle changes over time that happen. for women, especially in the mid to late thirties. But
if your timeline is shifted, it can happen even earlier than that, where you can have an LH surge,
but maybe it's not optimal. And that can really mess things up as well. And that sets the stage for
a poor corpus luteum, worse luteal phase hormones like estradiol and progesterone.
And progesterone we know is the hormone that sustains normally pregnancy. And so if that is not
optimal, then that's partly where we might see some. you know, losses because of luteal phase
dysfunction or even a non-pregnancy if the situation is bad enough. So again,
we never know exactly where things are breaking down, but when we see patterns, like for instance,
if you're tracking your LH kits and you have a surge and, you know, you're having a luteal phase
that's less than 10 days, that's definitely a marker. If you're tracking your LH kits and you never
quite get a dark line, you're wondering what that's about. It's really hard to interpret or hard to
read, or maybe they're positive some days and negative some days. and it's not really a clear
negative to positive that you can track, those are signs that maybe your luteal, your LH surge and
your LH function may not be hitting the threshold where it needs to be for a successful outcome.
So age is really important here. Carrying extra weight can also affect these things. So there's a
lot of data about getting women to be ovulatory, like metformin is a classic example where People
gave women metformin and said, oh, well, now people are having regular cycles again, but the live
birth rate didn't pan out. It's like, well, people are having regular cycles, but it's not
improving their pregnancy or live birth rates. Why is that? And my theory is that this is largely
in women who carry extra weight and it's correcting some of the problem, but not all the problem.
And that maybe we're getting people to ovulate, but all the dynamics of the menstrual cycle,
specifically the LH surge may not be optimal for those people. Again, I can't prove it, but I do
think that. just because somebody is having LH surge and having regular cycles does not necessarily
mean that that's going to convert into a, you know, a positive outcome ultimately.
And we all know that the weight creep is real during the fertility journey, right? We might've
started at a certain weight and then, you know, both combination due to being told not to exercise
the way we used to. And so we might be eating the same, but not exercising as much. And we know
that progesterone can make people hungrier. especially if you're taking a lot of progesterone, that
can certainly affect things too. And let's be real, like the emotional stress, sometimes we can
stress eat and that can put on extra weight as well. And so it's not uncommon to gain 20,
30, 40 pounds during the fertility journey. And all of a sudden say like, where did this weight
come on? Especially if it's been coming on gradually over a couple of years and then really have to
work to lose that if we want to get back to our pre-fertility journey BMI. Just thinking about the
fact that carrying extra weight does affect these things. And if that is pertinent to you talking
with your doctor about like a brief pause, maybe going on a GLP or really investing in like
lifestyle, you know, as you're undergoing the fertility treatments as well, there's different ways
to address it. But especially if you're trying to conceive outside of IVF, this can be a really
important way to restore a more optimal menstrual cycle. And the fourth thing I will say about
dysfunctional luteal phases, especially in busy women. is the same thing we talked about before is
hypothalamic amenorrhea. And what I find, again, physiology is a lot more complex than we learned
in medical school. It's not like somebody necessarily has hypothalamic amenorrhea or HA or not.
A lot of people live in this, especially a lot of my female physician patients, like this PCO
spectrum, but kind of HA spectrum as well. And so there's actually data that people can swing back
and forth. depending on factors like life stress and BMI. Even a few pounds difference can make a
difference in this, where somebody one day might have like a PCO phenotype with a high AMH, high
endothelial follicle count, maybe high LH levels. And then a couple months later, you know,
their, their cycles are still absent, but it's more like, you know, low FSH, low LH, low estradiol
at the start of the cycle. And I've seen this, you know, manifest a bunch of different ways. I've
seen it manifest where maybe somebody had a really tricky LH surge in the middle.
Like there's maybe like the kind of a weak positive, but not a full positive. Again, these tests
are not meant to be qualitatively interpreted really, but in terms of like being like, well, my
line was barely positive, but it was better than the day before those sorts of things. Or maybe
somebody has like, you know, a negative test one day and then a positive test the other day.
And it goes back to negative very quickly. Like again, inconsistently hard to interpret. And also
short luteal phases. Again, if you are having a short luteal phase. definitely under 10 days,
but even under 12 days can signify like a short luteal phase. You have to wonder if that LH surge
is happening in the appropriate way where there's that choreographed spike. Some people even have a
bimodal LH surge, which isn't necessarily wrong. It's just a variation, but it just shows again,
physiology is, it can be diverse and not just like having people in categories. But if the luteal
phase is short, that suggests that when that LH happens, there probably is an ovulation event, but.
those hormones don't last as long. Maybe it's just a crummier corpus luteum, which can happen with
luteal phase with this sort of dysfunction. It can happen with age. It can happen with egg quality
and other things. But if the luteal phase is short, you have to wonder like what's going on. And so
some people with HA truly just like never have a period. That was like me during college and early
medical school when I was running so many marathons, like my body just shut down. That makes total
sense. But like I said, there is this sort of incomplete HA PCO spectrum thing that can happen.
You can have HA without PCO, but I see a lot of the hybrid situations where maybe you get your
estradiol and it's like 20 and your LH is two and your FSH is three.
That would be a very classic example of somebody who has this, but there's something called
functional HA, which is basically where you can't always tell it from. The labs where the situation
is one of relative low estrogen because somebody is not ovulating and they have, you know, normal
FSH, normal LH, but the estradiologist stays low. It can be really hard to tell that from PCO.
Sometimes in PCO, the LH is higher than the FSH. Like we learned about, you know, two times was
part of the diagnostic criteria. It's not anymore. That's why one reason I like to check in LH with
my baseline labs, because I know not everybody does, but that gives me a window into like, could
this be HA? Could this be PCO? Like, what are we really dealing with here? But I do think that
there's a lot of female physicians, especially because of the, you know, many, many people do have
a lean BMI and not everybody, but many people do. And that really can affect how the LH surge is,
how the luteal phase is, and can be part of the story. So, you know, when we combine being a high
achieving woman, maybe a female physician, a stressful career, altered sleep schedules,
altered night shifts. Maybe, or maybe you're a trial attorney and you have a big case coming up and
all of a sudden there's all these deadlines and, you know, it's high stakes because you really want
to do right by your client. Like there's all these situations that can come up. But what I've
learned is that fertility is not just one giant thing. Usually it's like a bunch of vectors, like a
bunch of different little, littler things. And if the vectors are all lining up in like a bad way
that can keep people subfertile and sometimes some gentle life optimization, stress optimization.
I know we all have to work, but sometimes we hold ourselves to such standards where we may not need
to work quite as hard as we are. Or maybe there are small ways that we could lighten the schedule
without it having like a huge impact long-term. And so just looking at it,
is there any space in my days? If I had a kid already with this schedule, welcome that sort of
lifestyle. I think, you know, those are hard questions to ask and it can be hard to change our
habits, especially when. We live in a society that rewards us for productivity and all these
things. But when we can understand that our optimal menstrual physiology may be related to our
stress levels and how we fill our days and how many things we say yes to and all of that,
I think we can make a pretty solid argument for optimizing natural fertility as best we can and
taming some of the busyness, having a little space in our days, even giving ourselves transition
time. Maybe it's that you... take 15 minutes before you walk inside your house.
Once you get home and you, you know, put away the stress of the day and you enter in, or maybe it's
that you decide that you're going to start meditating in the morning or walking your dog a little
bit longer in the morning, like whatever it is, we are really unkind to ourselves. And like, for me
personally, when I stopped running marathons, that's when my LH church has happened again. And I
wasn't necessarily connecting the two. I was like, oh, this is just what happens. I need to be
running marathons. But if you question the assumptions of why, of the decisions that we're making,
right? Sometimes there's some room for some more optimal physiology. So I hope this was helpful.
Happy to answer any more questions you have about Elliot surges and stress and busyness. But again,
it's a hopeful message because I do think that there's a lot that we can do. And when people have
made even modest lifestyle changes, I've even seen like letrozole. If there's enough LH on board in
the context of even some mild ovulatory dysfunction, I've even seen letrozole, you know, overcome
that in people who were previously diagnosed with really low LH and HA. So anyway,
you know how much I love you. Can't wait to answer more of your science-y questions. Until the
next time, bye.