Many women entering premenopause whom I have spoken with say that applying the standard NFP rules during this time is very difficult. And indeed, it is. Why?

During premenopause you may expect the following changes in the basic fertility markers:

• Bleeding – it may be shorter, but it can also become longer, even up to 10 days. Changes in the intensity of bleeding may also be observed. In addition to menstrual bleeding, intermenstrual bleeding often occurs (not preceded by a phase of higher temperatures). Remember that such bleeding should be treated as a time of possible fertility.
• Irregular cycles – in premenopause, differences in cycle length can range from a dozen to even several dozen days. In the years immediately preceding menopause, menstruation may occur only once every six months. In such prolonged cycles, the body may make several attempts to ovulate, but due to insufficient hormone levels, ovulation does not occur. As a result, phases in which you may observe or feel cervical mucus (the fertile phase) alternate with phases of dryness (infertility). Occasionally, ovulation may occur and be confirmed by a temperature rise lasting at least three days (the post-ovulatory infertile phase).
• Changes in cervical mucus – in general, during premenopause the quality of mucus deteriorates and it is produced in smaller amounts. However, there are also situations in which a continuously present discharge can be observed.
• Changes in the cervix – sometimes during premenopause the cervix becomes less responsive to hormonal stimulation and remains consistently firm and dry.
• Changes in the basal body temperature chart – a previously clear temperature rise may become less distinct, occur more slowly than before, or not appear at all (a single-phase or “saw-tooth” chart).
• Changes in other fertility signs – ovulatory pain (in the lower abdomen or genital area), breast tenderness, or lower back pain that were previously observed may intensify, but they may also disappear completely.
• Hot flashes – in some women, an additional secondary sign appears, often coinciding with so-called “dry days,” the infertile period. Some researchers claim that at such times, estrogen levels are usually so low that ovulation cannot occur [1].

So how can one assess such symptoms?

Some practical tips for observing fertility biomarkers during premenopause:

• During premenopause, using only letter symbols, colors, or other general markings is no longer sufficient. More detailed, descriptive notes about the characteristics of the mucus and day-to-day comparisons will be necessary.
• Pay special attention to sensations associated with the presence of mucus in the vaginal vestibule and to their intensity, as the physical features of the mucus may be so subtle that they can go unnoticed. Record all observations on your cycle card.
• If there is no temperature rise and no ovulation, the post-ovulatory infertile phase cannot be determined; instead, only the pre-ovulatory infertile phase and the fertile phase will alternate.
• Pay attention to the presence of mucus during menstrual bleeding as well, especially when the bleeding begins to decrease (in premenopause, the fertile phase may start very early).
• Self-examination of the cervix is particularly recommended during premenopause; it is usually a very reliable biomarker that responds quickly to hormonal changes.
• If you have difficulty observing mucus, you can try observing and evaluating the secretion obtained during a cervical self-examination. There are also kits available to help collect mucus from the cervical opening (e.g., 2OS).
• Remember that devices such as microscopes used to assess cervical mucus or saliva are not intended for use during premenopause.
• Continue to measure basal body temperature regularly to confirm whether ovulation has occurred and whether a temperature rise has taken place.

The most challenging task ahead is choosing the appropriate rules for interpreting your observed fertility markers.

First, let us determine when you should modify the observation and interpretation rules you have been using so far:

• when you turn 40;
• when you notice any changes in the length of your individual cycle phases;
• when you observe a deterioration in fertility signs (mucus, cervix, basal body temperature).

In biphasic cycles:

• As long as biphasic cycles with periodic presence of cervical mucus occur, the standard rules of the symptothermal method can be applied.

Read more:

• If a weak or slow temperature rise is observed, the Peak Rule based solely on mucus observations can be used. The fertile phase ends on Day S+4 (the evening of the fourth day after the Peak Day of mucus). This is followed by the post-ovulatory infertile phase.

In monophasic cycles:

• Remember that in the absence of a temperature rise and ovulation, the post-ovulatory infertile phase cannot be determined. In this situation, only the pre-ovulatory infertile phase and the fertile phase alternate.
• During premenopause, when cycles become irregular and fertility signs disappear and reappear, none of the calculation rules (e.g., Rötzer, Döring, 5/6, or 20/21) can be used to determine the pre-ovulatory infertile phase.
• If there is no temperature rise but periods of mucus occur that do not result in ovulation, you may apply the Peak Rule (according to Prof. Rötzer’s method).

• A modification of this is the Peak Rule for the premenopausal period (as promoted by CCL International) [2], according to which the fertile phase ends on Day S+4 (the evening of the fourth day after the Peak Day of mucus), but note: the Peak Day is defined differently than in the standard method – as the last day on which any mucus is observed. The last day of intermenstrual bleeding or spotting may also be considered the Peak Day, provided it is followed by a dry day. This is followed by the pre-ovulatory infertile phase. Without a temperature rise and ovulation, the post-ovulatory infertile phase cannot be determined.
• If, after several monophasic cycles, a normal temperature rise associated with ovulation does occur, the standard symptothermal rule is then used to determine the post-ovulatory infertile phase.
• If, in the period preceding menopause, you observe a continuous discharge and the basal temperature chart remains monophasic, you should attempt to establish a Basic Infertile Pattern (BIP). The BIP is determined over 14 days by identifying the characteristic features of the continuously present discharge. Any change or deviation from the BIP marks the end of the pre-ovulatory infertile phase and the beginning of the fertile phase. According to the BIP rule used during premenopause, the end of the fertile phase is set at Day S+4 (the evening of the fourth day after the Peak Day of mucus).

• A proper diet – whole-grain products, little sugar and wheat flour, plenty of vegetables and fruit, fish, poultry rather than red meat, and adequate calcium intake.
• Elimination of salt, caffeine, alcohol, and cigarettes.
• Supplementation – magnesium, calcium, and vitamin D.
• Flaxseed oil, powdered maca root (Maca, Lepidium meyenii Walp., Lepidium peruvianum Chacon), soy products and other natural phytoestrogens may help alleviate unpleasant climacteric symptoms.
• Regular (!) physical activity such as long walks, running, aerobics, stretching exercises, cycling, and swimming.
• Improving the menstrual cycle (especially corpus luteum function) – for at least three months – with preparations such as Castagnus (based on chaste tree/Vitex agnus-castus), cod liver oil, natural progesterone (lutein), and regulation of the cycle with light exposure at night (for five days after the appearance of mucus, completely darken the bedroom).
• Improving cervical mucus quality – evening primrose oil, vitamin E, vitamin B6, flaxseed, drinking plenty of water throughout the day, and limiting the use of antihistamine medications.

Many of you may be wondering what the reproductive potential of women is during premenopause. Apart from age and the dramatically declining ability to conceive, pregnancy in premenopause is made more difficult by, among other factors:

• less frequent ovulation, anovulatory cycles, weak follicular development, and reduced secretion of key hormones;
• deterioration in the quality or complete disappearance of cervical mucus, which is essential for nourishing and transporting sperm and enabling their survival in the female reproductive tract;
• insufficient progesterone secretion, manifested by a shortened post-ovulatory (luteal, high-temperature) phase of the cycle, which in turn causes difficulties with embryo implantation and maintenance of pregnancy.

At the age of 45–50, the probability of conceiving a child is about 1 in 500, and at the age of 50 and over – about 1 in 10,000.

Based on:

Vicki Braun, “Snapshots of premenopause”, Family Foundations, CCL International, Cincinnati, Ohio, March/April 2012

Josef Rötzer, Elizabeth Rötzer, “Ja i mój cykl”, INER Polska, Warsaw 2007

Marilyn M. Shannon, “Fertility, Cycles and Nutrition”, CCL International, Cincinnati, Ohio, 2009

[1] Aguilar, N. The New No-Pill, No-Risk Birth Control, pp. 201–204, Rawson, Wade Publishers, Inc., New York, 1986.

[2] “The Art of Natural Family Planning® Transitions Student Guide”, CCL International, Cincinnati, Ohio, 2013.