Allison Sayre, MSN, WHNP-BC
Ovulation is at the center of female reproductive health, and reflects the synchronization between the brain, endocrine system, and ovaries. For many women, this remains steadfast and constant from month to month, but for others, it can be disrupted, delayed, or absent altogether. These disruptions not only impact fertility, but they can also influence broader hormonal balance, mood, metabolic health, and long-term disease risk.[1]
As integrative practitioners, understanding the biology behind ovulation, and the many factors that can disrupt it, is essential for guiding personalized, whole-person care, as ovulatory dysfunction often serves as an early warning sign of deeper systemic imbalances. In this article, we will discuss basic biology of ovulation, common ovulatory disruptors, and integrative strategies for supporting a healthy menstrual cycle.
The Biology of Ovulation
So, let’s start with some basic biology. At the heart of a woman’s menstrual cycle is the hypothalamic-pituitary-ovarian (HPO) axis. A woman’s cycle is on average 28 days and is broken down into the following phases:
1. The Follicular Phase (Day 1 to approximately Day 14):
This phase begins with the onset of menstruation. The hypothalamus secretes gonadotropin-releasing hormone (GnRH) in pulses, which stimulates the anterior pituitary to release follicle-stimulating hormone (FSH). FSH stimulates the growth of several ovarian follicles, though typically only one becomes dominant. These follicles then produce estradiol, which feeds back to the brain to modulate FSH.[1]
2. Ovulation (approximately Day 14):
The rise in estradiol triggers a positive feedback loop at the hypothalamic-pituitary level, leading to a dramatic rise in LH, known as the LH surge. This surge causes the dominant follicle to rupture and release an oocyte. This process is known as ovulation.[1]
3. The Luteal Phase (Post-ovulation; approximately Days 14-28):
The ruptured follicle becomes the corpus luteum, which then produces progesterone (and some estrogen). Progesterone stabilizes the endometrial lining and prepares it for potential implantation. If fertilization doesn’t occur, progesterone levels drop, the endometrium is shed, and a new cycle begins.[1]
Any disruption in this tightly regulated network, whether it be at the hypothalamus, pituitary, ovary, or in peripheral metabolic signals, can interfere with ovulation.
Common Disruptors of Ovulation
1. Chronic Stress and HPA Axis Dysregulation
Chronic psychological or physiological stress can lead to an activation of the hypothalamic-pituitary-adrenal (HPA) axis, causing an increase in cortisol. Elevated cortisol can suppress GnRH secretion, leading to decreased FSH and LH levels. Over time, this blunting effect may delay or completely inhibit ovulation. Chronic stress can also exacerbate insulin resistance and hyperandrogenism, further disrupting the HPA axis. It is important to note that clinically, stress-induced anovulation can often be subtle. Women may continue to have regular cycles, but without the LH surge or rise in progesterone.[2][3]
2. Polycystic Ovary Syndrome (PCOS)
PCOS is one of the most prevalent endocrine disorders affecting women of reproductive age and is a leading cause of chronic anovulation. It is characterized by hyperandrogenism, insulin resistance, and follicular arrest. While multiple follicles begin to develop, the dominant follicle often fails to mature and release an egg. Insulin resistance often plays a central role in the pathophysiology, causing ovarian theca cells to produce excess androgens, which further suppresses ovulatory signaling.[3][4]
3. Thyroid Dysfunction
Both hypothyroidism and hyperthyroidism can disrupt ovulation. In hypothyroidism, elevated levels of thyrotropin-releasing hormone (TRH) can elevate prolactin, which inhibits GnRH and impairs ovulation. In hyperthyroidism, elevated thyroid hormones can cause an increase in androgen levels and a decrease in the metabolic clearance of estradiol. This can result in elevated levels of estradiol and sex hormone-binding globulin (SHBG), disrupting feedback loops necessary for the LH surge.[4][5]
4. Relative Energy Deficiency/ Low Body Fat
Inadequate caloric intake or excessive exercise, commonly seen in athletes or individuals with disordered eating, can suppress ovulation via a condition known as functional hypothalamic amenorrhea. The body can perceive this energy scarcity as a threat and responds by downregulating reproductive function. This leads to the reduction of pulsatile GnRH secretion, which in turn causes a drop in LH and FSH, consequently resulting in a decline of estrogen and ultimately, anovulation.[4][6]
5. Inflammation and Immune Dysregulation
Chronic inflammation and immune dysregulation also can disrupt signaling within the hypothalamic-pituitary-ovarian (HPO) axis, leading to altered gonadotropin release and impaired follicular development. Elevated pro-inflammatory cytokines may interfere with ovarian hormone production, follicle maturation, and endometrial receptivity. Additionally, immune imbalances, such as autoimmunity or gut dysbiosis, can create a hostile internal environment that can contribute to poor oocyte quality, a decline in follicles, and potentially affect ovarian reserve. [3][7]
6. Environmental Toxins and Endocrine Disruptors
Exposures to endocrine-disrupting chemicals (EDCs), such as bisphenol A (BPA), phthalates, dioxins, and pesticides, can mimic or block natural hormones and interfere with ovulatory signaling. In fact, EDCs have been shown to alter estrogen and progesterone receptor activity, disrupt FSH and LH secretion, and accumulate in ovarian tissue, impairing folliculogenesis.[1]
7. Hyperprolactinemia
Elevated prolactin levels, often a result of stress, pituitary microadenomas, or medication side effects (e.g., antipsychotics, SSRIs), can suppress GnRH and inhibit ovulation. Even modest prolactin elevations can result in luteal phase abnormalities or anovulatory cycles.[4]
8. Other Disruptors
Other less common disruptors of ovulation include adrenal tumors, Cushing’s syndrome, congenital adrenal hyperplasia, and premature ovarian failure.[4][8]
Integrative Strategies for Healthy Ovulation
1. Nutritional support.
For overweight individuals or those with insulin resistance, nutritional support should prioritize blood sugar regulation and a healthy weight through a low-glycemic, anti-inflammatory, whole-foods diet.[3] For those with relative energy deficiency or low BMI, restoring adequate nutrition through balanced macronutrients, healthy fats, and key micronutrients is essential to reactivate the HPO axis and support hormone production.[6]
2. Stress-reduction.
Effective stress-reducing techniques such as mindfulness meditation, yoga, time in nature, and deep breathing can all help to regulate cortisol levels and restore balance to the HPO axis.[3]
3. Staying active.
Physical activity and regular exercise (a combination of aerobic and resistance training) can help to improve insulin sensitivity and reduce body fat, two factors that have been shown to positively impact ovulation.[3]
4. Testing.
The type of testing performed will vary depending on both the woman, her presentation, and her goals (e.g., fertility, cycle regulation). Common testing may include:
• Hormones (estradiol, progesterone, 17-hydroxyprogesterone, FSH, LH, AMH, total and free testosterone, DHEA-S) [8]
• Fasting glucose, fasting insulin, and 2-hour glucose challenge
• Complete thyroid panel (TSH, fT3, fT4, antibodies) [4][5]
• Prolactin: If elevated, magnetic resonance imaging (MRI) or computed tomography (CT) should be considered to rule out microadenoma. [4]
• Cortisol testing (saliva or urine)
• Transvaginal ultrasound to assess for polycystic ovaries and/or other structural issues [4][8]
5. Reduce Toxins.
Women should be encouraged to reduce toxic exposure when and where they can (e.g., clean cosmetics and household products, filtered water, organic food).[1]
6. Targeted support.
Personalized interventions, if relevant, that focus on areas such as inflammation, insulin sensitivity, and stress can help to further support healthy ovarian function.[3]
Conclusion
Ovulation is a complex indicator of female vitality, with disruptions in this process potentially signaling broader imbalances in metabolic, hormonal, immune, or neurological function. For practitioners, assessing ovulation provides a unique window into a patient’s systemic health and offers opportunities for meaningful, root-cause-oriented care. By recognizing and addressing key disruptors, practitioners can help restore reproductive rhythm and support overall hormonal resilience and well-being.
Disclaimer:
The information provided is for educational purposes only. Consult your physician or healthcare practitioner if you have specific questions before instituting any changes in your daily lifestyle including changes in diet, exercise, and supplement use.
Allison Sayre, MSN, WHNP specializes in women's health and functional medicine, blending both traditional and integrative approaches. With over 18 years of experience, she has empowered women to reclaim their health through personalized nutrition and supplementation, hormone balancing, and lifestyle modifications. She received her Bachelor of Science from Mount Carmel College of Nursing and her Master of Science from the University of Cincinnati. She has been a certified women’s health nurse practitioner since 2014 and has continued her education and training in functional medicine from both the Institute for Functional Medicine as well as the American Academy of Anti-Aging Medicine.