until 2001, there were no clinical guidelines to characterize
our reproductive life span. Finally, representatives from esteemed
organizations, including the American Society for Reproductive
Medicine (ASRM), the National Institutes of Health, and the
North American Menopause Society, pooled their knowledge and
developed the STRAW system. STRAW stands for the Stages of Reproductive
Aging Workshop in which it was developed, under the direction
of Dr. Soules.
of STRAW is that you can get a sense of what stage you are
in based on your menstrual patterns, symptoms, and the overall
characteristics of a stage, rather than just a certain hormone
range or chronological age. "Looking at the whole picture
makes it clearer that reproductive capacity is unique for
each individual," explains Dr. Soules. After all, there
are a great number of variables in each woman's genetic makeup,
health, and lifestyle habits that carry her more quickly or
slowly from one reproductive stage to another.
stages designated by STRAW aren't set in stone. "While
most women will progress from one stage to the next, some
will seesaw between stages or skip a stage altogether,"
says Dr. Soules. It's also important to keep in mind that
although normal menopause occurs between 42 and 58, the age
ranges in STRAW are based on the average age of 50 (so you
can feasibly be up to 8 years ahead of or behind the curve).
while the stages are based on the STRAW model, our experts
not affiliated with STRAW have also commented on fertility
issues to be aware of at each stage.
age: Puberty to age 20
levels. Your FSH and estrogen are within normal range
(although you probably have no reason to have them tested).
Following your first period, your menstrual cycles may take
several years to fall into the 28- to 31-day pattern that
you can expect for the majority of your reproductive years.
Your hormone feedback system may not be strong enough to always
induce ovulation, which is one reason why sexually active
women in this stage are slightly less fertile than their more
issues: "Women in this generation are the only group
whose smoking rates are on the rise. That's very bad news,
because you may be killing off without any trace a substantial
number of eggs that you'll wish you had 15 years down the
line, especially if you expect to delay childbearing,"
says Dr. Tilly.
advice: Single, teen mothers are the most economically
disadvantaged group in the nation. "Planning childbearing
with your career in mind and waiting for a supportive partner
are perfectly legitimate reasons to delay childbearing,"
says American culture scholar Margaret Marsh, Ph.D., professor
of history and dean of the faculty of arts and sciences at
Rutgers University in Camden, New Jersey, and coauthor of
The Empty Cradle: Infertility in America from Colonial Times
to the Present.
age: 20 to 38
levels: Your FSH and estrogen are within normal range
(you might want to get a baseline test at around age 35).
Your menstrual cycles should be regular throughout this stage.
One percent of the female population, however, experiences
menopause before the age of 40, where FSH levels prematurely
increase and menstrual cycles stop.
issues: This is the longest of all the stages. It's actually
broken into three segments. The first 7 years are your peak
fertility time; the next third marks your first slight fertility
decline, followed by the beginning of your second fertility
decline, around age 35. (The sharpest statistical drop in
fertility, however, occurs at the age of 45, according to
the U.S. Census Bureau.)
advice: Sexually transmitted diseases (STDS) are highest
among women in their twenties, and they're the leading cause
of infertility for this generation. "The greatest long-term
fertility advice we doctors can give is to avoid STDs by practicing
safe sex," says Wanda Ronner, M.D., a gynecologist at
Pennsylvania Hospital of the University of Pennsylvania Health
System in Philadelphia and coauthor with Dr. Marsh of The
Empty Cradle: Infertility in America from Colonial Times to
age: 38 to 42
levels: Your FSH levels may have jumped from around 5
mIU/mL to closer to 15 or 20. If a test indicates that your
FSH levels are normal and you're already 40, have the test
taken a second time, since levels in this stage tend to fluctuate
from month to month.
Although your FSH levels may have increased, you probably
still ovulate and menstruate on your usual 28- to 31-day schedule.
But since your follicles are getting less responsive to FSH,
they may produce less estrogen. As the body's estrogen receptors
take note, you may become more sensitive to extreme temperatures
or even experience hot flashes. Since lower estrogen levels
affect the elasticity and acidity of the vagina, you may need
a lubricant during sex or develop more yeast and bladder infections
than you did in younger years. Even if you didn't get PMS
in the past, you're now more likely to experience mood swings
and discomfort around the time of your period.
issues: Your natural increase in FSH may be so stimulating
to the ovary that it brings more than one egg to maturity.
That's why if you were to get pregnant in your late thirties,
you're more likely to have multiple births! (This probability
drops off in your forties, unless you use fertility drugs,
which also promote multiple births.) And since birth defects
increase in women over 35, you are advised to consider genetic
counseling before conceiving.
advice: "The first sign of elevated FSH is a call
to accelerate your childbearing plans, particularly if you
wish to conceive without medical intervention in the future,"
says Dr. Metzger. To maintain your ovulation consistency,
you may want to consider natural supplements such as vitex
or, if you are currently trying to conceive, a prescription
for clomiphene citrate (Clomid).
age: 42 to 46
levels: Your FSH may have doubled from the last stage,
up to around 30 mIU/mL. Estrogen could be declining (under
80 pg/mL) due to lower follicle quantity and quality, or it
may be temporarily elevated (above 100 pg/mL) in an attempt
to modulate high FSH.
As you get deeper into the menopausal transition, not only
is the follicle releasing less estrogen, it's also skimping
on progesterone, which normally soars in the second half of
your cycle. With only moderate amounts of estrogen stimulating
the uterus, and no progesterone, there's less uterine lining
to shed, and you do so earlier in your cycle. Consequently,
your cycles may shorten to 24 to 27 days instead of 28 to
31, and your periods might be heavier or lighter than they
used to be.
issues: Pregnancy and labor may require more medical attention
for women over 40. You are almost twice as likely to have
a cesarean birth as younger women, have a 7 percent chance
of developing gestational diabetes (compared to 1.7 percent
for a woman in her twenties), and are more likely to experience
high blood pressure in pregnancy (even if you didn't have
it already). Hopefully, you've kept up with a fitness program
and optimized your nutrition as part of your preconception
care plan -- which can help you beat the odds for high-risk
pregnancies, says Dr. Minkin.
advice: Whether or not you have opted to use medical intervention
like fertility drugs or in vitro fertilization (IVF) to increase
your chances of conception, make sure you ask your doctor
about taking progesterone to help the uterine lining build
up enough for a fertilized egg to implant and stick, urges
age: 46 to 50
levels: Your FSH levels continue to climb, typically as
high as 50 mIU/mL.
Even if your very high FSH successfully stimulates a follicle
to mature, that follicle can be "deaf" to the next
signal down the line, which is LH and its cohort hormones
telling it to release the egg. Expect ovulation to be hit
or miss -- this stage is characterized by two or more skipped
menstrual cycles. And then, just when you thought you could
stop clipping tampon coupons, your period might come back.
It may be a "phantom period" where you don't ovulate
but still have some endometrium to shed, or you may resume
your old ovulation pattern for a few more months or years.
The less frequently you ovulate, the less estrogen you produce
-- which often means more noticeable perimenopause symptoms.
issues: Mentally prepare yourself for pregnancy loss,
since half of pregnancies to women over 45 end in miscarriage.
"And since childbirth is more aerobic than a half marathon,
it's essential that you are physically 'trained' before conceiving.
At the least, try to walk 3 miles every other day," says
advice: "When considering if you have what it takes
to raise the child to adulthood, apply the hoop-shooting rule:
Ask yourself if you will be energetic and fit enough to shoot
hoops with your child on their 13th birthday," Dr. Minkin
and Postmenopausal Stage
levels: Your FSH levels will reach their peak, between
about 50 and 70 mIU/mL, where they will stay. Your ovaries
significantly decrease their production of estrogen, although
the adrenal glands continue to produce small amounts.
Once you haven't had a period for an entire year, you're officially
in menopause. You can now be almost certain of not flip-flopping
back into a surprise ovulatory cycle. Of interest, you may
still have a few hundred or even a few thousand eggs in your
follicles, but the last few hundred generally don't develop.
issues: Your last option for getting pregnant now may
be the high-tech medical intervention of using a donor egg
with an IVF treatment -- that is, if you have the financial
capability and your doctors think you're likely to respond.
When over-40 women undergo IVF with younger women's eggs,
they actually have very similar conception rates as younger
women. In order to truly "level the playing field,"
though, older women may need to have more embryos transferred
than younger women would and take progesterone along with
standard fertility drugs.
advice: The ASRM advises women to have counseling to understand
the full legal, ethical, psychological, and social issues
involved with using donor eggs or sperm. In fact, RESOLVE:
The National Infertility Association recommends that both
the couple receiving the egg and the donor of the egg work
with a lawyer.
Fertile Longer: Everything You Need to Know to Get Pregnant
Now -- Or Whenever You're Ready by Mary Kittel with
Deborah Metzger, M.D., Ph.D. © 2004 by Rodale Inc. (September
2004; $13.95US/$19.95CAN; 1-59486-053-X) Permission granted
by Rodale, Inc., Emmaus, PA 18098.
Kittel is a seasoned health writer and coauthor of numerous
books, including The Hormone Connection and Prevention's Ultimate
Guide to Women's Health and Wellness.
Metzger, M.D., Ph.D., is a leading expert in the field
of fertility and reproductive health. She is medical director
of Helena Women's Health in San Jose, California, and was
previously associate professor at the University of Connecticut
Health Center. She is an advisor to the national Endometriosis
Association and has lectured extensively throughout the world.
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