136. The Prolactin Problem: How One Hormone Can Derail Ovulation

Many women assume inconsistent ovulation is caused by stress, age, or simply “bad luck.” But sometimes the real cause is a hormone most people associate only with breastfeeding: Prolactin.

In this episode of Cycle Wisdom, Dr. Monica Minjeur explains how even mild elevations in prolactin may quietly disrupt ovulation, shorten the luteal phase, and make conception more difficult.

Through the story of Summer, an ER nurse experiencing repeated “false start” ovulation patterns, Dr. Minjeur walks listeners through how prolactin was identified as the missing piece—and how correcting it restored consistent ovulation and cycle balance.

In this episode you’ll learn:

• What prolactin does and why it affects ovulation
• Why mild elevations are often missed or dismissed
• How prolactin should be tested correctly
• The symptoms and charting patterns that may point to prolactin issues
• Lifestyle and medical treatments that can restore ovulation

Understanding prolactin can be the difference between cycles that stall out and cycles that consistently support ovulation and fertility.

If you’re struggling with ovulation irregularities, short luteal phases, or fertility concerns and want a personalized plan to restore hormone balance, visit radiantclinic.com to schedule a free discovery call.

Our team provides in-person medical care in Cedar Rapids, Iowa, and via telehealth visits in many states across the U.S. Charting instruction education is available worldwide.

Transcript

Speaker 0:01

Welcome back to Cycle Wisdom, where we empower women to restore natural menstrual cycles, to improve health and promote fertility. I'm your host, Dr. Monica Minjeur, and I'm so glad you're listening today. What if the reason your ovulation isn't consistent has nothing to do with just being stressed out or your age, but a quiet hormone that typically is meant for breastfeeding, that's firing at the wrong time. Today we're going to unpack an incredibly important hormone called prolactin. We're going to discuss why even mild elevations can disrupt ovulation and luteal phase strength, how to test for it correctly, and some simple and effective treatments that can help to bring your cycle and your ovulation back online. So let's start off with a patient story about summer. No, summer was an ER nurse and she was working rotating shifts. She and her husband had been trying to conceive for the past two years. When she came to see us, she said, my LH strips are showing positive, but nothing seems to happen after that. No temperature shift and no pregnancy. After two years of trying. So we started, as we always do, with evaluating her charting. This revealed, she had cycles that were happening every 30 to 40 days, and she had multiple times that looked like a false start where she had a patch of fertile cervical mucus, but then it never fully evolved, and eventually it led into what seemed like an ovulation pattern. Her luteal phase was short at only about nine to 10 days, and she did also note some additional symptoms on her chart, like mild headaches and occasional breast tenderness. Now because she worked as an ER nurse, she did have night shifts two to three times per week, so it was a bit challenging to get some labs drawn. Her initial prolactin level that was drawn was drawn in the middle of the day after she had had a busy overnight shift. This level was at 33 nanograms per milliliter, and ideally we're aiming for 14 or less to be ideal. We repeated her prolactin again at a time that she was fasting in the morning when she had had no stress, had slept well overnight, and even that level was at 27 nanograms per milliliter again. Ideal is less than 14. Her thyroid hormone was normal. Her ferritin was normal, and her progesterone levels after ovulation were quite low, but did confirm that ovulation had occurred. Her ultrasound looked normal, and so we started to discuss the different things she could do in order to help naturally decrease prolactin. Now, oftentimes we find that it will improve when we balance the other hormones, so we did work towards that. First, we discussed shift related. Stress and her sleep balanced. The hormone levels and her prolactin levels remained elevated, so we did end up starting her on a medication that is specifically designed to decrease prolactin levels. Over the course of the next two cycles, we noticed that her progesterone and prolactin levels were now within completely normal limits. Her ovulation was consistently around cycle day 16 or 17, and her luteal phase has also strengthened to 12 to 13 days. Summer is now feeling much more hopeful for her ability to conceive now that she has a predictable and consistently balanced ovulation time and hormone levels. So let's step this back a second and look at the big picture. What is prolactin and why do high levels disrupt cycles? So what normally physiologically happens in our bodies is that prolactin is oftentimes known as the lactation hormone. It's oftentimes also called. Oxytocin. Now prolactin levels will increase postpartum and during breastfeeding in order to help with milk production. One of the other benefits of prolactin being elevated though, is that it suppresses gonadotropin releasing hormone, which decreases luteinizing hormone and follicle stimulation hormone, and this typically leads to fewer ovulations, or in many cases absent ovulation altogether. Okay. Now, if you are not postpartum pregnant or breastfeeding, elevated prolactin will still cause these same issues of decreasing ovulation or decreasing the quality of ovulation, thus also decreasing the quality of that optimal progesterone after ovulation. So even moderate elevations in that 20 to 40 nanograms per milliliter range can cause disruptions in ovulation. We oftentimes also will see shortened luteal phases spotting scant fertile mucus, and false starts to an LH surge as some are noticed. Now, there are lots of different reasons why prolactin can elevate if you are not pregnant or breastfeeding, and the most common that we see are physiologic. So things like having increased stress, poor sleep, intense exercise. Intercourse close to the draw or a recent meal. This is why we say it's so important to consider when you had that prolactin tested. So ideally we say a random lab draw can be fine, but if it's elevated, it should always be accompanied by a follow-up test or at least one test that is done Fasting first thing in the morning when stress levels are lower. This is why oftentimes in our practice, we actually check the prolactin twice upon initial evaluation of all of your labs because it can change significantly. It's what we call a pulsatile hormone, meaning that it does change dramatically throughout the day. Now, other reasons that prolactin can be elevated are from certain medications, so there are many of the anti-psychotic medications and some antidepressant medications that can cause prolactin to elevate. Other interesting medications that can elevate prolactin are meds like metoclopramide, which is otherwise known as reglan. This is an anti-nausea medicine, opioid pain medication, and some estrogen medications. All of these can cause your prolactin to significantly elevated, so we always want to consider if there's a medication that may be causing it to elevate. And again, even if we understand the reason why, the fact that you have that elevated prolactin can cause problems with the ovulation dysfunction. We oftentimes also will see overlap of polycystic ovarian syndrome and thyroid dysfunction that run alongside high prolactin levels. Again, it's difficult to know sometimes, which came first, but oftentimes we have that polycystic ovarian syndrome where you're already having ovulation problems, oftentimes from insulin resistance. But if we add an elevated prolactin on top of that, that can further suppress ovulation. And then the final thing that I wanna talk about is that you can have changes in the pituitary gland itself. So our prolactin is produced in your pituitary gland, which sits in your brain actually just behind and between your eyes. Now you can have what's called a micro adenoma or a small benign growth in the pituitary gland that excretes excessive prolactin. Okay, so we typically will check for this if your prolactin is persistently elevated, above 30 nanograms per milliliter, and definitely if it's persistently above 50, primarily because we want to understand what the cause is of that prolactin elevation. Now the good news is that even if you have one of these micro adenomas, these benign growths in your brain, like I said, over 99% of the time, they're completely benign and don't cause any issues other than excreting excessive prolactin. However, it is important to understand that we want to follow along and to see what is the size of that micro adenoma doing over time. So if you are found to have a micro adenoma, we typically will refer you to an endocrinologist or a neurology specialist who can monitor these over time and make sure they don't continue to grow larger. One of the interesting things because of where the pituitary gland is located is that if you do have a micro adenoma or even a macro adenoma, which is a larger mass, if it starts to grow bigger, it can actually start to push on your optic chiasm, which is part of the nerves for your eyes. And it can actually cause headaches as well as peripheral vision field blindness. So this is why, just based on its location, it can cause problems in addition to the potential hormonal causes. So again, it's important to understand some of the reasons why we see this going on in order to discern how much attention we need to pay and what else needs to be done for follow up. So again, how we would evaluate this. First and foremost, focusing on what are we seeing with your charting? Not just when are your periods happening, but more importantly, and especially when it comes to prolactin, looking at what are we seeing with those ovulation patterns? Does it look like it's nice and consistent? Are we identifying good cervical mucus followed by a temperature shift? Are we looking to have a clear luteal phase window that ideally is at least 12 days or more? We also are always going to certainly be checking those labs. So again, as I mentioned earlier, prolactin levels are typically the most accurate if they are drawn early in the morning when you are fasting before 10:00 AM. We want to make sure that you have been avoiding any breast stimulation or nipple stimulation because that can also increase your prolactin levels and ideally, no vigorous exercise or intercourse that morning that you get your labs drawn. If needed, we can repeat an elevated value to confirm if that's the case. Frequently I will find that one test is normal and one may be elevated. Or if they're both low, then we're in okay shape. But again, with prolactin being a pulsatile hormone, it's important to not rely on just one lab test in order to make the diagnosis. We also would always wanna be checking for other things that could be causing ovulation dysfunction, right? So thinking about things like insulin resistance, thyroid dysfunction, vitamin deficiency, progesterone and estrogen levels. All of these help to confirm what exactly the underlying problem is. And then again, as I mentioned, to consider doing an MRI of the pituitary gland in your brain, if that prolactin is consistently elevated or if you have an elevation of prolactin that is accompanied by anything like. Breast or nipple discharge headaches or visual field disturbances, or persistent amenorrhea, which is loss of periods altogether. Now, typically when we find something going on with a pituitary gland, your prolactin levels are going to be quite a bit higher, and if they are high enough, it can actually block ovulation altogether. So it is a common level that is oftentimes checked. But I like to talk about the numbers because many women are told that it is normal. To have elevations, and I just wanna stress that it's really important to understand is it persistently elevated or is it just a one time that was elevated? Because again, persistent elevations accompanied by ovulation dysfunction can create problems when it comes to fertility. So how do we treat this? If we find that you have prolactin elevations, we want to first focus on what are the lifestyle changes that might need to be made. So first and foremost, make sure that the timing is correct. Morning fasting lab draw well rested. We want to reduce any nipple stimulation or friction. Brass that are too tight. Frequent breast checks, avoiding chest targeted exercise the morning of your labs because anything that is causing additional sensitivity can increase your prolactin. Focusing on getting adequate sleep, consistent sleep window when possible. And if you are somebody who is a shift worker trying to stick to as regular of a schedule as possible. The other piece that we always wanna focus on is fixing any co-factors that may be causing ovulation dysfunction. So again, thyroid dysfunction, iron, looking at your medication list to see if there are any medications that could have an alternative prescribed if appropriate. All of these things can play an impact when it comes to elevated prolactin. And then finally, if prolactin is still elevated. Despite lifestyle changes, despite fixing the underlying co-factors, there are medications specifically targeted to blocking prolactin. So the most common ones that we use in our practice are going to be Cabergoline or bromo Crypting. Now, both of these medications specifically decrease prolactin levels and help to restore ovulation and lengthen the luteal phase. The nice thing with these meds is that we can start with a dosage that is low and slow, and then recheck your levels again in about four to six weeks and make adjustments from there. If you have been found to have a micro adenoma that is secreting prolactin. These medications are especially effective and it is incredibly rare that we would ever need to have any sort of surgery because these prescription strength medications can actually decrease the size of those macro adenomas. So what are some of the commonly asked questions we get? The most common is probably, I had a prolactin level that was elevated once it was 26. Do I need to have an MRI? And the answer to this is not necessarily, I always recommend repeating it with the correct parameters, fasting first thing in the morning to assess those levels. In fact, in our practice, we oftentimes will check levels at least three times before we discern if you need to have an MRI done or not, because there are so many other. Physiologic changes that can happen that cause that prolactin to elevate. Now, certainly if your levels are consistently above 30, and especially if you have any of those symptoms like a persistent headache or visual field blindness, especially in your peripheral vision, we definitely want to check thatm RI right away. Can I take medicines like Cabergoline while I'm trying to conceive? And the answer is yes. Now, oftentimes we find that our patients that are trying to get pregnant will stay on Cabergoline to make sure that the prolactin levels stay nice and low normal while we continue to watch ovulation quality. We typically discontinue the Cabergoline once you have that positive pregnancy test with very few exceptions because your prolactin levels should increase during breastfeeding. We typically do not need to continue the suppression with Cabergoline during pregnancy unless your levels were in the high a hundred to 200 ranges prior to starting. So if I have ovulation dysfunction. Could I just lower my prolactin levels? Won't that fix everything? Now, oftentimes if prolactin is a part of the story, decreasing the levels will often restore ovulation, but we always need to remember there can be multiple other factors. Also, playing a role with ovulation dysfunction, as well as the quality of your luteal phase. So focusing on those lifestyle changes, optimizing your other nutrients is also still incredibly important. And then probably the most common, what if I'm breastfeeding and I'm trying to conceive. Now elevated prolactin levels are normal during lactation, and the return of your cycles can be incredibly variable across the board. So we would always talk through what are your expectations and provide you with that support depending upon your goals and symptoms. I oftentimes find that women, especially if they've been breastfeeding for a year or more, their prolactin levels may have already dropped back to normal ranges, and they may be having regular cycles. In these cases, it is not necessary to block prolactin in order to try and conceive. F in some women it is still going to be incredibly difficult to try and conceive if the prolactin levels are high from breastfeeding. And so we have that discussion about when does it make sense for you to stop breastfeeding and when does it make sense for you to say, Hey, I want to focus instead on trying to conceive. Instead. The two things do not necessarily need to be mutually exclusive, but everybody is different and so we wanna understand what is best for you. When we make these changes with medications or the lifestyle changes, we oftentimes should see improvements within one to two cycles. And so this is the timeframe as far as understanding. How do we see those changes in prolactin giving a positive impact on your ovulation? Imagine if your fertile windows stopped fizzling out and finally followed through because prolactin was tested the right way, treated appropriately, and your daily routine signaled a great return of your hormones. Over the course of a few months, your ovulation could start to land reliably. Your luteal phase can hold steady and your confidence can return to improve health and promote fertility.

Speaker 2 17:58

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