What Are Fertility Awareness-Based Methods (FABMs)?

It wasn’t until the spring of 2024 that I was introduced to the world of fertility awareness-based methods (FABMs).

And to be totally honest, when I initially heard the term, my first thought went to “family planning.” But very quickly, I learned it was SO. MUCH. MORE. Yes, you can use FABMs for natural family planning. However, in my opinion, FABMs provide much more than a means to avoid or prevent pregnancy. 

• FABMs help you as a patient to understand the parameters or a normal menstrual cycle. 

• FABMs help you understand your menstrual cycle in a way that is not typically taught in your standard health education in middle or high school.

• FABMs help you learn how to track your cycle, understand your body, and empower you to advocate for your own health. 

It wasn’t until I was nearly 40 that I was taught how to chart my own menstrual cycle. 

It wasn’t until I was nearly 40 that I was able to learn how to identify when I ovulate.

It wasn’t until I was nearly 40 that I really understood that ovulation is the 5th vital sign– essential to our overall health.

It wasn’t until I was nearly 40 that I learned about my own biomarkers (cervical mucus, basal body temperature, and urinary hormones) and how to use them to help me understand my menstrual cycle. 

It wasn’t until I was nearly 40 that I was introduced to multiple methods for natural family planning.

I was a nearly 40-year-old woman, a mother of five, AND a nurse practitioner, and yet I had never been introduced to ANY of this information in my prior primary/secondary, undergraduate, or master’s education, nor from any other medical professional. And so, I made it my mission to learn as much as I could about the topic, so that I could provide this information to my patients, too. 

I often get the question “Is it normal to…” from patients. 

Is it normal to have periods that last eight days long?

Is it normal to have super heavy periods?

Is it normal to have PMS symptoms?

Is it normal to have cervical discharge around ovulation?

After learning about FABMs, I researched many of the various methods to see what training program I wanted to pursue. Ultimately, I decided to pursue the FEMM teacher training, as well as the FEMM medical management training. I have officially completed both programs and, therefore, for the sake of today’s blog, when I share the normal parameters for various aspects of the menstrual cycle, I will be referencing the FEMM parameters. So, just understand that other methods may not have the exact same parameters, but they should be relatively close 🙂.

For this month’s blog, I wanted to share some of the normal parameters of a healthy menstrual cycle, as well as what symptoms are NORMAL and what symptoms would require a further medical workup. 

How many days should my overall cycle length be? (from the first day of my last menstrual period to the first day of my next menstrual period?)

The overall length of the menstrual cycle should be anywhere from 24 to 36 days in length. If your cycle is SHORTER than 24 days, it would warrant further investigation. Similarly, if your cycle is LONGER than 36 days in length, that, too, would require further medical workup. 

How many days of bleeding is normal for my menstrual bleed?

Three-seven days of bleeding is considered within normal limits. Anything shorter than three days or longer than seven days would warrant further evaluation. 

The quantity of bleeding matters, too!!! If your period is extremely light or extremely heavy, that indicates that it is possible there were hormone irregularities in the previous cycle. In general, you don’t want a period that is super light OR super heavy. You should have a mix of quantity of bleeding (light, medium, heavy) with at least one day of either medium or heavy bleeding throughout one menses, but if you ONLY have heavy days, that might be a cause for concern. 

Clinically, heavy menstrual bleeding, called menorrhagia, is defined as losing more than 80ml of blood during one menstrual period. Patients experiencing heavy menstrual bleeding should seek care to determine the cause of the heavy bleeding. Menorrhagia is NOT normal. Conversely, there is also a problem with very light bleeding! This can reflect hormonal abnormalities as well.  

And, what if you are not ovulating or having cycles at all?? If you have had two consecutive missed menses and/or three missed menses in one year, you should be evaluated by a medical professional 

What if I have spotting / bleeding between my periods?

As a general rule of thumb, there should be no spotting/bleeding between menstrual cycles. Spotting can sometimes occur around ovulation or hormonal changes, for example, but spotting can also be reflective of hormonal imbalances, structural abnormalities (such as polyps, fibroids, etc.), infection, or more. Therefore, it is important to document your symptoms and seek further evaluation if you are experiencing any bleeding outside of your menses. 

What should “normal” cervical mucus look like?

During the ovulatory phase of your menstrual cycle, estrogen levels are rising, which should result in the estrogen acting on the cervix to produce estrogenic mucus. You want to see a steady, clear build-up of cervical mucus, rather than patches of mucus that are not consistent.

In the early days of estrogen levels rising, a woman might notice her cervical mucus simply as a moistness or scant, thick, cloudy, etc. Estrogenic mucus, particularly as ovulation approaches, becomes clear, stretchy, and lubricative. It is often described as “egg-white like.” As ovulation approaches, you should have at least five-six days of estrogenic mucus with at least two-three days of that highly estrogenic mucus, which is clear, stretchy, and/or lubricative. 

If you have any questions or concerns about your cervical mucus or find your cervical mucus is not typical, it is important to seek care from a healthcare professional to rule out hormonal imbalance or infection, etc.

Signs/symptoms of abnormal cervical mucus might include:

• Discharge with a color–this could be yellow, green, greyish, etc.

• Discharge with a foul odor

• Thick, clumpy mucus

• Frothy-looking cervical mucus

• A sudden increase in the volume of cervical mucus 

• Cervical mucus associated with vaginal itching, burning, redness, sores, etc.

What is the length of a normal luteal phase?

The luteal phase begins the day after peak day (the last day of high-quality estrogenic mucus before dryness). The luteal phase ends on the day prior to the first day of the next menstrual cycle. A normal luteal length is anywhere from 9-18 days. A luteal length shorter than nine days or longer than 18 days can indicate an abnormality and, therefore, would warrant further evaluation.

If you experience three or more irregular cycles in a year or two consecutive irregular cycles, I strongly encourage you to follow up with your primary care provider or another medical professional who can do a deep dive into your hormones to determine the underlying cause of your irregular cycles. 

I wanted to address some questions that I am commonly asked in our well-woman exams. 

Frequently asked questions:

1. Are painful periods normal? 

   While most women will experience some MILD to moderate symptoms such as cramping, it is NOT normal to experience significantly painful periods. It is not normal to experience so much pain during your periods that you need to miss work or school or other social functions. If you are experiencing significant pain during your menses, it could indicate that there is an abnormal, underlying cause for the pain. 

2. Are PMS symptoms normal?

   Again, if your PMS symptoms are mild, this may be normal. Natural hormonal fluctuations can impact a woman’s energy levels and mood. However, if your symptoms are significant/severe, this could indicate an underlying issue causing your symptoms. Please be evaluated if your symptoms are impacting your normal activities of daily living. 

3. How can I learn to identify when I am ovulating?

   Cycle charting and working with a trained teacher or instructor of a fertility awareness-based method can help you to understand your body’s biomarkers to help identify when you are ovulating. These biomarkers may include:

   1. Cervical mucus

   2. Basal body temperature

   3. Urinary hormones 

Keep in mind…ovulation is a sign of HEALTH. It is considered the fifth vital sign. So, if you are not ovulating, please seek further evaluation to identify any potential underlying causes preventing you from ovulating. 

If I want to learn more about fertility awareness-based methods, where can I get more information? Here are a few sites for you to explore: 

1. FEMM - femmhealth.org

2. The Marquette Method - https://www.marquette.edu/nursing/institute-natural-family-planning/classes.php

3. The Billings Ovulation Method: https://billings.life/en/

4. The Creighton Model: https://creightonmodel.com/teacherlocation/

5. Couple to Couples League: https://learnnfp.org/

6. Justisse Method: https://learnnfp.org/

Learning to chart your cycle will change your life. It will enable you to understand your body in a way you never have before. It will allow you to understand your body’s biomarkers and identify your approximate time of ovulation. It will help you to better predict the start date of your next menstrual cycle. It will help you to either avoid pregnancy or achieve pregnancy, depending upon where you are at in your life. And most of all, it will provide you with the necessary knowledge to know how to identify abnormalities in your menstrual cycle and to advocate for yourself to receive proper evaluation, care, and treatment. 

I’d love to hear from YOU! Do you currently use any fertility awareness-based method? If not, have you used one in the past? Did you learn anything new today as a result of this blog?