Doctor, My Menstrual Bleeding is Not Normal.

Life would be simpler if all women began menstruating at the same age, had 27 to 38 days between each period, 4 days of bleeding, and everyone ceased bleeding at age 50. This isn’t always the case. Many variations in menstrual patterns may occur. There are many factors that can affect those patterns leading women to question, “When should I see a doctor?” or “Could something be wrong with me?”

To understand menstrual irregularity, it’s important to review the regular menstrual cycle. The uterine lining is controlled by two hormones produced by the ovaries. Estrogen is secreted throughout the cycle, which causes the lining to grow and thicken. Progesterone, released at ovulation, prevents the lining from shedding. Menstruation occurs when the ovary stops progesterone production near the end of a cycle. The withdrawal of progesterone induces the lining to shed as a period.

Alterations in regular menstrual bleeding are common. Examples include  longer, shorter, or irregular intervals between bleeding, a missed period, chronic daily bleeding, bleeding after sex, longer lasting periods, mid-cycle spotting or bleeding, and heavy, “clotty” periods.

The causes of these aberrations may be grouped into three categories: uterine structural abnormalities, alterations in normal hormone production, and external hormonal influences (patient using hormonal therapy). Let’s take a closer look at these causes.

Structural abnormalities, examples are fibroids, polyps, cervical inflammation, and adenomyosis (infiltration of the uterine muscle by tissue from the uterine lining). These abnormalities are typically associated with heavy periods, chronic daily bleeding, bleeding between periods, or bleeding after intercourse.

Alterations in hormone production can result in shortened, prolonged, or extremely irregular intervals between periods, or even the cessation of periods altogether. Frequent causes of alterations in hormone production are absence of adequate body fat (think of athletes, exercisers, dancers, anorexics, or the chronically diseased), obesity, sudden, extreme weight changes, thyroid abnormalities, or pituitary and adrenal malfunctions. Medications like antipsychotics, steroids, and chemotherapy agents can alter normal hormone production, as can psychological or physical stress.

Changes in ovarian function occur with aging, and the ovarian hormones, may not be cyclically produced, which can result in varying intervals between periods as well.

Polycystic Ovarian Syndrome is a common condition in which ovulation does not occur regularly; consequently, progesterone is not released in a cyclic manner. Irregular intervals between menses occur, and menses may sometimes be heavy, lasting for days.

External Hormonal influences including prescription hormonal medications, Birth control pills, the progesterone IUD (Mirena), the contraceptive skin implant (Implanon or Nexplanon), the contraceptive shot (Depoprovera), and menopausal hormone replacement regimens may cause sudden onsets of unpredictable bleeding or missed periods, because they can affect the integrity of the uterine lining. This is most often seen when starting a new hormonal medication. As the uterine lining adjusts to the new regimen, these problems will often subside given time.

Here are a few key facts to keep in mind. Various aberrations in menstrual bleeding are described above .If the episode is an isolated one and not ongoing, don’t panic! Just call us with a clear description of the bleeding and we may be able to give a reassuring explanation by phone. If the alteration deserves immediate attention, we will be glad to see you in the office. If abnormal bleeding becomes an ongoing problem, an investigation is necessary and should include a clear history, a pelvic examination and blood work. In some cases an ultrasound may also be warranted.