Your Period: When is it Time to Investigate?

The menstrual cycle, frequently referred to as “the period” is a sensitive yet very common topic we, as gynecologists, deal with on a daily basis. It is actually linked to many complaints we encounter in clinics and emergency room settings. Because of peer pressure and self-comparison to others, some women tend to judge their menstrual cycles as “abnormal”. So, the aim of today’s article is to look into what is considered to be physiologically normal? How much can menstrual cycles differ between women and yet remain in the spectrum of “normal”? And, what are the different period related physiologic abnormalities we commonly see?

Starting with the basics, the normal menstrual cycle is tightly coordinated by a series of hormonal changes that result in the release of a mature egg on a monthly basis. The first day of bleeding (menses) is day 1 of the cycle which in turn is divided into two phases; the first is called the follicular phase which differs among women, and the second is called the luteal phase which is stable in length lasting for 14 days in all women. Ovulation (the release of the egg) marks the end of the follicular phase and the beginning of the luteal phase.
The average menstrual cycle lasts 28 ± 7 days, with the follicular phase lasting 7-21 days and the luteal phase lasting only 14 days.

So, the question is, when and why does your period drop its normality?

Heavy and Prolonged Periods

The first issue some women face is called “menorrhagia” which is a medical term describing heavy and prolonged periods. In normal cycles, women are expected to lose up to 40 millilitres of blood over 4 to 8 days, which is equivalent to 2-3 tablespoons of blood! So, women who lose more than 80 millilitres (5-6 tablespoons) or bleed for more than 7-8 days per month are considered to have heavy or prolonged periods. But practically speaking, how can you tell if you have heavy cycles?
Well, if you soak a pad or tampon every one to three hours on the heaviest day of your period, this could be a sign of heavy cycles. If you bleed for more than 7-8 days or you need to use both tampons and pads together then again this can signify you having abnormally heavy periods. Also, if you pass blood clots larger than 2.5 cm in diameter (the size of a grape) this can be an objective marker of "menorrhagia".
This abnormal bleeding pattern can be secondary to many factors and the most common reasons behind heavy cycles can be divided into three categories as follows:

• Structural problems, such as fibroids (check my previous article about fibroids “Uterine Fibroids, the truth behind them!”), polyps (fleshy grape-like growths of glands and connective tissues in the uterine cavity), adenomyosis (endometrial gland tissues seeping into the musculature of the uterus) and hyperplasia (thickening of the uterine lining which can be a precursor for cancer)
  
  
• Bleeding tendencies, such as congenital (born with) or acquired bleeding problems (Von Willebrand disease, platelet dysfunction…), or the intake of blood thinners (aspirin, Plavix, heparin…)
  
  
• Hormonal imbalances causing “anovulation” which is when women do not ovulate once per month. This can be secondary to polycystic ovary syndrome (PCOS), thyroid problem and even simple stress, weight change and extreme diets which can negatively impact the hormonal balances in your body and eventually cause heavy cycles.

This heavy bleeding pattern simply causes blood loss and potentially can lead to anemia (low blood count) with all of its subsequent symptoms of dizziness, loss of consciousness, racing heart rate (palpitations), easy fatigability, difficulty breathing, chest pain, headache…

You should seek immediate help in case of any suspected heavy vaginal bleeding, or symptoms of anemia.

Expect your physician to take your full medical, gynecologic, social, sexual, obstetrical and surgical histories. And, expect him/her to take some blood tests for anemia and hormonal workups, and to do an ultrasound to check for the presence or absence of any structural pathologies causing your heavy cycles (fibroids, polyps, thickened lining, adenomyosis).
Also, a pregnancy test is ALWAYS recommended in such instances regardless of the sexual activity history or contraception use.
Finally, in some cases (if you have risk factors for cancer: advanced age, history of polycystic ovary syndrome, family or personal history of cancer, the use of some medications…) then your physician might take an office based sample of the endometrial tissues to check for endometrial hyperplasia (thickening in the uterine lining) or cancer.

The treatment depends on the cause of the bleeding, your preference (medical versus surgical), whether you want to prevent pregnancy as well and your desire for future child birth. I will not go through the different management plans as they are beyond the scope of today’s article.

Delayed Period

This entity is called “oligomenorrhea”, which is defined as infrequent menstrual period (fewer than 6 to 8 periods per year). This is mainly secondary to hormonal imbalances leading to anovulation (your body would not release an egg on a monthly basis), and this will lead to a delayed period and a heavy one when it hits. The main reasons for "oligomenorrhea" are:

• Polycystic ovary syndrome (PCOS), which is characterized by irregular periods, excessive hair growth and acne, in addition to ovarian cysts on ultrasound (no need to have all 3 findings for a PCOS diagnosis as it’s a dynamic one).
  
  
• Ovarian insufficiency/failure (early menopause before the age of 40) which was seen to be associated with a time of oligomenorrhea and delayed periods before menses halt altogether.
  
  
• Peri-menopause, which is the period of few years preceding menopause (the cessation of periods for 12 consecutive months), is characterized by irregular bleeding patterns.
  
  
• Problems in the thyroid gland (the gland anterior to your neck) and prolactin producing gland (brain milk gland)  
  
  
• Simple immaturity in the natural hormonal access (this is mainly seen in teenagers who fail to stabilize their hormones and periods for few years after their first menstruation) which is completely normal!
  
  
• Hypothalamic problems secondary to weight loss, weight gain, stress, depression, anorexia or bulimia nervosa (eating disorders), anxiety and strenuous exercise.
  
  
• Pregnancy !! Never forget pregnancy as a potential cause for any period related issue regardless of sexual history and contraception use.

Again here, the treatment plan depends on the exact pathology behind oligomenorrhea, which is beyond the scope of toady’s article.

Absent Period

This condition, called "Amenorrhea", is very similar to the just described "oligomenorrhea", but more drastic as it signifies the absence of menstrual periods. This can be classified as “primary” which is when menstrual periods do not start by the age of 15, or “secondary” which is the absence of period for 3-6 months in women who previously had periods. The reasons behind "amenorrhea" are similar to those of oligomenorrhea, as most stem from a hormonal imbalance. Again, here the treatment depends on the reason.
In the special population of girls with “primary amenorrhea” (no period by the age of 15) there are other non-hormonal reasons one should keep in mind (such as the absence of a uterus, genetic males with androgen insensitivity syndrome and vaginal obstruction).

Painful Period

This is known as “dysmenorrhea” which is one of the most common problems women meet.  This is more commonly seen in young women, as periods are expected to become less and less painful as women get older. The culprits in painful periods are “prostaglandins” which are endogenous, natural  chemicals causing uterine muscle contraction and decrease blood flow to the uterus, both manifesting as significant pain and discomfort. Some women experience diarrhea and nausea also secondary to the prostaglandins.
The characteristic period pain is often described as crampy in nature, located in the pelvic area and sometimes radiating to the thighs and back. This pain is on-off, starting just before or with the menstrual blood flow, and decreasing in intensity within one to three days into the cycle. This pain usually ranges from mild to debilitating!
The only diagnosis of this condition depends on your “story”, so know yourself and relay your exact menstrual history to your physician for an accurate diagnosis.
The most common reason for this condition, is a natural response to prostaglandins meaning that an underlying pathology is not presence to explain the pain. This entity is called “primary dysmenorrhea”.
Many risk factors have been linked to a worse period pain, such as smoking, younger age (especially adolescents), stressful lifestyle and family history (genetics play a role)
On the other hand, some women turn out to have pathologic reasons behind their painful periods which we refer to as “secondary dysmenorrhea” such as:

• Endometriosis (endometrial tissues outside the uterus)
  
  
• Fibroids (check my article “Uterine Fibroids, the truth behind them!”)
  
  
• Adenomyosis (endometrial tissues seeping into the uterine muscular wall)
  
  
• Ovarian cysts
  
  
• Use of copper non-hormonal intrauterine device (an article tackling this topic will be published in the future) …

The main treatment scheme again stems from the management of the root cause, but the mainstay of therapy includes pain killers (mainly anti-inflammatory medications) and hormonal contraceptive methods. To note that stress relieving exercises and healthy lifestyles are proven to improve period pains as well. Also, the application of heat to the lower abdomen was shown to be an effective reliever of pain.
What about other "natural" interventions?
Behavioral counseling (teaching the patient how to think about the pain using desensitization-based procedures, coping strategies and hypnosis) was neither supported nor refuted by the high quality body of evidence we have, yet some women were shown to benefit from these different coping techniques (to note that these are not considered first line therapies).
Moreover, acupuncture and acupressure were also studies with no robust evidence about the value in the management of neither primary nor secondary dysmenorrhea.
Finally, some dietary changes were associated with some reduction in period pains such as:

• Low fat vegetarian diet
  
  
• Increased dairy intake
  
  
• Vitamin E (500 units per day or 200 unites twice per day beginning 2 days before menses and continuing through the first 3 days of bleeding)
  
  
• Vitamin B1 (100 mg daily), Vitamin D3 (single oral 300,000 international units/1ml given 5 days prior to the expected day of period), Vitamin B6 (200 mg daily) and fish oil supplements were shown as well to be more effective than placebo in controlling period pains.
  
  
• Ginger powder (750-2000 mg on days 1 and 3 of the menstrual cycle)

Nonetheless, keep in mind that vitamin supplementation can somehow improve the pain while having a significant reported failure rate and is thus not considered to be a sole therapy plan.  

Inter-menstrual Spotting

This final entity is also commonly reported by patients who describe having spotting and light bleeding in between their cycles. This can also be secondary to hormonal imbalances as well as structural pathologies in the uterus (polyps) or the cervix (polyps, infections or more serious reasons such as cervical pre-cancer or cancer). Here is a chance for me to remind you again about the value of routine gynecologic check-ups (yearly) and the performance of regular pap smears in order to screen for and manage any cervical pathology before it becomes symptomatic.
You should also keep in mind that some contraceptive methods, such as birth control pills and the dermal implant (rod inserted in the arm for contraception lasting for 3 years) can cause inter-menstrual spotting as side effects.    
Here also, the treatment depends on the cause behind this irregular spotting, so always follow with your physician in the setting of any abnormal bleeding pattern.

In conclusion, normal periods and normal cycles are known to have strict general criteria yet they are not necessarily homogeneous across all women. As I have previously mentioned, healthy menstrual cycles can differ up to 14 days among women! It is true that the average cycle is around 28 days, however some cycles are normally short, occurring every 21 days, and some others are naturally long, occurring every 35 days.
The only time you should seek medical advice is when your periods are too heavy, causing anemia symptoms, too irregular, unexpected, very painful or absent! And the best comparative standard that you should follow is yourself, as any change in your period pattern from baseline should trigger potential investigation. But as I always advise you, do not stress about your periods, and do not overthink about them, as stress is a known notorious culprit in upsetting your natural hormones and thus cycles.

Karam

Disclaimer 1: I do not encourage you to initiate any medication I mention in my articles before consulting with your physician. 

Disclaimer 2: Any further concerns and discussions can be held through my personal email found in the Blog's description box.