Menstrual Problems

 PMS

 Heavy Periods

 Absent Periods

 Painful Periods

 Diagnosis

 Treatment

 Outlook

What Are Menstrual Problems?

Menstrual cycles often bring about a variety of uncomfortable symptoms leading up to
your period. Premenstrual syndrome (PMS) encompasses the most common issues,
such as mild cramping and fatigue, but the symptoms usually go away when your
period begins.

However, other, more serious menstrual problems may also occur. Menstruation that
is too heavy or too light, or the complete absence of a cycle, may suggest that there
are other issues that are contributing to an abnormal menstrual cycle.

Remember that a “normal” menstrual cycle means something different for every
woman. A cycle that’s regular for you may be abnormal for someone else. It’s
important to stay in tune with your body and to talk to your doctor if you notice any
significant changes to your menstrual cycle.

There are several different menstrual problems that you may experience.
Premenstrual Syndrome
PMS occurs one to two weeks before your period begins. Some women experience a
range of physical and emotional symptoms. Others experience few symptoms or even
none at all. PMS can cause:

 bloating
 irritability
 backaches
 headaches
 breast soreness
 acne
 food cravings
 excessive fatigue
 depression
 anxiety
 feelings of stress
 insomnia
 constipation
 diarrhea
 mild stomach cramps

You may experience different symptoms every month, and the severity of these
symptoms can also vary. PMS is uncomfortable, but it’s generally not worrisome
unless it interferes with your normal activities.
Heavy Periods
Another common menstrual problem is a heavy period. Also called menorrhagia,
heavy periods cause you to bleed more than normal. You may also have your period
for longer than the average of five to seven days.

Menorrhagia is mostly caused by imbalances in hormone levels, especially

progesterone and estrogen.

Other causes of heavy or irregular menstrual bleeding include:

 puberty
 vaginal infections
 inflammation of the cervix
 underactive thyroid gland (hypothyroidism)
 noncancerous uterus tumors (fibroids)
 changes in diet or exercise

Absent Periods
In some cases, women may not get their period. This is called amenorrhea. Primary
amenorrhea is when you don’t get your first period by age 16. This may be caused by
an issue with the pituitary gland, a congenital defect of the female reproductive
system, or a delay in puberty. Secondary amenorrhea occurs when you stop getting
your regular periods for six months or more.

Common causes of primary amenorrhea and secondary amenorrhea in teens include:

 anorexia
  overactive thyroid gland (hyperthyroidism)
 ovarian cysts
 sudden weight gain or loss
 stopping birth control
 pregnancy

When adults do not menstruate, the common causes are often different. These may
include:

 premature ovarian failure

 pelvic inflammatory disease (a reproductive infection)
 stopping birth control
 pregnancy
 breastfeeding
 menopause

A missed period could mean that you’re pregnant. If you suspect you may be
pregnant, be sure to take a pregnancy test. Drugstore pregnancy tests are the least
expensive way to determine whether or not you are pregnant. To get the most accurate
results, wait until you have missed your period by at least one day before taking the
test.

Painful Periods
Not only can your period be lighter or heavier than normal, but it can also be painful.
Cramps are normal during PMS and they also occur when your uterus contracts as
your period begins. However, some women experience excruciating pain. Also called
dysmenorrhea, extremely painful menstruation is likely linked to an underlying
medical problem, such as:
  fibroids
 pelvic inflammatory disease
 abnormal tissue growth outside of the uterus (endometriosis)

Diagnosing Menstrual Problems

The first step in diagnosing menstrual problems is to see your doctor. Your doctor will
want to know about your symptoms and for how long you’ve been experiencing them.
It may help to come prepared with notes on your menstrual cycle, how regular it is,
and any symptoms you have been experiencing. Your doctor can use these notes to
help figure out what is abnormal.

In addition to a physical exam, your doctor will likely do a pelvic exam. A pelvic
exam allows your doctor to assess your reproductive organs and to determine if your
vagina or cervix is inflamed. A Pap smear will also be performed to rule out the
possibility of cancer or other underlying conditions.

Blood tests can help determine whether hormonal imbalances are causing your
menstrual problems. If you suspect that you may be pregnant, your doctor or nurse
practitioner will order a blood or urine pregnancy test during your visit.

Other tests your doctor may use to help diagnose the source of your menstrual
problems include:

 endometrial biopsy (used to extract a sample of your uterine lining that can be
sent for further analysis)
 hysteroscopy (a small camera is inserted into your uterus to help your doctor
find any abnormalities)
 ultrasound (used to produce a picture of your uterus)
Treating Menstrual Problems
The type of treatment will depend on what’s causing the problems with your
menstrual cycle. Birth control pills can relieve symptoms of PMS, as well as regulate
heavy flows. If a heavier or lighter than normal flow is related to a thyroid or other
hormonal disorder, you may experience more regularity once you start hormone
replacements.

Dysmenorrhea may be hormone related, but you may also require further medical
treatment to address the problem. For example, antibiotics are used to treat pelvic
inflammatory disease.

Long-Term Outlook
Irregularities between periods are normal, so the occasional light or heavy flow is
generally not something to worry about. However, if you experience severe pain or a
heavy flow with blood clots, you should call your doctor right away. It’s is also
recommended that you get medical attention if your periods occur less than 21 days
apart, or if they happen more than 35 days apart.
Stages of the Menstrual
Cycle

The purpose of the monthly menstrual cycle is to

prepare for pregnancy. Menstrual cycles vary in length
and intensity.

During each menstrual cycle, an egg develops and is released from the ovaries. The
lining of the uterus builds up. If a pregnancy doesn’t happen, the uterine lining sheds
during a menstrual period. Then the cycle starts again.

The menstrual cycle is divided into four phases:

 menstrual phase
 follicular phase
 ovulation phase
 luteal phase
The length of each phase can vary and change over time.

Menstrual phase
The menstrual phase is the first stage of the menstrual cycle. It’s also when you get
your period.
This phase starts when an egg from the previous cycle isn’t fertilized. Because
pregnancy hasn’t taken place, levels of the hormones estrogen and progesterone drop.

The thickened lining of your uterus, which would support a pregnancy, is no longer
needed, so it sheds through your vagina. During your period, you release a
combination of blood, mucus, and tissue from your uterus.

You may have period symptoms like these:

 cramps (try these home remedies)

 tender breasts
 bloating
 mood swings
 irritability
 headaches
 tiredness
 low back pain

Follicular phase
The follicular phase starts on the first day of your period (so there is some overlap
with the menstrual phase) and ends when you ovulate.

It starts when the hypothalamus signals your pituitary gland to release follicle-
stimulating hormone (FSH). This hormone stimulates your ovaries to produce around
5 to 20 small sacs called follicles. Each follicle contains an immature egg.

Only the healthiest egg will eventually mature. (On rare occasions, a female may have
two eggs mature.) The rest of the follicles will be reabsorbed into your body.
The maturing follicle sets off a surge in estrogen that thickens the lining of your
uterus. This creates a nutrient-rich environment for an embryo to grow.

The average follicular phaseTrusted Source lasts for about 16 days. It can range from
11 to 27 days, depending on your cycle.

Ovulation phase
Rising estrogen levels during the follicular phase trigger your pituitary gland to
release luteinizing hormone (LH). This is what starts the process of ovulation.

Ovulation is when your ovary releases a mature egg. The egg travels down the
fallopian tube toward the uterus to be fertilized by sperm.

The ovulation phase is the time during your menstrual cycle when you can get
pregnant. You can tell that you’re ovulating by symptoms like these:

 a slight rise in basal body temperature

 thicker discharge that has the texture of egg whites

Ovulation happens around day 14 if you have a 28-day cycle — right in the middle of
your menstrual cycle. It lasts about 24 hours. After a day, the egg will die or dissolve
if it isn’t fertilized.

DID YOU KNOW?

Because sperm can live up to 5 days, pregnancy can occur as a result of sex 5 days
before ovulation.
Luteal phase
After the follicle releases its egg, it changes into the corpus luteum. This structure
releases hormones, mainly progesterone and some estrogen. The rise in hormones
keeps your uterine lining thick and ready for a fertilized egg to implant.

If you do get pregnant, your body will produce human chorionic gonadotropin (hCG).
This is the hormone pregnancy tests detect. It helps maintain the corpus luteum and
keeps the uterine lining thick.

If you don’t get pregnant, the corpus luteum will shrink away and be resorbed. This
leads to decreased levels of estrogen and progesterone, which causes the onset of your
period. The uterine lining will shed during your period.

During this phase, if you don’t get pregnant, you may experience symptoms
of premenstrual syndrome (PMS). These include:

 bloating
 breast swelling, pain, or tenderness
 mood changes
 headache
 weight gain
 changes in sexual desire
 food cravings
 trouble sleeping

The luteal phase lasts for 11 to 17 days. The average lengthTrusted Source is 14 days.
Identifying common issues
Every menstrual cycle is different. Some people get their period at the same time each
month. Others are more irregular. Some bleed more heavily or for a longer number of
days than others.

Your menstrual cycle can also change during certain times of your life. For example,
it can get irregular as you get close to menopause.

One way to find out if you’re having any issues with your menstrual cycle is to track
your periods. Write down when they start and end. Also record any changes to the
amount or number of days you bleed, and whether you have spotting between periods.

Any of these things can alter your menstrual cycle:

 Birth control. The birth control pill may make your periods shorter and lighter.
While on some pills, you won’t get a period at all.
 Pregnancy. Your periods should stop during pregnancy. Missed periods are
one of the most obvious first signs that you’re pregnant.
 Polycystic ovary syndrome (PCOS). This hormonal imbalance prevents an egg
from developing normally in the ovaries. PCOS causes irregular menstrual
cycles and missed periods.
 Uterine fibroids. These noncancerous growths in your uterus can make your
periods longer and heavier than usual.
 Eating disorders. Anorexia, bulimia, and other eating disorders can disrupt
your menstrual cycle and make your periods stop.

Here are a few signs of a problem with your menstrual cycle:

 You’ve skipped periods, or your periods have stopped entirely.

 Your periods are irregular.
  You bleed for more than 7 days.
 Your periods are less than 21 days or more than 35 days apart.
 You bleed between periods (heavier than spotting).

If you have these or other problems with your menstrual cycle or periods, talk with a
healthcare professional.

Irregular Periods
Menstrual periods typically last four to seven days and occur roughly every 28 days. Examples
of irregular periods include periods that occur fewer than 21 days or more than 35 days apart,
missing three or more periods in row, and menstrual flow that’s much heavier or lighter than
usual.

Overview
What are irregular periods?

Most women and people assigned female at birth (AFAB) have menstrual periods that last four
to seven days. Your period usually occurs every 28 days, but normal menstrual cycles can range
from 21 days to 35 days. In fact, the average cycle length is 29 days. Many things cause irregular
periods (or irregular menstruation) such as changes in hormone levels, stress, certain health
conditions, medications and more.

What are examples of irregular periods?

Your period is still considered “regular” even if it varies slightly from cycle to cycle. Examples
of irregular menstruation include:

 Periods that occur fewer than 21 days or more than 35 days apart.
 Missing three or more periods in a row.
 Menstrual flow (bleeding) that’s much heavier or lighter than usual.
 Periods that last longer than seven days.
 Length of time between cycles varies by more than nine days. For example, one cycle is
28 days, the next is 37 days and the next is 29 days.
 Periods that are accompanied by severe pain, cramping, nausea or vomiting.
 Bleeding or spotting that happens between periods, after menopause or after sexual
intercourse.
 Soaking through one or more tampons or sanitary pads in an hour.
Your menstrual cycle may not always be predictable — and that may be OK. It’s normal to have
slight variations in cycle length or have a menstrual period that seems slightly heavier or lighter
in flow than your previous period. Menstrual irregularities are fairly common, and you don’t
have to be able to predict your cycle to the exact day for it to be considered “normal.”

Conditions related to irregular menstruation

 Amenorrhea: A condition where your periods have stopped completely. The absence of
a period for 90 days or more is considered abnormal unless you’re pregnant,
breastfeeding or going through menopause (which generally occurs between ages 45 and
55). If you haven’t started menstruating by age 15 or 16 or within three years of your
breasts developing, you may also have amenorrhea.
 Oligomenorrhea: A condition where your periods occur infrequently. You may go more
than 35 days between periods or have six to eight periods a year.
 Dysmenorrhea: A medical term for painful periods and severe menstrual cramps. Some
discomfort during your cycle is normal.
 Abnormal uterine bleeding: Abnormal uterine bleeding is bleeding between monthly
periods, prolonged bleeding or an extremely heavy period.

Symptoms and Causes

What is the cause of my irregular periods?

There are many causes of irregular periods, ranging from stress to more serious underlying
medical conditions.

Medical conditions and irregular periods

Certain health conditions are associated with missed menstrual periods. They include:

 Endometriosis: Endometriosis occurs when endometrial tissue grows outside of your

uterus. The tissue often attaches itself to your ovaries or fallopian tubes. Endometriosis
may cause abnormal bleeding, cramps or severe pain before and during your period.
 Pelvic inflammatory disease: Pelvic inflammatory disease (PID) is a bacterial infection
that affects the female reproductive system. It’s typically caused by an untreated sexually
transmitted infection (STI). Bacteria enter your vagina and spread to your uterus and
upper genital tract. Symptoms of PID include a heavy vaginal discharge with an
unpleasant odor, irregular periods and pelvic pain.
 Polycystic ovary syndrome: In polycystic ovary syndrome (PCOS), your ovaries make
large amounts of androgens, which are a type of hormone. This hormone prevents or
delays ovulation, causing irregular periods. People with PCOS may stop menstruating
completely.
 Primary ovarian insufficiency: This condition occurs in cisgender women under age 40
whose ovaries don’t function as they should, causing missed or irregular periods. It can
occur during treatment for cancer with chemotherapy and radiation or if you have certain
autoimmune conditions.
  Thyroid or pituitary gland disorders: Hypothyroidism (underactive thyroid),
hyperthyroidism (overactive thyroid) and other thyroid or pituitary gland disorders affect
your hormones. This causes your period to be irregular.
 Bleeding disorders: You may experience heavy menstrual bleeding if you develop a
bleeding or blood clotting disorder.
 Uterine cancer or ovarian cancer: Certain cancers can affect a person’s menstrual
period. Changes may include bleeding that’s heavier than usual or missed periods.

Lifestyle factors and irregular periods

Disruptions or changes in your daily routine can have an impact on your menstrual cycle. Some
examples of lifestyle factors include:

 Stress.
 Gaining or losing a significant amount of weight.
 Exercise routines that result in very low body fat (long-distance runners, dancers or
gymnasts).
 Viruses or other illnesses.

Other causes of abnormal menstruation

Certain medications, complications of pregnancy or breastfeeding (chestfeeding) may also cause

your period to be irregular. Other causes include:

 Birth control pills: Most birth control pills contain a combination of hormones. The pills
prevent pregnancy by keeping your ovaries from releasing eggs. Going on or off birth
control pills can affect menstruation. You may have irregular or missed periods for up to
six months after discontinuing birth control pills.
 Medications, such as steroids or anticoagulant drugs (blood thinners).
 Miscarriage or an ectopic pregnancy (the fertilized egg implants outside your uterus).
 Surgery, scarring or blockages in your uterus, ovaries or fallopian tubes.

Diagnosis and Tests

How are irregular periods diagnosed?

If you sense changes in your menstrual cycle, begin keeping records of when your periods begin
and end. Note symptoms, the amount of flow or if you experience cramping, bleeding between
periods or passing large clots. These are all helpful to share with your healthcare provider.

To diagnose irregular periods, your provider will ask you about your menstrual cycle and
medical history. They’ll perform a physical examination, including a pelvic exam. They might
also order certain tests, including:

 Pelvic ultrasound: An ultrasound can detect irregular bleeding due to uterine fibroids,
polyps or an ovarian cyst.
  Endometrial biopsy: Your provider removes a sample of tissue from the lining of your
uterus. It can help diagnose endometriosis, hormonal imbalances or precancerous cells.
 Hysteroscopy: A procedure that allows your provider to look inside your uterus in order
to diagnose and treat certain causes of abnormal bleeding.

Management and Treatment

How are irregular periods treated?

The treatment for irregular periods depends on the underlying cause.

Medication for irregular periods

Medications are often the first treatment for irregular periods. If medication doesn’t help, your
provider may recommend surgery. Possible medications include:

 Hormonal birth control: Irregular or heavy bleeding caused by PCOS, uterine fibroids,
endometriosis or other medical conditions may be managed with hormonal birth control.
They also help by regulating your cycle, making it more predictable. These can be
combination hormonal birth control pills that consist of estrogen and progestin, or
progestin-only birth control. Both types come in different forms like pills, a vaginal ring,
injection or an IUD (intrauterine device).
 Tranexamic acid:A medication prescribed to treat heavy menstrual bleeding. You take
one pill at the start of your period to control your bleeding.
 Pain relievers: You may find relief from mild to moderate pain or cramps by taking an
over-the-counter pain reliever, such as ibuprofen or acetaminophen.
 Hormone therapy:Hormone therapy may be helpful if your irregular period is due to
perimenopause. It can also help with other menopausal symptoms like vaginal dryness
and hot flashes. There are risks associated with hormone therapy, so be sure to discuss
these with your healthcare provider.
 Antibiotics:You may be given antibiotics if the cause of irregular bleeding is from an
infection.
 Gonadotropin-releasing hormone agonists:These medications shrink the size of uterine
fibroids and control heavy bleeding, but temporarily stop your menstrual period.

Surgery for irregular periods

There are surgical treatment options depending on your condition, age and whether you want to
get pregnant in the future. Surgical treatments for irregular periods include:

 Endometrial ablation: Endometrial ablation is a procedure that uses heat, cold or

different types of energy to destroy the tissue that lines your uterus so you bleed less
during your period. You must have a form of birth control to have this procedure. If you
still wish to get pregnant in the future, you shouldn’t have this procedure.
 Myomectomy: A procedure to remove uterine fibroids, a cause of irregular bleeding.
  Uterine artery embolization: A procedure that cuts off blood supply to your uterus in
order to stop uterine fibroids.
 Hysterectomy: In severe cases, surgery may be necessary to remove excess endometrial
tissue growing in your pelvis or abdomen. A hysterectomy might be required as a last
resort if your uterus has been severely damaged.

Prevention
How can I lower my risk of having an irregular period?

Here are some recommendations for self-care:

 Try to maintain a healthy lifestyle by exercising moderately and eating nutritious foods.
If you want to lose weight, do it gradually instead of turning to diets that drastically limit
your calorie and food intake.
 Make sure you get enough rest.
 Practice stress reduction and relaxation techniques.
 Cut back on prolonged or intense exercise routines.
 Use birth control pills or other contraceptive methods as directed.
 Change your tampons or sanitary pads every four to six hours to avoid toxic shock
syndrome and prevent infections.
 See your gynecologist and primary care provider for regular check-ups.

Living With
When should you see your provider about irregular periods?

Contact a healthcare provider if you have painful or irregular periods or any of the following
symptoms:

 Severe pain (cramping) during your period or between periods.

 Unusually heavy bleeding (soaking through a sanitary pad or tampon every hour for two
to three hours) or passing large clots (larger than a quarter).
 Foul-smelling vaginal discharge.
 A period lasting longer than seven days.
 Vaginal bleeding or spotting between periods or after you’ve gone through menopause.
 Periods that become very irregular after you’ve had regular menstrual cycles.
 Nausea or vomiting during your period.
 Symptoms of toxic shock syndrome (TSS), such as fever, vomiting, diarrhea, fainting or
dizziness.

You should also see your provider if you think you might be pregnant.

Additional Common Questions

Is it normal to miss a period for two months?

Skipping one or two periods isn’t ideal, but it’s not too concerning. Take a look at any changes in
your life recently. Things like stress, a new workout routine, losing or gaining weight, or
changing birth control can all impact your cycle. Call your healthcare provider if you miss your
period for three or more months in a row or if you experience other unusual symptoms during
your next period.

How much delay in periods is normal?

Slight delays in your period are typically OK. Some people are able to predict their period to the
exact day, while others can’t. Contact your provider if you notice a sudden change in the time
between cycles or the duration (days) of your period, especially if it’s significant. This doesn’t
always indicate a problem, but it’s a good idea to get it checked out.

When are irregular periods more common?

Irregular periods are more common when you first begin menstruating (around age 9 to 14) or
during perimenopause (around age 50 or just before menopause).

Should I be worried if my period is irregular?

Irregular periods may be nothing to worry about because some variation in menstruation is
normal. What’s normal for you may be different from what’s normal for your closest friends.
However, certain symptoms could be a sign of a bigger problem.

Contact your gynecologist if you’re concerned about your menstrual cycle or if you’re trying to
get pregnant and have unpredictable periods (this can make getting pregnant difficult). They’ll be
able to tell you what’s normal and if treatment is needed.