Updated: Jun 5
Several years ago, a friend of mine was dying of cancer. She dribbled us information over the past year of her life, only the good news, but we all knew it was coming; she was dying. A group of us were talking about, well, who-knows-what; I honestly can't even remember now what the details were or how we got here, but in one way or another, I was sharing about how our monthly cycle is a reassuring indicator of health. Maybe I was even talking about hormonal birth control and how we don't cycle on these pills, but rather have withdrawal bleeding so they can mask early indications of imbalance. She shared that she hadn't had a cycle for years, sort of questioning me, and was never told that was a problem. Then we all looked at each other. I regretted the course of that conversation and not recognizing where it was headed and she recognized that she had missed an ominous sign that might have alerted her earlier in her life. We all took a deep breath, all aware that we did trust nature, we trusted our bodies, and we really were grateful to be women and to represent the rhythm of the seasons - but we have lost the knowledge of how empowering these rhythms are for us, in spite of their seemingly inconvenient interruptions. We knew women like our friend, were suffering because women have fallen out of touch with their bodies, with their inner-knowings.
Our menstrual cycle is controlled by our endocrine system, the command station of hormone control, and the endocrine system is quite sensitive. Stress, weight loss, travel, major life changes, and even spending extensive time with any particular cycling woman can throw off your hormones and therefore, your cycle pattern. So, it's normal on occasion, and with explainable cause, to have an irregular cycle - maybe longer, shorter, or even missed entirely. Breastfeeding, hormonal contraceptives, and #perimenopause are also causes of menstrual cycle disruptors because they alter estrogen and progesterone. Having said that, there really is no perfect cycle.
Our practice members have exclusive access to programs in which we break down the intricacies of our monthly moon, and we further discuss the phenomenon of "feeling hormonal," and what it looks like to appreciate the seasons of our cycle. What about though, when our cycles are off? What does this mean? What if they are heavy or long and how do we know if we are ovulating?
Long Menstrual Cycles
By definition, a long menstrual cycle is those separated by more than 34 days from the start of one menses, to the start of the next. The start of our menses is brought on by a drop in progesterone which naturally occurs after ovulation. These long cycles are indication that you're not ovulating regularly, or maybe not even at all. Many times poly-cystic ovarian syndrome (#PCOS) is the cause.
When you cycle longer, your uterine lining grows thicker and thicker, which typically leads to heavier flow and more #cramps, but just a few years of this, gone unchecked, increases the incidence of endometrial cancer. PCOS and not ovulating can be a problem if you're trying to get pregnant as 28-29 days is much more optimal. Our goal then is to work towards a 26 to 34 day cycle range.
Short Menstrual Cycles
If your cycles are shorter than 26 days, again from the start of one menses to the start of the next, then we consider this a short menstrual cycle. Beyond the mere nuisance of a too frequent cycle is the risk of having #estrogen levels which are too high which is also a risk for endometrial and breast cancer.
Short cycles are often, yet controversially, called luteal phase dysfunction because there is lower progesterone. This may indicate your ovaries are coming to the end of their supply of eggs and #perimenopause is approaching. If you're older than about 42 years, this is likely in line with your transition into menopause, but younger, this is indicative of primary ovarian insufficiency.
More frequent blood loss can also increase the incidence of #anemia, which may cause increased fatigue, even impact your mood and ability to think clearly. Certainly it can wipe your stamina and make it difficult to engage in a healthy exercise routine.
Having fewer than eight cycles in a year or skipping three or more moons is what we term, amenorrhea. A skipped menses here or there can simply be a response to stress, travel, or big changes in your life, in which this is a good reminder to self-evaluate, draw healthy boundaries, and assure you aren't pushing too hard in life. Generally, once the #stress is passed, your menses will get regular again on their own.
Skipped moons are the most common sign you'll notice when you are pregnant as well, and ongoing amenorrhea is reassuring when your goal is to breastfeed exclusively for those first six months or more. Your elevated prolactin while #breastfeeding, suppresses both estrogen and progesterone, so your menses stays at bay. Hormonal contraception, antidepressants, blood pressure medications, and certain chemotherapy drugs can prevent ovulation and suppress your flow.
If not any of these reasons though, or related to your transitioning into menopause, then the most common reason for skipped periods is what we call hypothalamic amenorrhea. When you are under a high amount of stress, such as significant weight loss, you simply aren't in a state of health that would support pregnancy so your body halts reproductive function to spare your energy and wellbeing. This is common in teens, even into your twenties and thirties, when life can be especially chaotic and demanding. If you're a high-intensity athlete or restrict your diet, there's a good chance your skipped periods relate to this. This may simply mean attending #hotyoga five or more times a week.
Potentially this is a serious problem. Nutritional deficiencies may need addressed and when long term, this may impact bone health, even at a young age. The thyroid may play a role, even Celiac disease. The good news though is that this is reversible, well, Celiac disease is not but it can be well managed and the consequences resolved.
PCOS, as mentioned, can cause long cycles or missed menses entirely, but the difference between hypothalamic amenorrhea and PCOS is that the former doesn't cause the unwanted hair or other symptoms common to PCOS, like cystic acne. Obtaining labs can help distinguish the difference here too. Headaches or weakness may indicate a tumor, potentially in the hypothalamus, pituitary, or adrenal glands. Asherman's syndrome is yet another pathology that would explain lack of flow, which results from surgical procedures in the uterus.
If your cycles are regular, then the likelihood that you are ovulating is quite high. Observing for cyclic changes can further help assure you are ovulating, such as feeling mittelschmerz and identifying cervical mucus changes, breast fullness late in our cycle, and most especially, postovulatory basal body temperature elevations. Once in a while, sure, this may happen and it is common for young girls to not ovulate that first year after they get their first flow, but if this is your usual pattern, it is a big deal.
We look for PCOS and HA, as described previously, but we also evaluate the thyroid and evaluate estrogen levels which can pose risk long term. If you're not ovulating, you're not producing adequate progesterone and this one regulates other hormones which are important, such as androgens. If you're hoping to get pregnant, this is an even bigger issue.
Ovulation is an inner barometer of overall health, that your brain and your ovaries are effectively communicating, that you have healthy ovarian function, that you have sufficient fat absorption, and knowing that if you desired, your body feels it would be safe enough to manage a pregnancy is quite reassuring. Even if you do not desire pregnancy, this is important to assure is occurring or that it is restored if not.
Clinicians call this one, menorrhagia, and it occurs when your flow is longer than seven days or if you are using more than six pads or tampons per day, or soaking through more than two in an hour, or even if passing large clots. Sadly, most women are reassured that this is normal when they do report this to their clinician, but this is clear indication of hormone imbalance.
Heavy flow is generally either the result of high estrogen or low progesterone. High estrogen levels lead to a significant buildup of the uterine lining. When that sheds, heavy bleeding occurs and usually with it, heavy cramping. Low progesterone is usually related to PCOS and the absence of ovulation. Periods are often irregular or farther apart but when they do occur, they are quite heavy.
Endometriosis, adenomyosis, uterine #fibroids, and thyroid disease are other causes. Primary ovarian insufficiency and perimenopause are also associated with heavier flow as well, but at least 20 percent of women have some sort of inherited bleeding disorder such as von Willebrand disease. While this may seem normal for you, a chronically heavy period can result in anemia, causing fatigue and brain fog, even depression. Personally, I've struggled with this as I transition through perimenopause and while anemia hasn't been an issue for me, I do feel incapable of working that first heavy day. I can barely leave the house as there seems to be no solution to preventing overflow and a necessary change in clothing. A heavy flow can certainly impact your work and lifestyle. This really isn't something to just deal.
Flows shorter than three days may seem delightful, but these scant or short flows are signs of imbalance. Often this indicates low estrogen or hypothalamic amenorrhea, or be a symptom of PCOS, #hypothyroidism, or primary ovarian insufficiency. Other less common reasons are cervical stenosis, usually the result of a surgical procedure that causes scaring and adhesions so the flow has difficulty escaping the uterus.
If you're trying to get pregnant and your #endometrium is scant, less than 7mm thick, then there is really no where for your ovum to dig in and make a home. Miscarriages are far more common, and this is partly how hormonal birth control works and is so effective. An ultrasound can determine uterine thickness accurately and is minimally invasive.
Bleeding between Moons
We often refer to this as abnormal uterine bleeding, or more specifically, metrorrhagia. We diagnose this when there is spotting or bleeding more like a period, between your moons, which may be light brown and scant. Of course when you're pregnant, this can be quite concerning. Typically we tell moms that brown blood is old blood and typically of no concern, but the preference certainly is to see no blood after known pregnancy.
Staring and stopping hormonal birth control can cause spotting, as can being on too low a dose particularly for your weight. IUDs often cause spotting and the Mirena is known for spotting for as long as that first year after placement. Emergency contraception may also cause bleeding. Uterine fibroids, cervical polyps, endometriosis, adenomyosis, PCOS, and some sexually transmitted diseases can also cause you to see some blood loss outside your menstrual flow. The big red flag though with bleeding between moons is the potential for cancer.
Goodness do I remember these in my youth, to the point of passing out in school. We call this dysmenorrhea as clinicians and it can occur for a few reasons. When it occurs around the time of your menses, feels achy or crampy, and lasts for about three days and is maybe associated with nausea, vomiting, diarrhea, a back ache, #headache or dizziness, then we call this primary dysmenorrhea.
If though, this paid is related to another underlying issue such as abdominal or pelvic pain or pressure that goes beyond the menses, or even #constipation or bowel movements, urinary or pain during intercourse, then we call this secondary dysmenorrhea. Endometriosis is typically the cause here, although fibroids are also a common cause. This latter issue tends to get worse, not better, with age if the underlying conditions aren't addressed.
While awareness of your menses is appropriate, even anticipation, because of mild cramps that tell you your uterus is at work, one should not be disturbed, suffer, or miss work because their menses is so uncomfortable. You should be living on ibuprofen during your flow. The words I feel like I am getting stabbed shouldn't even cross your mind. If so, reach out to your clinician for answers.
Ibuprofen is effective because it reduces prostaglandins, which is where your hormones are out of balance with dysmenorrhea. This overproduction of inflammatory prostaglandins causes your uterus to spasm, cramp, and seemingly seize up. Interestingly, if you are producing low levels of prostaglandins, this is also painful. Elevated estrogen is yet another reason your flow might be painful because this creates a thicker endometrium and therefore, more work for your uterus to expel with each flow so contractions are stronger.
All these reasons are indications that you need to be seen by your primary care provider, and even in the young gals who are menstruating, when this is really bothersome, it can't also be normal. While some irregular cycles and missed periods may be normal, some moodiness, and mild acne can be tolerated as those hormones balance themselves initially, pain requiring medication, heavy periods, acne, and severe depression are indication of pathology and better to figure this out early than progress towards PCOS or endometriosis and infertility later into your childbearing years.