March 22 2021 | Written by Rhea Kumar (She/Her), in collaboration with OB/GYN Dr. Taryn Taylor, MD, PhD, FRCSC.
Let’s talk about irregular periods (and get ready, this one is JAM PACKED with information).
For some, irregular periods may cause alarm, for some, it may not seem like the end of the world. Speaking from personal experience, I’ve suffered with irregular periods for almost five years, and no, I’ve never taken it seriously enough to seek medical advice. Go ahead, call me neglectful, too easy-going, because yes, you’d be right. This isn’t something that should just be overlooked, because it could be telling you something much deeper about what’s going on with your reproductive system.
14 to 25 percent of menstruators, according to the National Institutes of Health, are affected by menstrual irregularities.
If you’ve been experiencing menstrual irregularities, sit tight and take note, because we’ll be talking to Dr. Taryn Taylor, MD, PhD, FRCSC, who agreed to help us tackle some necessary questions that we’ve been asked by readers, and to provide you the information you need to guide your own health journey.
Dr. Taylor is currently an Assistant Professor at the Department of Obstetrics & Gynecology at London Health Sciences Centre and a Scientist for the Centre for Education Research & Innovation at Schulich School of Medicine & Dentistry.
She says that it is her job to ensure that people are able to control their cycles, rather than allow their cycles to control them.
She speaks on her experiences of consoling upset and tearful patients who feel hopeless as they deal with the heaviness or unpredictability of their periods.
I thought that the best way to start off would be by asking Dr. Taylor how an irregular period is defined and exactly what the ‘regular’ range is for a period so we can better understand what to do when your period falls outside of the range.
1. What is the medical definition of an irregular period and what is considered the regular range?
Generally, one should get their period every 28-35 days in patients who are in menstruating, and not on any form of hormonal birth control. The hard and fast medical definition: if there’s no bleeding for 2+ months, this is considered irregular.
2. What is the hypothalamic-pituitary-ovarian axis (HPO axis)? How does it control your period?
The HPO axis is a tightly regulated system controlling female reproduction and refers to the signalled connection between the hypothalamus, the pituitary gland, and the ovaries (which then signal to the uterus).
A regular period would indicate that the communication between the hypothalamus and pituitary gland sends a signal to the ovaries, which then sends a signal to the uterus to either grow or shed its lining, depending on which stage of the cycle it is at. In a person suffering from irregular periods due to hormonal causes, this signal pathway is interrupted in some way.
3. What is the biggest misconception that patients come in with regarding their irregular periods?
The internet is swirling with correct information and misinformation, how do you correct such gaps in knowledge?
There’s one common thing that I hear a lot when we ask patients about the regularity of their cycles. A patient might say “My periods are irregular” but in fact what they mean is their period may come every 28 days one cycle and then 30 days the next cycle. That’s actually considered normal and regular because normal cycles can vary from 28-35 days.
There’s also the misconceptions about whether an IUD or birth control is safe or healthy. (Writer’s note: Keep reading as Dr. Taylor explains these two and how they may help you with period regulation)
4. What are some possible treatment options for a 20-something experiencing irregular periods?
First and foremost, we would begin with a lot of data gathering, asking a patient about symptoms that could help us identify an underlying cause. We ask about symptoms related to other hormonal level problems which involve the pituitary gland as it’s responsible for many other hormonal processes that can interfere with periods. This may lead us to ask about acne, stress levels, weight gain and hair growth that may be bothersome or that you actively remove.
Putting these pieces together will direct us to good treatment options and what makes the most sense for a patient.
5. Why might an IUD be prescribed to someone who experiences irregular periods?
Sometimes a patient may be surprised when they’re advised to use an IUD as a treatment to regulate their period. There’s a common misconception that the use of IUDs and even the birth control pill might not be healthy or safe to stop or decrease menstrual bleeding.
However, in the context of an IUD, we sometimes prescribe this to decreased bleeding (even if birth control isn’t needed) because we know up to 60 percent of women stop bleeding after 1 year with the highest dose levonorgestrel-containing IUD. It’s important to know that the menstrual blood isn’t actually stuck in the uterus. Rather, some patients with heavy periods have a really thick uterus lining, therefore the IUD thins out the lining, so when the uterus gets the signal to shed, there won’t be anything to shed. For some women, this is the difference between not being able to go to work or be active during the period and then finally having their lives back.
6. Why might birth control be prescribed to someone who experiences irregular periods?
So, for example, nine out of ten times, when a patient says that they are experiencing “three periods a year,” it means lack of ovulation, and we know that they aren’t experiencing a regular sequence of events.
The hypothalamus and pituitary glands aren’t signalling properly to the ovaries, and so there’s no egg released each month and the usual sequence of events that tells the uterus to shed doesn’t reliably happen.
The birth control pill can help because it intercepts the mixed-up signalling pathway and “talks” to the uterus on its own and provides a steady level of estrogen and progesterone rather than relying on internal signalling. Then, the lining is able to grow normally and then shed regularly during the hormone free interval (placebo pills).
7. Can you explain the importance of estrogen and progesterone levels for the regulation of one’s period?
Estrogen acts like a fertilizer; it tells the uterine lining to grow and prepare for a possible fertilized egg. After ovulation, progesterone levels surge and then fall (if an egg hasn’t been fertilized) as a signal to the uterus to shed its lining.
When there’s an imbalance between these hormones, particularly an excess of estrogen, the lining can grow too much and increase the risk of abnormal cell growth, such as cancer or precancerous cells. We can see this in patients who do not ovulate regularly (thus not getting a regular progesterone surge) and who carry extra weight around their middle. This extra weight (called central adiposity) can actually generate its own estrogen, in addition to what is made by the ovaries. That’s why it's common to prescribe birth control in patients who are not ovulating, which ensures that a patient receives the right amount of estrogen and progesterone.
Estrogen itself isn’t bad or inherently dangerous. It is important for bone health in younger women and for cardiovascular health as we get older.
Time to play myth busters. A lot of people I know have asked whether someone's normal cycle range may change as they hit major milestones in their life. For example, as they grow from adolescence into their twenties, or from their twenties to thirties.
8. How true is this?
As far as milestones, I’m not sure I’d routinely say that transitions like those you mentioned would signal that. But, young patients in their adolescence may have irregular periods as their HPO axis is still developing. So, for adolescence, their period may be early, late, or only a few times a year. However, if this persists into your early twenties, then I’d suggest reaching out to your healthcare provider.
However, a ‘milestone’ decade that many are aware of is when a woman reaches her forties, and enters a perimenopause stage, where periods tend to become closer together, some cycles become anovulatory (not releasing an egg every cycle), and therefore their periods get heavier.
9. What’s the connection between PCOS and irregular periods?
Polycystic ovary syndrome is a condition that is associated with anovulatory cycles, meaning that there is irregular bleeding and often no release of an egg, or unscheduled eggs through the year. We often acknowledge that PCOS may be a part of a larger spectrum of “metabolic syndrome,” as patients often have a higher lifetime risk of diabetes, high blood pressure, and we’re still unpacking the ins and outs of why some get PCOS and why some don’t. However, there could be a familial component, so having family history might be a piece of information that can help.
10. Can lifestyle and behaviour, such as sleep patterns, diet, weight etc. affect one’s period and its regularity?
When I meet any patient with irregular periods, the approach is to think about the possible structural reasons for irregular bleeding, which can include polyps in the uterus, fibroids, which is a benign but common growth on the muscle of the uterus, and cancer is something always in the back of our minds. However, for a healthy young woman, that’s not common.
Patients with low body mass index may not experience a regular period. Likewise, patients with a higher body mass index, such as those suffering with PCOS, may also experience irregular periods. While we are taught that the best line of therapy for those with higher body mass is weight loss of a certain degree, we are also increasingly aware that body mass index is not a very reliable indicator of overall health and wellbeing.
Stress can also affect the hypothalamus which is a component of the HPO axis.
11. What can someone do today if they believe they are in need of medical advice about their irregular period?
It’s best when patients come in and they’ve spent time keeping track of their period over the past 3-6 months including their symptoms. These could include bloating, breast tenderness, or whether the period is just not coming. A family doctor is a great place to start, as many are more than equipped and able to work up the diagnosis of irregular bleeding and to create a good treatment plan.
After our interview, and on a much lighter note, Dr. Taylor graciously assured me that there really is no ‘normal’, when it comes to an individual health journey, and there’s “No limits to what your period can throw a wrench into.”