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When to See a Doctor for Menstrual Irregularities

Menstrual irregularities are common and often harmless – but may cause discomfort and worry. The implications can range from being a nuisance to signaling a more serious underlying problem.

For peace of mind, and long-term health, it’s important to rule out a condition that requires treatment. Once that has occurred, you and your doctor together can address ways to reduce the impact that menstrual irregularities have on your life.

Betty Ng, MD, of the Department of Obstetrics and Gynecology at Brigham and Women’s Hospital, reminds patients that to understand what constitutes abnormal menstruation, it’s important first to define what is normal. This depends somewhat on your age.

  • For adolescents, the onset of menstruation (called menarche) varies, though it typically occurs at 12 to 13 years of age. Within two years, menstruation for 95 percent of teens falls into a regular pattern. Girls who reach menarche early also tend to become regular more quickly. For those who begin their period later, the pattern may set in later. 
  • For women of reproductive age (18 to 50 years) menstrual cycles typically last 28 to 35 days, measured from the first day of bleeding in one cycle until the first day of the next. The menstrual period typically lasts four to six days.
  • In postmenopausal women (those who have ceased menstruating) any bleeding is considered abnormal and should be discussed with a physician.

Across the age spectrum, menstrual irregularities fall into four major categories:

1.      Amenorrhea, absence of menstruation

“Primary amenorrhea” describes when menstruation has not begun during adolescence. The first discussion and evaluation should be with the teen’s pediatrician, who may refer you to a gynecologist. The evaluation for primary amenorrhea will look for congenital causes, as well as hormone irregularities.

When someone who has been menstruating normally ceases to have a period for more than three cycles, it is called “secondary amenorrhea.” Ng advises women who have not had a period for six months to see a doctor – but some may opt to make an appointment sooner.

After ruling out pregnancy as the cause of absent menstruation, a physician will ask about recent changes such as weight loss or gain, new medications, and change in activity levels. The physician will check the thyroid gland and pelvic organs for masses or cysts (abnormal growths can disrupt normal menstrual cycles) and possibly order ultrasound imaging.

For secondary amenorrhea, the cause usually is revealed in lab tests. These involve a simple blood test to check levels of reproductive hormones. If an irregularity is found, hormonal treatment can be used to regulate the menstrual cycle, or additional imaging may be ordered.

Doctors also will screen the patient for polycystic ovary syndrome (PCOS), a hormonal problem in young women that is associated with a range of symptoms that may include acne, hirsutism, and overweight. PCOS is a common cause of secondary amenorrhea, but also can be associated with other patterns of irregular bleeding. A physician can guide patients to appropriate medical treatments and lifestyle modifications to address PCOS.

Another cause of both primary and secondary amenorrhea can be excessive exercise that disrupts estrogen production. These teens and women generally are advised to increase caloric intake and possibly decrease exercise.

2.      Frequent Bleeding

A woman who menstruates regularly, but in shorter-than-normal cycles, is considered “polymenstrual.” But many women who meet this definition just have a short cycle, with no concerning medical condition. “There are women who bleed every 22 days and are fine,” says Ng.

Generally, though, cycles of less than 21 days can be concerning, as it may indicate hormonal dysfunction. These women also may be at risk for anemia from blood loss. For a healthy woman, a consistently short cycle is worth mentioning in a regular check-up. But a sudden and sustained change in cycle should prompt a visit to your physician.  

“If you normally have a 32-day cycle and it becomes irregular and/or more frequent – come in,” Ng tells patients. A gynecologist would test for possible causes of abnormal bleeding known by the acronym PALM-COEIN. This includes polyps, structural lesions of the uterus, bleeding disorders, and rarely malignancy.

3.      Bleeding Between Cycles

For someone who has regular cycles but also experiences bleeding mid-cycle, this “inter-menstrual” bleeding is very likely related to ovulation, says Ng.  

Bleeding that occurs during other times of the cycle should be addressed with a physician. The typical workup includes lab tests and pelvic ultrasound to look for masses including fibroids (which are predominantly non-cancerous), overgrowth of the endometrial lining, and polyps – most of which can be treated.

Medical consensus is that women over age 45 who experience bleeding between cycles should be tested to rule out any malignant growth in the pelvic area. But even younger women (especially those who are obese, hypertensive, or diabetic) may have additional risks.

Once a structural problem or malignancy has been ruled out, any further care depends on how inconvenienced a woman is by the bleeding.

“How much someone is bothered by it may dictate whether any treatment is called for,” says Ng. For   appropriate candidates, birth control pills (which contain hormones that control build-up and shedding of the uterine lining) may be prescribed to regulate bleeding. An intrauterine device (IUD) that emits the progesterone hormone is another possible treatment.

4.      Excessively Heavy Periods

The amount of blood flow that is considered normal, while difficult to quantify, is generally considered 1 to 2.7 ounces during one period. “Heavy” menstrual bleeding that exceeds this amount is described as soaking through a pad or tampon within two hours, waking at night to change a pad, or clots larger than one inch.

The amount of blood flow ranges from one woman to the next and may vary from month to month. But a woman who experiences a change to excessively heavy periods that recur for more than three months should see a physician, advises Ng.

A doctor’s first question likely will be: Did the heavy flow began with the first period, or much later? Among young women who have excessive flow from the start of menses, up to about 25 percent may have an underlying bleeding disorder condition. If heavy periods begin later, the gynecologist will evaluate with imaging and biopsy to rule out harmful conditions, using the PALM-COEIN classification of potential causes.

Absent these underlying causes, a physician will be on the lookout for negative consequences of menstrual irregularities: anemia (caused by excessive blood loss), difficulty conceiving, fibroids, and severe impact to daily life due to the bleeding. If none of these are present, a doctor and patient may decide together that it is okay not to intervene.

Across the range of menstrual irregularities, the goal of testing is to rule out causes that would require treatment to preserve health and enable fertility. Many of these conditions can be addressed by a gynecologist who can provide a referral, if necessary, to an appropriate specialist.  

While the majority of irregular menstruation is more nuisance than health menace, it is important to rule out serious conditions and to treat underlying causes.  

“I tell my patients: If there is a change in your usual pattern, and you are concerned by it, come see me,” says Ng. “If we find nothing wrong, you may opt not to treat the irregular bleeding. But it’s good to rule out a medical problem.”

To make an appointment with a gynecologist at Brigham and Women’s Hospital, please call our Physician Referral Line at (800) 294-9999, M-F, 8 am to 5 pm ET.

-Sandy J.