I have had emails from several young women, asking about irregular periods: why, what does it mean, does it affect fertility? As always, I must start this discussion by stating that this paper cannot be taken as medical advice but only as general information that may or may not apply to your condition. If you have a problem talk to your doctor.

Irregular periods:

Your period can be irregular either by interval or by the period itself. Most people’s periods occur about once a month. The periods may be 28 days from start to start or it may be from two to six weeks and still be considered "normal". The interval may also gradually change as one gets older. Mostly people generally learn what to expect in flow and cramps. It may vary some from month to month but most people have a norm that they come to expect. My experience in talking to people who are worried about their periods, is that the flow causes more concerns. I can’t argue that a heavy menstrual period is very annoying and can really crimp a lifestyle. The resultant anemia and fatigue are debilitating and the problem may frequently result in a need for treatment, either medical or surgical. But in terms of the potential for serious disease, probably the irregularity in interval is more significant.

The menstrual cycle is controlled by several interrelated feedback loops. I will go into an abbreviated version of the way I remember the physiologic explanation and then try to explain what it really means. The first thing that happens is that the body’s estrogen level starts to fall. The pituitary gland, in the base of the brain, responds to this by sending a signal, FSH, to the ovary to "make more estrogen". The ovary responds by selecting a follicle or small, tiny cyst with an egg in it. This follicle begins to grow and the growing follicle secretes more estrogen and satisfies the pituitary’s demand. When the level gets to a certain set point it triggers the release from the pituitary, of a second signal, LH, that makes the follicle burst and release the egg. When this happens the follicle begins to secrete progesterone (a hormone thought to be related to PMS) in addition to estrogen. The estrogen has been causing the lining of the uterus to grow and thicken, and now the progesterone starts to ripen the lining to prepare it for the possibility that an embryo will be trying to implant there. Almost exactly 14 days after the egg is released, the follicle stops working and the levels of estrogen and progesterone in the body drop. This decrease in progesterone causes the uterine lining to disintegrate and to be expelled. The fall in the estrogen level starts the whole process over again. This cycle controls the interval between the periods. Having a higher estrogen level for longer seems to make the period heavier because there is longer for the uterine lining to grow. The absence of ovulation is supposed to mean an absence of cramps but I have not found this to be always true.

I am sure that everyone can see that this is a very complicated system and very easy to screw up. That is why there are Birth Control Pills for women but not men. Most people, when they are just starting their periods will have very irregular periods for a year or two. Most of the time this is caused by a failure of ovulation. The cycle starts out normally and the follicle grows and produces estrogen but for some reason the signal to ovulate, is either never sent or not received. The lining of the uterus then continues to grow until it either starts to break down spontaneously or until ovulation occurs and a normal but overdue period occurs. Either way the bleeding is usually heavier, sometimes much heavier, than normal. Some women will continue to do this for more or less all of their menstrual life. This is then called anovulation or sometimes Poly Cystic Ovary Disease or PCOD. It may be normal for someone to do this at the beginning and the end of their menstrual career, but if it goes on too long it may cause several problems. It is still not clear what the relationships are in the condition--what is cause and what is effect-- but some things are clear. Obesity is often related. People with PCOD have a tendency to become obese and have more trouble losing weight than do non-PCO people. Obese people tend to develop PCO, often at a certain weight level. If they lose below a given point their periods normalize. Above there, it will be abnormal. Whether as a cause or as a result of increased estrogen secretion, androgens, male hormones, are produced in excess. This results in acne and hair changes. Hair may grow in a "male " pattern on the midline of the abdomen, the nipples, and the face. In severe cases male pattern baldness may occur. In many people there is a tendency to develop diabetes. If one doesn’t ovulate, one can’t become pregnant, so infertility is a problem. If the periods continue irregular for many years, a tendency to develop cancer in the uterus develops. The longer the process continues, the more likely these symptoms are to occur. The treatment of PCO is based on several things. First and most important is to restore a normal cycle. Birth control pills work the best. This suppresses the body’s own abnormal hormone production and generally helps to normalize things. Weight loss is very difficult to achieve but helps to restore the body’s normal hormone balance. If hair growth remains a problem even after normalizing the periods, a medicine called Spironolactone, which is a diuretic as well as a "hormone adjuster" sometimes, helps. Infertility is usually treated with clomiphene, a fertility medicine, with very good results. Most PCO patients, with help, can get pregnant. Recently we have begun treating PCO with the diabetes drug, metformin. This seems to modify the way the body uses insulin but the end result is usually regular periods and restored fertility. The metformin may also help with weight loss too. 

The condition is called Polycystic ovary because of the many follicles that develop into cysts. These are like little blisters about 1cm in diameter, on the ovary. There are a bunch of them, hence- Polycystic disease, or Many cyst disease.

Sometimes there is only one cyst that starts to develop normally but fails to release the egg like it should. It may continue to grow and get to be several centimeters in diameter. Alternatively, an otherwise normal cyst may not break down after ovulation like it should. These are types of ovarian cysts and may cause an occasional skipped period or two. They may also cause enough pain to be confused with an ectopic pregnancy or they may rupture and cause bleeding internally and pain. Fortunately they usually just quietly go away. When one of these is diagnosed, usually, the best advice is just to wait. Eight or nine times out of ten it will spontaneously drain or disappear and there will be no need for any surgery. Once in a while, if the cyst is very large or persistent over several months or if it is very painful, surgery may be necessary. Virtually always this can be done through the laparoscope as day surgery. Most of the time someone who has been out of work with the pain of an ovarian cyst finds that after surgery she is able to return to normal activities in 24 hours.

There are other less common causes of irregular periods. Weight loss is a problem for some people. This is a cause of skipped periods in female athletes, especially dancers or athletes and people with anorexia and bulimia. Without a certain level of body fat, which varies some from person to person, ovulation stops and the estrogen level drops back to a pre-pubertal level. Unfortunately, bone strength is dependent on estrogen. It is well recognized that some athletes, despite vigorous exercise and an excellent diet, end up with osteoporosis, just as if they were elderly ladies.

Another common cause of skipped periods is STRESS! We live in a normally stressful world. I don’t want to try to guess if it was more stressful in the past when we had to worry about being eaten by a saber-tooth tiger or now when the TV brings every calamity in the universe home to us in living color. We could a least fight the tiger but we can’t do much about the whole world. Most people adapt to a certain level of stress but when that rises, like during final exams, or illness or family problems, the periods may stop. This is usually temporary and returns to normal very quickly. Some people react to stress by frequent, irregular periods. This seems doubly unfair.

Rarely irregular and abnormal periods are caused by medical disease. Glandular problems like diabetes or thyroid disease may interfere with the periods. Serious kidney or liver disease or any widespread metabolic condition may cause problems. Anemia may be both a cause and a result of problem periods. These causes are very uncommon and probably account for less than 5% of people who are seen for abnormal periods.

One of the most common and usually most benign causes of missed periods is Birth Control Pills. Most people who take BCP’s have shorter and lighter periods. This is a benefit and an advantage to taking the pills. Sometimes the period is so short and light that you don’t even notice you had one and then you wonder if you are pregnant. Usually when someone stops their pills because they think they might be pregnant, they soon get that way. Before stopping the pills, check a pregnancy test. Usually the dose of hormones that your body gets from the pills is just too low to cause a period. It is sort of like having a lawn. Normally if there has been enough rain when you cut the grass there are a bunch of clippings. If you don’t water the grass when you cut it there are no clippings in the bag. This is like your uterus and a very low dose of estrogen. This can occur even after many years on the pills. Some people may find that it is more likely to happen at certain seasons of the year. It is harmless unless you let it make you stop your pills and then accidentally get pregnant.

Of course pregnancy is a caused of missed periods and should not be forgotten. If you miss a period--get a pregnancy test. Most of them are now positive as little as 10 days after conception. That is even before you miss a period.

If you have irregular periods, either infrequent or too frequent, you should go to a doctor to find out what is going on. Most often it is just maturational, which is to say that it will get normal with time. But don’t forget that there are a few conditions that may lead to problems if neglected. Usually the treatment for irregular periods will be BCP’s but it is necessary to make a diagnosis first. In some few cases this may be truly lifesaving, if we find a large ovarian cyst or one of the very rare but unpleasant ovarian cancers. But even with PCO disease, making the diagnosis and starting treatment early helps avoid a lot of complications and potential problems.

Heavy and Painful Periods:

Periods that are a problem because of pain or heavy flow may stem from structural problems in the uterus. Two of the more common causes are fibroids and adenomyosis. Fibroids, sometimes called myomas or leiomyomas are muscle growth in the uterus. They may be in the uterine cavity, in the muscle of the uterus or just under the outer surface of the uterus. They may cause cramps, heavy bleeding, and pressure against other organs, pain with intercourse, or a feeling of heaviness in the pelvis that may be unbearable. They may interfere with pregnancy. As much as half of the time however, they cause no problems at all and a person doesn’t even know she has them. Fibroids may be diagnosed by exam or by an ultrasound. The choices for treatment are 1. Waiting for menopause, when they begin to shrink. 2. Removing just the fibroid. 3. Removing the uterus. 4. Sometimes medicines, such as Lupron, may be used but the effect is usually temporary. Adenomyosis is when the lining tissue of the uterus, the part that produces the period, burrows down into the muscle of the uterus. When the period occurs then in addition to the normal flow, some of the bleeding takes place into the uterine muscle. This is like a deep and painful bruise. It may make the flow heavier. This condition is difficult to diagnose without removing the uterus but MRI or ultrasound may help. Most often the problem is heavy, painful periods that don’t improve with medicines and at hysterectomy the diagnosis is made.

Pain may be due to endometriosis. Endometriosis is when the lining tissue of the uterus is found outside of the uterus, usually in the pelvis or around the ovaries. When the normal period occurs, the "exiled" tissue bleeds. The menstrual fluid is very irritating to the internal organs and can cause severe pain. Scarring, adhesions and cysts from endometriosis may cause persistent pain and pain with intercourse. The treatment for endometriosis is either surgical: remove the endometriosis, or medical: surpress the endometriosis with Lupron or hormones. Sometimes hysterectomy with or without removal of the ovaries is the only solution. 

Scar tissue in the pelvis from previous surgery or infection may cause pain with the period or during intercourse, if it interferes with the movement of the uterus.

Sometimes the problem isn’t structural. Even looking inside surgically and examining the uterus and ovaries doesn’t give a diagnosis. We can then call the problem "functional" but it doesn’t much matter to the sufferer. Sometimes there just is no obvious reason for the problem. That does not mean that the problem doesn’t exist, just that doctors aren’t smart enough to understand it. Even if there is no evident cause for very heavy or painful periods the treatment may be the same. 1. Medical: BCP’s or other hormones. NSAID’s like ibuprofen, or naprosyn The Mirena IUD may prove to be usefull in improving problem periods. 2. Minor or conservative surgery: removing fibroids, or destroying the uterine lining. 3. Major surgery: Plucking out the offending organ, sometimes called hysterectomy. The severity of the problem, your age, reproductive plans, and general medical condition will influence your choices.