Irregular Periods
When a woman moves from regular menstruation to peri-menopause, the first symptom she normally notices is irregular periods. When your monthly cycle changes, bleeding may become heavier and more frequent (closer intervals and unpredictable occurrences). You may experience premenstrual syndrome (PMS) that is worse than normal. This may seem counter-intuitive (aren’t my periods supposed to end?!) but it is completely normal. Once you get closer to Menopause (the cessation of menstruation) you will likely experience increased irregularities ranging from shorter cycles, (very) unpredictable cycle duration, (abnormally) heavy and/or prolonged bleeding and worsened PMS.
90% of women have experienced periods lasting longer than ten days
A key study concluded that, among women ages 42 - 52, more than 90% had experienced periods lasting longer than 10 days. In the same study 78% of women reported having blood flow that was “heavy.” Although these changes are disconcerting, particularly for women who have experienced a lifetime of predictable menstrual cycles, it is normal and common. Treatment for period irregularity consists of practical lifestyle coping actions, prescription medications, and, in severe cases, surgery.
Why is this happening?
A woman’s monthly menstrual cycle is controlled by the release of estrogen and progesterone, as well as luteinizing and follicle-stimulating hormones. Estrogen promotes the thickening of the lining to the uterus (endometrium) and progesterone controls the depths of the lining created and its interaction with a fertilized egg during pregnancy. During menopause, estrogen levels drop and progesterone reacts, as the normal monthly uterine cycle is altered. Experiencing irregular periods is a sign of this hormonal imbalance and the trigger effect of lowered estrogen production.
When a woman experiences heavier-than-normal bleeding, her estrogen level can be high in comparison to her progesterone level. These factors contribute to your uterine lining building up and can lead to heavier periods (when pregnancy does not occur and progesterone acts). Abnormal, heavy periods are given the medical term, “menorrhagia.” For many women, the condition of heavy periods or clinical menorrhagia results in discomfort during their normal, daily activities and, particularly, when they exercise.
For most women her menstrual cycle will become very irregular close to the end of peri-menopause
Due to the absence of regular ovulation (luteinizing hormone-initiated activity), your menstrual cycle becomes very irregular close to the end of peri-menopause. Prior to your final period, your cycle will be characterized by long intervals between periods and unpredictable frequency. At different times, you may experience lighter-than-normal periods due to changes in the thickness of the uterine lining growth as well.
When to speak to your doctor
An irregular period, meaning the disruption of your ovulation, can have many causes other than the onset of peri-menopause. Thyroid and prolactin abnormalities, PCOS, Endometriosis, Pelvic inflammatory disease, undernourishment and extreme stress are just a few. In the peri-menopause age group, endometrial hyperplasia - an irregular thickening of the lining of the uterus - and polyps are important to identify. Some types of endometrial hyperplasia are associated with an increased risk of uterine cancer. So regardless of your age please speak to your doctor if your periods are interfering with your daily activities or if you notice the following patterns:
- spotting or bleeding between menstrual periods, or a sense that your period isn’t ending
- menstrual cycles that are less than 21 days in length
- you have not experienced a period for three months or more
- if you are post menopausal and you are experiencing any bleeding
- soaked pads or tampons hourly for several consecutive hours
- the need to wake up during the night to change your sanitary protection
- bleeding for longer than 7 days
- passing blood clots larger than 2.5cm
If you are experiencing any of the symptoms above, it is likely that you have progressed into the peri-menopausal phase. It is important that you seek medical care, to eliminate any other medical cause or concern regarding your symptoms. Fortunately, there is excellent help available, with treatment options and a wealth of quality information.
Surgery
If your condition of menorrhagia does not respond to other, lesser treatment options, surgery may be advised. Surgeries related to abnormal vaginal bleeding are:
- Uterine artery ablation
- Hysteroscopy
- Ultrasound-guided fibroid removal
- Myomectomy (fibroid removal)
- Hysterectomy (removal of the uterus)
Although surgical procedures were more common in the past, medical technology, research, and treatment options have improved and surgery is considered a “last resort” option. You are not at greater risk for surgery when you speak to a healthcare professional, and it is important to receive a full and accurate diagnosis in order to ensure undiagnosed conditions are not present.
Other impacted areas
Excessive vaginal blood loss (Menorrhagia) can lead to iron deficiency and clinical anemia. You may need to receive prescription treatment for anemia, as well as treatment of associated menorrhagia symptoms.
Diagnosis
A doctor will assess your menstrual pattern, changes to the pattern, level of blood loss, and clotting or other issues you have noticed. It will be helpful to your doctor if you track your periods on an app such as Clue or to make notes regarding their frequency and intensity for this purpose.
In order to eliminate other possible causes for changes in your menstrual pattern, your healthcare provider will likely do a physical examination (potentially including a pelvic exam), and may ask for blood work, a PAP test, Endometrial ultrasound and/ or other routine testing.
Possible triggers or risk factors
There are no direct triggers or risk factors that externally influence heavy or irregular periods.
Want to speak with a Menopause doctor?
Treatments & remedies
Treatment depends on the underlying cause and severity but is generally focussed on symptom management or regulation of the menstrual cycle through hormone treatment. Surgical options are available but are a last resort.
At every stage in a woman’s life, living a healthy lifestyle is important. When it comes to irregular periods there are a few lifestyle strategies that can help make it more bearable either in terms of frequency irregularity and/or the heaviness of your flow. It won’t completely solve the problem, but as they're relatively simple to implement and certainly won’t make it worse, it is worth a shot right?
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Nutrition
When it comes to irregular periods your weight and diet can have a big impact. Having a (very) low body weight and BMI, training like a professional athlete, and/or are eating disorders can all result in something that’s called “Relative Energy Deficiency Syndrome” which frequently causes irregular or absence of menstruation all together. Maintaining a healthy weight is always important of course, but especially so when your body is going through a major transformation that menopause is.
The optimal diet for peri-menopause and maintaining a healthy weight focuses on the principles of the Mediterranean diet. This diet focuses on whole grains, fruits, vegetables, seafood, beans, and nuts.
Exercise
At every stage in a woman’s life, living a healthy lifestyle is important. When it comes to irregular periods there are a few lifestyle strategies that can help make it more bearable either in terms of frequency irregularity and/or the heaviness of your flow. It won’t completely solve the problem, but as they're relatively simple to implement and certainly won’t make it worse, it is worth a shot right?
Mindset
Stress essentially makes everything worse, and when it comes to your menstrual cycle it can lead to irregular, more painful or heavier periods. Stress works differently for everyone and there is no one answer to how to reduce stress in your life. But have a critical look at your life, identify stressors and try to reduce that as much as you can. Improving your sleeping also tends to make people experience less stress. .
Supplements
- Ginger and Vitex (Chasteberry) are sometimes recommended for dietary supplementation and relief of heavy menstrual bleeding. Ginger and Vitex have both performed well in clinical studies and may provide a decrease in blood loss.
- Following diagnostic assessment, it is possible that your doctor will advise a daily multivitamin (folic acid, Vitamin C, Vitamin B12, etc.) to ensure healthy red blood cell maintenance.
- As well, in cases of heavy bleeding and the presence of anemia, you may need to take iron supplements until your blood tests stabilize.
OTC Products
- If your menstrual cycle includes cramping, ibuprofen is a common over-the-counter medication women find effective for pain relief. If you have been using OTC solutions for a prolonged period of time, it is important to consult with a doctor regarding your symptoms, to ensure that you receive an accurate diagnosis and the most effective treatment available.
- If you are experiencing heavy bleeding, absorbent period underwear is also effective for additional protection against leakage by doubling it with a pad or tampon. Absorbent period underwear looks just like normal underwear, and can be used as daily protection against the sudden onset of an irregular period as well.
Prescription
Tranexamic acid is an antifibrinolytic that controls bleeding by helping blood to clot. It is an effective non-hormonal, prescription treatment that reduces bleeding and is especially effective for those suffering from heavy menstrual periods, irregular peri-menopausal periods, it can prevent monthly bleeding.
Hormone Treatment
- The effects of HRT treatment on symptoms of irregular bleeding require careful treatment planning with your healthcare professional. It is possible that estrogen replacement will be combined with progestin, to ensure the maximum long-term hormone replacement benefits. Sequential progesterone can be prescribed for women suffering from heavy periods, as the supplementation of progesterone may create lighter or more regular menstruation. During times of menopausal estrogen spiking (causing heavy bleeding), progesterone can offset estrogen’s effects.
- Low-dose oral contraceptives are a hormonal-adjustment alternative that allows you to control the regularity of your menstrual cycle. It can be used to avoid menstruation altogether, eliminating the concern of heavy or highly unpredictable bleeding.
- Hormonal IUDs (intrauterine devices) such as Mirena is frequently used for this purpose. If you have irregular bleeding and are not seeking pregnancy, low-dose birth control pills or an IUD may provide a well-rounded solution. By suppressing ovulation, your menstrual flow will be regulated and the effects of endometriosis, if present, are also stabilized. Low-dose oral contraceptives are known to protect women against endometrial and ovarian cancers, stave off hot flashes, reduce vaginal dryness, and prevent bone loss.
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FAQ
What are the symptoms of Menopause?
There are roughly 34 symptoms of Menopause with the most commonly experienced being:
- Irregular periods
- Vaginal dryness
- Hot flashes
- Night sweats
- Fatigue
- Sleep problems
- Mood changes and irritability
- Weight gain
- Thinning hair and dry skin
Medically reviewed and detailed symptom fact sheets can be found here, and a general overview of what (peri) menopause is and entails can be found here.
What is the average age of Menopause?
The average age for menopause in Asian women (including women in Singapore) is 50 - 52. The onset of peri-menopause is usually in a women's mid 40s, with 3.7% of women experiencing it before the age of 30.
What are the symptoms of Menopause?
There are 34 different symptoms associated with the Menopause transition impacting women on a mental, emotional and physical level. Symptoms range from the well known Hot Flashes & Night sweats, to depression, anxiety and a dry itchy skin. For and overview of all symptoms and detailed symptoms fact sheets please click here.
Do men get Menopause?
The short answer is No. “Male Menopause” or “andropause” are terms that are being used by the media, but have no medical basis. Testosterone levels in men do decline as they age, but this is a very gradual process at less than 2% per year starting from their 30s/40s. There is no sudden drop in Testosterone around midlife causing severe symptoms as is the case with Menopause. In many cases the symptoms that are claimed to be part of “male menopause” have nothing to do with (a change in) hormones.
References
Berger, D., Schaffner, W., Schrader, E., Meier, B., & Brattström, A. (2000). Efficacy of Vitex agnus castus L. extract Ze 440 in patients with pre-menstrual syndrome (PMS). Archives of Gynecology and Obstetrics, 264(3), 150–153.
Bofill Rodriguez M, Lethaby A, Farquhar C. Non-steroidal anti-inflammatory drugs for heavy menstrual bleeding. Cochrane Database Syst Rev. 2019 Sep 19;9(9):CD000400. doi: 10.1002/14651858.CD000400.pub4. PMID: 31535715; PMCID: PMC6751587.
Chen, C. X., Barrett, B., & Kwekkeboom, K. L. (2016). Efficacy of Oral Ginger (Zingiber officinale) for Dysmenorrhea: A Systematic Review and Meta-Analysis. Evidence-Based Complementary and Alternative Medicine, 2016, 1–10.
Kashefi F, Khajehei M, Alavinia M, Golmakani E, Asili J. Effect of ginger (Zingiber officinale) on heavy menstrual bleeding: a placebo-controlled, randomized clinical trial. Phytother Res. 2015 Jan;29(1):114-9. doi: 10.1002/ptr.5235. Epub 2014 Oct 8. PMID: 25298352.
Menorrhagia (heavy menstrual bleeding) - Symptoms and causes. (2022, July 1). Mayo Clinic. link
Paramsothy, P., Harlow, S. D., Greendale, G. A., Gold, E. B., Crawford, S. L., Elliott, M. R., Lisabeth, L. D., & Randolph, J. F. (2014). Bleeding patterns during the menopausal transition in the multi-ethnic Study of Women’s Health Across the Nation (SWAN): a prospective cohort study. BJOG: An International Journal of Obstetrics & Gynaecology, 121(12), 1564–1573.
Irregular Periods
When a woman moves from regular menstruation to peri-menopause, the first symptom she normally notices is irregular periods. When your monthly cycle changes, bleeding may become heavier and more frequent (closer intervals and unpredictable occurrences). You may experience premenstrual syndrome (PMS) that is worse than normal. This may seem counter-intuitive (aren’t my periods supposed to end?!) but it is completely normal. Once you get closer to Menopause (the cessation of menstruation) you will likely experience increased irregularities ranging from shorter cycles, (very) unpredictable cycle duration, (abnormally) heavy and/or prolonged bleeding and worsened PMS.
90% of women have experienced periods lasting longer than ten days
A key study concluded that, among women ages 42 - 52, more than 90% had experienced periods lasting longer than 10 days. In the same study 78% of women reported having blood flow that was “heavy.” Although these changes are disconcerting, particularly for women who have experienced a lifetime of predictable menstrual cycles, it is normal and common. Treatment for period irregularity consists of practical lifestyle coping actions, prescription medications, and, in severe cases, surgery.
Dr. June Tan Sheren
Why this is happening
A woman’s monthly menstrual cycle is controlled by the release of estrogen and progesterone, as well as luteinizing and follicle-stimulating hormones. Estrogen promotes the thickening of the lining to the uterus (endometrium) and progesterone controls the depths of the lining created and its interaction with a fertilized egg during pregnancy. During menopause, estrogen levels drop and progesterone reacts, as the normal monthly uterine cycle is altered. Experiencing irregular periods is a sign of this hormonal imbalance and the trigger effect of lowered estrogen production.
When a woman experiences heavier-than-normal bleeding, her estrogen level can be high in comparison to her progesterone level. These factors contribute to your uterine lining building up and can lead to heavier periods (when pregnancy does not occur and progesterone acts). Abnormal, heavy periods are given the medical term, “menorrhagia.” For many women, the condition of heavy periods or clinical menorrhagia results in discomfort during their normal, daily activities and, particularly, when they exercise.
For most women her menstrual cycle will become very irregular close to the end of peri-menopause
Due to the absence of regular ovulation (luteinizing hormone-initiated activity), your menstrual cycle becomes very irregular close to the end of peri-menopause. Prior to your final period, your cycle will be characterized by long intervals between periods and unpredictable frequency. At different times, you may experience lighter-than-normal periods due to changes in the thickness of the uterine lining growth as well.
When to speak to your doctor
An irregular period, meaning the disruption of your ovulation, can have many causes other than the onset of peri-menopause. Thyroid and prolactin abnormalities, PCOS, Endometriosis, Pelvic inflammatory disease, undernourishment and extreme stress are just a few. In the peri-menopause age group, endometrial hyperplasia - an irregular thickening of the lining of the uterus - and polyps are important to identify. Some types of endometrial hyperplasia are associated with an increased risk of uterine cancer. So regardless of your age please speak to your doctor if your periods are interfering with your daily activities or if you notice the following patterns:
- spotting or bleeding between menstrual periods, or a sense that your period isn’t ending
- menstrual cycles that are less than 21 days in length
- you have not experienced a period for three months or more
- if you are post menopausal and you are experiencing any bleeding
- soaked pads or tampons hourly for several consecutive hours
- the need to wake up during the night to change your sanitary protection
- bleeding for longer than 7 days
- passing blood clots larger than 2.5cm
If you are experiencing any of the symptoms above, it is likely that you have progressed into the peri-menopausal phase. It is important that you seek medical care, to eliminate any other medical cause or concern regarding your symptoms. Fortunately, there is excellent help available, with treatment options and a wealth of quality information.
Surgery
If your condition of menorrhagia does not respond to other, lesser treatment options, surgery may be advised. Surgeries related to abnormal vaginal bleeding are:
- Uterine artery ablation
- Hysteroscopy
- Ultrasound-guided fibroid removal
- Myomectomy (fibroid removal)
- Hysterectomy (removal of the uterus)
Although surgical procedures were more common in the past, medical technology, research, and treatment options have improved and surgery is considered a “last resort” option. You are not at greater risk for surgery when you speak to a healthcare professional, and it is important to receive a full and accurate diagnosis in order to ensure undiagnosed conditions are not present.
Other impacted areas
Excessive vaginal blood loss (Menorrhagia) can lead to iron deficiency and clinical anemia. You may need to receive prescription treatment for anemia, as well as treatment of associated menorrhagia symptoms.
Diagnosis
A doctor will assess your menstrual pattern, changes to the pattern, level of blood loss, and clotting or other issues you have noticed. It will be helpful to your doctor if you track your periods on an app such as Clue or to make notes regarding their frequency and intensity for this purpose.
In order to eliminate other possible causes for changes in your menstrual pattern, your healthcare provider will likely do a physical examination (potentially including a pelvic exam), and may ask for blood work, a PAP test, Endometrial ultrasound and/ or other routine testing.
Possible triggers or risk factors
There are no direct triggers or risk factors that externally influence heavy or irregular periods.
Treatments & Remedies
Treatment depends on the underlying cause and severity but is generally focussed on symptom management or regulation of the menstrual cycle through hormone treatment. Surgical options are available but are a last resort.
At every stage in a woman’s life, living a healthy lifestyle is important. When it comes to irregular periods there are a few lifestyle strategies that can help make it more bearable either in terms of frequency irregularity and/or the heaviness of your flow. It won’t completely solve the problem, but as they're relatively simple to implement and certainly won’t make it worse, it is worth a shot right?
Products
- Ginger and Vitex (Chasteberry) are sometimes recommended for dietary supplementation and relief of heavy menstrual bleeding. Ginger and Vitex have both performed well in clinical studies and may provide a decrease in blood loss.
- Following diagnostic assessment, it is possible that your doctor will advise a daily multivitamin (folic acid, Vitamin C, Vitamin B12, etc.) to ensure healthy red blood cell maintenance.
- As well, in cases of heavy bleeding and the presence of anemia, you may need to take iron supplements until your blood tests stabilize.
- If your menstrual cycle includes cramping, ibuprofen is a common over-the-counter medication women find effective for pain relief. If you have been using OTC solutions for a prolonged period of time, it is important to consult with a doctor regarding your symptoms, to ensure that you receive an accurate diagnosis and the most effective treatment available.
- If you are experiencing heavy bleeding, absorbent period underwear is also effective for additional protection against leakage by doubling it with a pad or tampon. Absorbent period underwear looks just like normal underwear, and can be used as daily protection against the sudden onset of an irregular period as well.
Tranexamic acid is an antifibrinolytic that controls bleeding by helping blood to clot. It is an effective non-hormonal, prescription treatment that reduces bleeding and is especially effective for those suffering from heavy menstrual periods, irregular peri-menopausal periods, it can prevent monthly bleeding.
Lifestyle
When it comes to irregular periods your weight and diet can have a big impact. Having a (very) low body weight and BMI, training like a professional athlete, and/or are eating disorders can all result in something that’s called “Relative Energy Deficiency Syndrome” which frequently causes irregular or absence of menstruation all together. Maintaining a healthy weight is always important of course, but especially so when your body is going through a major transformation that menopause is.
The optimal diet for peri-menopause and maintaining a healthy weight focuses on the principles of the Mediterranean diet. This diet focuses on whole grains, fruits, vegetables, seafood, beans, and nuts.
At every stage in a woman’s life, living a healthy lifestyle is important. When it comes to irregular periods there are a few lifestyle strategies that can help make it more bearable either in terms of frequency irregularity and/or the heaviness of your flow. It won’t completely solve the problem, but as they're relatively simple to implement and certainly won’t make it worse, it is worth a shot right?
Stress essentially makes everything worse, and when it comes to your menstrual cycle it can lead to irregular, more painful or heavier periods. Stress works differently for everyone and there is no one answer to how to reduce stress in your life. But have a critical look at your life, identify stressors and try to reduce that as much as you can. Improving your sleeping also tends to make people experience less stress. .
Holistic
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