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What Causes Irregular Periods


While heart rate, blood pressure, respiratory rate, and body temperature have always been markers of health, for women, there is now a fifth way to determine their wellbeing. The American College of Obstetrics and Gynecology recommends menstruation as a way to monitor women’s health as it requires two important brain glands, the hypothalamus and pituitary, as well as the ovaries, uterus, and fallopian tubes to all function well.

While menstruation’s symptoms, such as changes in hormones, energy levels, and the gastrointestinal system, often feel like they’re wreaking havoc on the body, a woman’s monthly flow is an indicator of healthy hormone levels and properly functioning glands that enable ovulation to occur.

The menstrual flow process

For monthly menstruation to occur, with cycles typically ranging from every 21 to 35 days, the uterus, ovaries, hypothalamus, and pituitary glands must be functioning well.

For menstruation and ovulation to happen, the following must take place:

  • The hypothalamus starts the process by signaling the pituitary gland to make two hormones: follicle-stimulating hormone (FSH) and luteinizing hormone (LH). FSH lets the ovaries know it’s time to begin making an egg sac, called a follicle.
  • The ovaries produce estrogen, progesterone, and testosterone.
  • Estrogen levels rise leading up to ovulation. If an egg isn’t fertilized, estrogen levels drop.
  • Estrogen levels decreasing cause the uterus to shed its lining.
  • Once the lining sheds, hormones increase again, re-starting the monthly process.

Monthly menstruation means you are probably not pregnant, you can probably get pregnant, premenstrual symptoms go away and you are not in menopause.

Signs of menstrual irregularities

There are several indications that there may be issues with one's menstrual cycle. If you are experiencing any of the following, it’s important to speak with your doctor.

  • No menstruation by three years after breast development.
  • No menstruation by 14 accompanied by abnormal face hair growth.
  • No menstruation by 14, and signs of under-eating or over-excising are present.
  • No menstruation by 15.
  • Menstrual flow occurs more frequently than every 21 days or less frequently than every 45 days.
  • Delay of menstrual flow by 90 days.
  • Menstrual flow lasts longer than 7 days.
  • Heavy menstrual flow, requiring a new pad or tampon every 1 to 2 hours.
  • Heavy menstrual flow accompanied by frequent bruising or family history of excessive bleeding.

A new menstrual disorder classification list, called PALM-COEIN, has been approved by The International Federation of Gynecology and Obstetrics and supported by the American College of Obstetrics and Gynecology.

The name PALM-COEIN represents the following menstrual disorders:

  • Polyps
  • Adenomyosis
  • Leiomyoma
  • Malignancy and hyperplasia
  • Coagulopathy
  • Ovulatory dysfunction
  • Endometrial
  • Iatrogenic
  • Not yet classified

Conditions affecting menstruation

Proper hormone levels are crucial to a regular menstrual flow. The following conditions or factors can cause hormonal imbalances, leading to a delayed or halted menstrual cycle:

  • Lack of ovulation or anovulation
  • Excess body weight
  • Low body weight due to eating disorders, such as anorexia nervosa
  • Stress
  • Excessive exercise
  • Medications, such as birth control pills, steroids, and chemotherapy
  • Pituitary growths
  • Lack of sleep
  • Pelvic infections, such as sexually transmitted diseases
  • Bleeding or clotting disorders
  • Thyroid disease
  • Uterine growths or fibroids
  • Radiation exposure
  • Polycystic Ovarian Syndrome
  • Adrenal diseases

Leading causes of menstrual flow disruptions

No ovulation

  • Lack of ovulation occurs when an ovary egg sac doesn't release an egg.
  • When no egg sac is present, the ovaries don't produce progesterone.
  • Too much estrogen and no progesterone causes the uterine lining to grow unevenly with fragile blood vessels.
  • Once the lining outgrows its blood supply, the uterus sheds the lining sporadically and unpredictably. Heavy and prolonged bleeding follows.
  • A lack of bleeding can also halt ovulation, resulting from too much progesterone and not enough estrogen.
  • Taking contraceptives also halts ovulation and can lead to menstrual flow lightening or stopping.

Polycystic Ovarian Syndrome (PCOS)

There are two categories of PCOS based on the presence of insulin levels. Even more specific, there are five types of PCOS based on insulin resistance and androgen levels. The five categories are:

  1. Insulin-Resistance PCOS (Type 1 PCOS): Causes ovulatory dysfunction. Insulin resistance. Elevated testosterone levels.
  2. Non-insulin Resistance PCOS (Type II PCOS): Causes ovulatory dysfunction. Elevated testosterone levels.
  3. Non-traditional PCOS I: Causes ovulatory dysfunction. Insulin resistance.
  4. Non-traditional PCOS II: Insulin resistance. Elevated testosterone levels.
  5. Idiopathic Hirsutism: Elevated testosterone levels.

PCOS symptoms include:

  • Excessive hair growth on the face, chest, stomach, and back
  • Irregular or absent periods
  • Acne
  • Ovarian cysts
  • Excessive weight in the abdomen
  • Pelvic pain
  • Brown patches of skin on the underarms, groin, and inner thigh
  • Sleep apnea
  • Infertility
  • Glucose intolerance

For women experiencing any of the above symptoms, speak with your doctor as they can perform the following tests to determine whether PCOS is present:

  • Fasting insulin and fasting glucose levels
  • Serum androgens (testosterone, DHEA, androstenedione)
  • Thyroid panel (TSH, T4, T3)
  • Zinc tally test
  • Urine iodine and selenium
  • 25-OH vitamin D
  • Adrenal Stress Panel
  1. Bleeding disorders

Bleeding disorders such as Von Willebrand’s disease and Factor VIII deficiency can cause heavy menstrual flow lasting longer than 7 days.

  1. Polyps

Polyps are benign growths that can cause menstrual flow disruptions. They grow on the uterus lining or cervical canal.

  1. Cancer

Estrogen-secreting tumors or advanced cervical cancer may lead to menstrual flow disruptions. Uterine cancer is most likely to affect the morbidly obese or women 50 and older, but can also occur in those who are younger.

Next steps

If you are experiencing issues with your menstrual flow, discuss them with your healthcare professional. A doctor can determine the cause of the problems and a treatment plan.

References:

ACOG Committee Opinion No. 651: Menstruation in girls and adolescents: Using the menstrual cycle as a vital sign. Obstet Gynecol. 2015 Dec. 126 (6):e143-6.

Cleveland Clinic (2019). Abnormal Menstruation (Periods).

Kadir RA, Economides DL, Sabin CA, Owens D, & Lee CA. Frequency of inherited bleeding disorders in women with menorrhagia. Lancet. 1998 Feb 14. 351 (9101):485-9.

Marshall WA, Tanner JM. Variations in pattern of pubertal changes in girls. Arch Dis Child. 1969 Jun. 44(235):291-303.

Munro MG, Critchley HO, Broder MS, Fraser IS. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet. 2011 Apr. 113(1):3-13.

Munro MG, Critchley HOD, Fraser IS, & FIGO Menstrual Disorders Committee. The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. Int J Gynaecol Obstet. 2018 Dec. 143 (3):393-408.

Ragni MV, Bontempo FA, & Hassett AC. von Willebrand disease and bleeding in women. Haemophilia. 1999 Sep. 5 (5):313-7.

Shankar M, Lee CA, Sabin CA, Economides DL, & Kadir RA. von Willebrand disease in women with menorrhagia: a systematic review. BJOG. 2004 Jul. 111 (7):734-40.

Werner EJ, Broxson EH, Tucker EL, Giroux DS, Shults J, & Abshire TC. Prevalence of von Willebrand disease in children: a multiethnic study. J Pediatr. 1993 Dec. 123 (6):893-8.

World Health Organization. Longitudinal study of menstrual patterns in the early postmenarcheal period, duration of bleeding episodes and menstrual cycles. World Health Organization Task Force on Adolescent Reproductive Health. J Adolesc Health Care. 1986 Jul. 7 (4):236-44.

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