Period Problems

Let’s dive headlong into the girliest of all girly issues. “Period problems” are a very common women’s health issue at Perimenopause.

What’s “Normal”?

Firstly, how do you know if your periods are “normal”? Generally speaking girls begin menstruating at age 9 to 15 (menarche) and have their last period (menopause) at age 45 to 55 (average age 51). There is a lot of variation amongst healthy women but it would be wise to consult your doctor if you fall greatly outside these ranges. Around menarche (when your periods first start) and menopause (when they end) it can be normal to experience a lot of irregularity in bleeding patterns, which usually settles into a somewhat regular cycle of 21-35 days when a woman is ovulating regularly.

A good place to start when trying to work out what’s normal for you is to track your periods and symptoms. This can be as simple as keeping a diary or calendar with big red X’s to mark your bleeding days, or you can get really fancy and use one of the many period-tracking Apps that are available. Whatever you use, that information will be really valuable in helping you and your GP work out what’s going on.

If you have symptoms like pain or heavy bleeding try to keep track of the severity or amount using some sort of rating scale, eg. scoring the pain out of 10, or noting the number of soaked super tampons used per day. It would also be really helpful to know your family’s menstrual and gynaecological history. A history of painful or irregular periods, infertility, early menopause, or diagnoses like endometriosis in close female relatives may increase your risk of having certain conditions.

If have some kind of abnormality with your periods it can be overwhelming to sift through the huge range of possible causes. It helps to narrow it down by category, such as whether the problem relates to the frequency or regularity of bleeding, amount of bleeding or pain.

Problems with the Frequency of Bleeding

Amenorrhea (no periods):  This can be either primary, meaning that you have never gotten a period, or secondary, meaning your periods stopped after a while. An important cause to rule out here is PREGNANCY, so if you think this might be at all possible you should buy a pee-test immediately. Other possible causes include polycystic ovarian syndrome (PCOS), genetic conditions, abnormalities of the uterus or cervix and a range of hormonal disorders. Basically, if you’re not having periods by age 16 you need to see a doctor for investigations.

Polymenorrhea (too-frequent periods): ie. the cycle is shorter than 21 days. This may occur normally at menarche or menopause, but it is important (and sometimes difficult) to establish whether it is truly a short cycle (in which ovulation has occurred), or whether there’s bleeding from another cause occurring between periods (intermenstrual bleeding). Causes may include stress or psychological disturbance, endometriosis, STI’s, hormonal abnormalities, use of hormonal contraceptives, malnutrition or (rarely) cancer. Women with very frequent periods should be assessed by a doctor, and consider getting your iron level checked particularly if you are excessively tired or breathless.

Oligomenorrhea (infrequent and/ or irregular periods):  This can also be classified as primary or secondary depending on whether it started early after menarche or later, and also occurs commonly at menarche or menopause. Other possible causes include: PCOS; genetic or hormonal disorders including diabetes and thyroid problems; cervical or uterine abnormalities; use of hormonal contraceptives; eating disorders, overexercising, underweight or malnourishment;stress or psychological disturbance; some medications, and pregnancy. Again, this is one that should be assessed by your doctor.

Problems with the Amount of bleeding

Usually the problem here is too much bleeding, known as menorrhagia (I don’t think I’ve ever had someone complain that their periods were too light!). This can be devastating for some women, preventing them from leaving the house or participating in activities for fear of “flooding”. Often it causes iron-deficiency anaemia through severe blood loss, leaving women feeling exhausted or breathless.

Menorrhagia is more common in older women due to irregular ovulations as they approach menopause (dysfunctional uterine bleeding) but other causes include: fibroids (benign growths in the uterus); adenomyosis (like endometriosis within the wall of the uterus); thyroid disorders; endometrial hyperplasia (overgrowth of the uterine lining); blood clotting problems; medications; pregnancy complications and (rarely) cancer.

What Treatments are there for Heavy Periods?

Your GP can arrange investigations to work out the underlying cause, and then make the appropriate treatment recommendations or refer to a specialist. There are lots of treatments that can be offered to help reduce the bleeding:

• Non-steroidal anti-inflammatory drugs (NSAID’s, like naproxen or ibuprofen). When started at period onset, used regularly and at maximum dosing for several days, they can reduce blood flow and period pain significantly. Always take them with food.
• Other medications to reduce blood flow, eg. tranexamic acid or progestins.
• The pill, which reduces blood flow and can allow “period skipping”.
• Implanon, depo injections or the Mirena intrauterine device. These are all hormonal contraceptives which can reduce bleeding, although Mirena will do this most reliably and Implanon may make bleeding more frequent for some users.
• Endometrial ablation, ie. the lining of the uterus is cauterised by a specialist (Gynae).
• Other gynaecological procedures may be useful, eg. fibroid removal.
• Hysterectomy. This is usually the last-ditch option but may be appropriate for women who have completed their family or not responded to other treatments.

Painful Periods

Period pain (dysmenorrhea) is very common. In fact, a study undertaken in Canberra of over 1000 schoolgirls aged 15-19 found that 93% had painful periods. 21% of these had severe period pain and 26% missed school.  Generally speaking, a doctor should be consulted if period pain causes distress or inability to attend school or other activities.

Period pain that starts within the few years after menarche is called primary dysmenorrhea and is less likely to be due to an underlying gynaecological condition. It is very reasonable to try NSAID’s for this type of period pain, used exactly as described above for menorrhagia, ie. early, hard and often. Your GP can offer other treatment options if this doesn’t work. Secondary dysmenorrhea occurs in women who are older and previously had minimal or no period pain; this is more likely to be related to some underlying gynaecological disorder.

Endometriosis can be a cause of significant period and pelvic pain. This is more likely if pelvic pain occurs outside the first two days of the period or doesn’t get better on treatments like the pill or NSAID’s. According to Endometriosis Australia, up to 70% of girls who continue to have pain on the pill will have endometriosis. Adenomyosis is a related condition that can also cause severe period pain. Other causes of pelvic pain include fibroids, ovarian cysts, infections, copper IUD’s and non-gynaecological pelvic pain (eg. bowel pain, UTI’s).

Whatever your menstrual issue, it pays to be well-informed and know when it’s time to see your doctor. Some of my favourite resources on this are:

• Jean Hailes for Women’s Health
• Healthdirect
• Women’s Health Queensland: A great primer about how the menstrual cycle works.
• Better Health Channel

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