Every woman’s cycle is different, but a “textbook” menstrual cycle occurs monthly (typically 28 days). The menstrual cycle begins on day 1 of the period and can be broken into two phases; the follicular and the luteal phase. The Follicular phase is the first part of the cycle and happens between the days of 1-14. This part prepares an egg to be released from the ovary and builds the lining of the uterus. The luteal phase which is the second half, occurs after ovulation, between days 15-28 of a 28-day cycle. This part of the cycle prepares the uterus and body to accept a fertilised egg or to start the next cycle if pregnancy doesn’t happen. These changes occur throughout the cycle due to a rise and fall of sex hormones.
As we said, not many people have a textbook cycle, and there are lots of things that can go wrong with your period – it may disappear (Amenorrhoea), it may become irregular (Oligomenorrhea), it may be extremely heavy (Menorrhagia ), it may be very painful (Dysmenorrhoea) or you may bleed when you shouldn’t (e.g. between your periods, after sex, and after the menopause). In this article, we are going to cover abnormal signs and symptoms which we shouldn’t accept as just part and parcel of having a period.
No.1: Very heavy periods
Very heavy periods, otherwise known as menorrhagia (1) can be a very common symptom. You might be wondering how much is too much and it can be very difficult to quantify how much bleeding is ‘too much’. Technically it is defined as blood loss of 80ml or more (about half a teacup full) and/or lasts for more than 7 days (2). But I’m sure you will agree that it’s not exactly easy to measure how much blood you’ve actually lost and, even so, some women have their period for 7 days but it isn’t significantly heavy nor does it disrupt their quality of life.
So here are some things to consider:
- Do you use more than one type of sanitary product? E.g. tampon and sanitary towel?
- Do you have to change a sanitary towel very often? (every 1-2 hours)
- Do you experience ‘flooding’, where you bleed through to your clothes or bedding?
- Blood clots larger than the size of a 10p coin
- If you bleed for more than 7 days
- If your bleeding is impacting your energy levels or you feel short of breath
- If your bleeding is interfering with your quality of life (physically, emotionally or socially).
There are several causes of heavy periods. It may be normal for you, or you may have an occasional heavy cycle, which again, may be normal.
Bleeding may be heavy due to conditions such as fibroids, endometriosis, thyroid disease, stress, polycystic ovarian syndrome and certain medication e.g. anticoagulants.
If you have symptoms that you are losing a lot of blood such as feeling fatigued or short of breath, you should speak to a doctor without delay.
Heavy periods may be treated with medication e.g. hormonal contraception or tranexamic acid, a coil (e.g. the Mirena coil), anti-inflammatory medications, and in some cases, surgery may be required.
Are you concerned about having heavy periods? The NHS have a questionnaire https://www.nhs.uk/conditions/heavy-periods/ which can help you to understand how heavy your bleeding is.
No.2: Irregular or absent periods
It’s very common for women to experience a missed period at some point in their reproductive life. Periods can also be infrequent and erratic – particularly during stressful periods of our lives. That’s okay and usually nothing to worry about, however, if it continues to happen consecutively over a few months – that’s when you should go see your doctor.
Amenorrhoea (absent periods) is considered primary (never had a period by the time of expected puberty – usually by 15 years of age) or secondary (previously had a period but has now stopped for 3-6 months consecutively). Oligomenorrhea is the term for infrequent or irregular periods – occurring less frequently than every 35 days or less than 6-8 periods per year. There is considerable overlap between secondary amenorrhoea and oligomenorrhoea so we will discuss them together.
When a woman first has periods or is approaching the menopause, it is common for periods to be irregular for a period of time (5).
If you are late expecting your period, the first thing to do is to take a pregnancy test if there is any risk of pregnancy. Do keep in mind that no contraceptive is 100% effective, and hence this is important to check before seeing your doctor.
Your periods may become irregular or absent with hormonal contraception such as contraceptive pills, or hormonal coil (Mirena).
If you are going through a period of stress, you may have a delayed or absent period. This also includes things such as excessive exercise, restrictive dieting, rapid weight loss, or low BMI, which your body may perceive as stress.
Medical conditions such as thyroid disease or polycystic ovarian syndrome may also cause irregular or absent cycles.
If you have not had a period for more than 3 months, you should speak to your GP. They will be able to ask questions and examine you to help to determine what the cause may be.
- Concerns about becoming pregnant with irregular cycles
- Bleed for longer than 7 days
- Have a period more frequently than every 21 days
- Or have significant changes between cycles
No.3: Bleeding between periods, after sex or after the menopause
Bleeding in between your periods, after sex or after the menopause should generally warrant a discussion with your doctor (5).
Hormonal contraceptives may disrupt bleeding, this includes emergency contraception (the morning-after pill), so this is less of a cause for concern.
Bleeding between periods (inter-menstrual bleeding)
Bleeding between your periods can be due to many reasons including;
- Ovulation spotting
- Early pregnancy
- Hormonal fluctuations during the perimenopause
- Missed oral contraception or breakthrough bleeding
- Physical conditions (such as fibroids and polyps) and infections.
- Vaginal dryness
- PCOS
- Cancer
Bleeding after sex (post-coital bleeding)
Some people may experience spotting after their first time having sex, which is normal, however, consistently spotting after penetrative vaginal sex is not considered normal and is something to always speak to your doctor about. This may be due to trauma, vaginal dryness, infection or changes to your cervix.
Bleeding after the menopause (post-menopausal bleeding)
Although changes in bleeding are to be expected during perimenopause, if you experience bleeding after you’ve gone through the menopause (so bleeding 12 months after your last period) you should arrange an appointment with your doctor to be investigated. Although most cases are found to be benign, cancer of the womb should be ruled out promptly.
If you have any of these symptoms, you should speak to your doctor. They may examine you, screen for sexual infection, visualise your cervix and arrange an ultrasound scan depending on your symptoms.
No.4: Very painful periods
It is very common to experience some discomfort and cramping the days before and during your period. Although this is often mild, for some women the pain is so severe that it stops them from doing their normal day-to-day activities and causes them to miss work or school.
Painful periods, otherwise known as dysmenorrheoa (6), may have several causes. It is not clear why some women may experience more period pain than others. During a period, your uterus produces a chemical called prostaglandin which increases the contractions of the uterus and hence increases pain.
There are several causes of painful periods such as endometriosis, adenomyosis, fibroids and pelvic inflammatory disease.
When it comes to your health, you should not feel like you need to tolerate anything which is painful or abnormal for you. There are many treatment options available.
Summary
Every woman is different, if you notice a change from your normal cycle, abnormal bleeding or abnormal pain, do consult a healthcare professional.
It is important to ensure that you look after your female health, and that may include tracking your periods to help notice changes, and ensuring that checks such as regular sexual health screening and smear tests are carried out.
