Pain, bleeding, and missed periods may be signs that something is wrong.
By Dulce Zamora
Reviewed By Brunilda Nazario
In her 20s, Theresa Lauigan experienced heavy bleeding and painful cramping during her menstrual cycle. Her doctor told her she had fibroids, noncancerous growths in her uterus, and termed it a "wait and see" situation. A few years later, when the menstrual pain became unbearable, Theresa pressed her doctor to further investigate the matter.
Turns out, she has endometriosis -- a gynecological condition in which the lining of the uterus, which is usually shed monthly, is present outside of the uterus. The condition is associated with chronic pelvic pain and can be associated with infertility.
Theresa has had two surgeries to take care of the problem.
Theresa's menstrual pain is now more manageable, but wishes the endometriosis was found earlier. Because of complications that developed, doctors say her ability to have children is impaired. Her best bet for pregnancy is in vitro fertilization within the next few years.
"If the endometriosis was found earlier, I might have planned my life better," says the 33-year-old, who urges women with severe menstrual problems to speak up. "If a woman feels like something is really going on (with her body), she should really push her doctor more on it."
Many women experience menstrual problems such as heavy bleeding, severe pain, and irregular cycles. Most of these problems aren't usually serious and most are temporary. However, in some cases the ailments may actually signal problems in the body.
"For a woman, the menstrual cycle is a really good indicator of her overall health status," says Saralyn Mark, MD, senior medical adviser for the Office on Women's Health, a division of the U.S. Department of Health and Human Services.
Women with eating disorders may not have periods. "The body senses that it's not a good time to get pregnant," says Mark.
WebMD compiled a list of common menstrual problems, and asked the experts whether they should be causes of concern for women.
But first, it's helpful to know what's considered "normal," and what women could do to help their doctor better pinpoint trouble.
The Healthy Zone
A regular menstrual cycle means different things to different women. Age, for example can affect what's described as a normal pattern. When adolescents first get their periods, they can expect irregular cycles for a year or two as sex hormones stabilize. The menstrual cycle becomes erratic again around the perimenopause. During this time, just before menopause, ovarian hormone levels begin to fluctuate. Woman again experience irregular cycles.
Yet between adolescence and perimenopause, women can expect to have regular monthly cycles. That is, of course, barring pregnancy, illness, medications, stress, and other problems (such as cysts) that may change the pattern.
It's also not uncommon to have a variation in one month.
Menstruation that occurs between 22 and 40 days apart falls within the norm, says Robert Shenken, MD, president of the American Society for Reproductive Medicine. The first day of the menstrual cycle is counted from the first day of vaginal bleeding.
The pattern, however, should not vary tremendously. "If a woman was having a 40-day cycle, and all of a sudden, she's having a 22-day cycle, that would be a concern," says Shenken. "The cycle links should be within plus or minus five days."
A significant change could be sign of a problem. Many experts interviewed by WebMD, say it's best to observe your periods over a three-month before becoming overly worried.
Menstrual bleeding time or an actual period, is usually two to eight days long, and anything outside of that is a cause of concern, says Shenken.
The best way to figure out if something is wrong is to visit a doctor, who can evaluate your symptoms.
Pinpointing Menstrual Trouble
Want to find out if something is wrong with your cycle? Do the work yourself. This does not mean diagnosing yourself, but keeping a menstrual diary helps.
"The hardest time to try to figure something out is when someone comes in and hasn't really tracked anything -- they know something's abnormal but they don't know how abnormal or when," says Roger Lobo, MD, a member of the Endocrine Society, and a professor and chair of the department of obstetrics and gynecology at Columbia University in New York. "The more detailed the information [you record], the better."
Some helpful things to note:
- How many days is it from the first day of one period to another?
- How long do your periods last?
- How heavy/light is the bleeding? What are the heaviest days in your cycle?
- Do you have spotting in between periods? If so, when? After sex?
- Do you have pain? Describe it. Where is it coming from? When does it occur?
- What are your other symptoms? Do you experience headaches, backaches, gastrointestinal problems, fatigue, or fainting spells? Do you have any unusual discharge?
- Are you taking any medications?
When consulting a doctor for a menstrual problem, it's important to report your medical history (if it's not already known), and family history of disease. Make sure to tell the physician what else is going on in your life. Sometimes emotional distress, diet, or exercise can affect the menstrual cycle.
Keeping track of your periods not only assists physicians, it can also help you determine what's normal and abnormal for your body. It could give you a clue if you're pregnant, when it's best to be more vigilant about contraception, when you're ovulating, or if you could be experiencing perimenopause.
"Nobody knows one's body more than the patient herself," says Mark, stressing the importance of being an educated consumer. "If it's a concern to you and you take the time to visit your physician, then that really needs to be looked at."
The relationship between patient and doctor should be a partnership, adds Mark. If your doctor isn't meeting your needs, it may be time to find one who will pay attention.
For menstruation-related issues, a doctor may do a physical exam including a pelvic exam, and a pregnancy test. Your pulse and other vital signs will be checked. You may be asked to provide a sample of your urine or blood. A physician may also order a vaginal ultrasound; this will help get a closer look at the uterus and ovaries.
The type of exam you will have depends on your symptoms, age, clues from your history and physical exam, and what your doctor thinks is appropriate for your situation.
Common Menstrual Problems
If you haven't had a period by age 16, you'll need to be evaluated by a doctor. Many things could be to blame including eating disorders, hormonal problems, excess stress or exercise, and undernutrition in a young teen. Other possible culprits could be a genetic disorder, ovarian tumors, ovary failure, poorly formed reproductive organs, or problems in the nervous system or pituitary gland which secrete hormones that trigger puberty.
On the other hand, if you've had a normal menstrual cycle, and you skipped a month, see a doctor. You may be pregnant.
"The first rule-out for no cycles in any woman during all of her years of menses always has to be pregnancy," says Nancy Church, MD, FACOG, an ob-gyn in private practice in Chicago.
After the possibility of pregnancy as the cause of a missed period is eliminated, the doctor may ask a few more questions to better determine the reason for an irregular or missed period. Possible causes include:
- Medication use, including birth control pills
- Poor nutrition, including eating disorders
- Extreme weight loss
- Ongoing illness
- Sudden weight gain or obesity
- Hormonal problems including thyroid disorders and polycystic ovary syndrome (PCOS)
Also keep in mind that it's not uncommon to skip one or two periods a year. If you miss one cycle, chances are your next one may be heavier. That's because the lack of a period may have led to a buildup of the uterine lining from the last month.
Missing more than two periods in a row is unhealthy. It can put you at risk for uterine cancer because of the excessive exposure to estrogen. On the other hand, missing a period from a lack of estrogen can increase the risk of osteoporosis.
Irregular periods may mean you are not ovulating properly. This can be of great concern to women trying to get pregnant.
Bleeding Between Periods
Spotting in between periods can be a sign of a problem, particularly if it happens for a prolonged duration. Vaginal spotting in girls who are less than 10 years old, during pregnancy, or after menopause should be evaluated.
Light bleeding between periods may mean the progesterone level in your body is not high enough. In people who use birth control pills, this can happen if they do not take pills at a regular time each day. Or it may mean that the dosage of birth control pills may need to be adjusted.
"Bleeding the week before your cycle means your progesterone is not high enough or your pill is not strong enough," says Church, who notes that it's best to consult a doctor about the matter.
Minor bleeding is also a common side effect of the contraceptive Depo-Provera. Other possible causes of abnormal vaginal bleeding include:
- Pregnancy problems
- Intraurine device (IUD) use
- Hormone irregularities due to an overactive thyroid, or diabetes
Heavy Bleeding, Prolonged Bleeding, and Clots
Each woman's assessment of her period varies. What is heavy or prolonged bleeding for one woman is normal for another. It's a good idea for women with prolonged bleeding, heavy bleeding, or excess clots to get checked for anemia.
Women with excess bleeding are prone to developing iron deficiency anemia.
If periods become heavier or thicker over time, there may be nothing to fret about as long as annual pelvic exams and biannual blood tests are performed. Talk to your doctor about ways to help prevent anemia or control excess or heavy bleeding.
It is normal for clots to come out with heavy menstruation. Blood can collect during sleep, and come out thicker in the morning. This is OK providing it doesn't happen for a long time, during pregnancy, or in between periods.
Women who are concerned about the thickness, heaviness, or length of their flow should see their doctors. Sometimes it helps to report how many pads or tampons you've used per hour or per day. Be aware, however, that perception of blood loss is highly subjective.
"The problem is that a woman's assessment of the amount of bleeding does not correlate real well with the amount of actual blood loss that they have," says Shenken. "Some women who complain of heavy menses actually have blood loss that's less than 60 milliliters, which is considered within a normal range."
Nonetheless, changing a full pad or tampon every hour is a warning sign of a problem.
Anytime you have a concern regarding heavy or prolonged bleeding, or clots, see your doctor. Possible causes include:
- Uterine Fibroids
- Uterine Cancer
- Reproductive problems such as endometriosis
- Hormonal imbalances including PCOS and thyroid problems
- Blood disorders such as van Willebrand's disease
- High doses of aspirin
- Contraceptive use, including IUD and hormonal birth control methods
Cramps are a part of many women's cycles. "We believe about 40% of adult women have menstrual pain, and about 10% are often very incapacitated for a few days each month," says Mark, noting it's one of the most common reasons why women miss work.
It is normal to feel dull or throbbing pain in the lower abdomen just before or during the first few days of a menstrual flow. This happens as contractions push out uterine lining if fertilization hasn't occurred.
Beyond normal menstrual pain, intense, prolonged, or unusual aches may signal the following problems:
- Pelvic inflammatory disease
- IUD use
- Uterine fibroids and uterine polyps
Menstrual pain becomes a concern when it becomes so severe that it disrupts a woman's day-to-day functioning. It can also be a concern if it happens one week or more before the start of a period, if it continues beyond the first few days of flow, or if it happens midcycle.
The prolonged use of painkillers is also a clue to a problem. "Some women may take them three days before the onset of their periods, and usually needing to continue to day two of the flow," says Mark. "If they're finding that they're having to do that for the whole week, the week before or the week after, that's something to be concerned about."
When consulting with a doctor, it helps to describe the type, severity, and radiation of pain.
Published March 14, 2005.
SOURCES: Theresa Lauigan. Saralyn Mark, MD, senior medical adviser, Office on Women's Health, a division of the U.S. Department of Health and Human Services. Robert Shenken, MD, president, American Society for Reproductive Medicine. Roger Lobo, MD, member, Endocrine Society; and professor and chair, department of obstetrics and gynecology, Columbia University, New York City. Nancy Church, MD, FACOG, ob-gyn, private practice, Chicago. WebMD Medical Reference from The Gynecological Sourcebook: "Menstrual Health," "Preventing Pregnancy." WebMD Medical Reference in collaboration with The Cleveland Clinic: "Your Guide to Endometriosis," "Absence of Periods." WebMD Medical Reference with Healthwise: "Abnormal Vaginal Bleeding." "Hypothyroidism," "Hyperthyroidism," Mayo Clinic web site.