Understanding menstrual changes

When it comes to menstruation, normal can be a little difficult to define. What’s typical for one woman might not be for another. For example, while the typical interval from the start of one menstrual cycle to the next is 28 days, a healthy cycle can range anywhere from 21 to 35 days.

As you approach menopause — defined as one year since your last menstrual period — what’s usual for you can also change. During the years just before menopause, which doctors refer to as perimenopause, women’s cycles often change in length. Bleeding may become heavier or lighter. You may even miss a period from time to time. Add these changes on top of existing individual variation, and it can be hard to know what’s a problem — and what’s not.

We asked Dr. Karen Carlson, an internal medicine specialist and associate professor at Harvard Medical School, for some guidelines that women can use to determine how to tell which changes are normal variations and which should be brought to the attention of a doctor. Here are her answers.

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Q. Is it common for women to experience changes to menstruation during perimenopause?

A. Changes in menstruation are to be expected during perimenopause, which starts on average four years before the last menstrual period.

Q. What kind of changes are typical in the years before menopause?

A. Cycles often get shorter as a woman enters the late reproductive years in her 40s. With the onset of perimenopause, the intervals between periods start to get longer. More dramatic changes in menstruation can also occur, including skipped periods and occasional episodes of heavier bleeding. After several years of irregularity, menstrual periods stop altogether.  It’s important to note that there is no typical pattern, so women should not hesitate to report a concern to their physician.

Q. Are there certain types of bleeding that should be brought to the attention of your doctor?

A. In general, heavier or prolonged bleeding (more than seven days) is a greater concern than absence of bleeding. Continued irregular bleeding or spotting between periods is not typical and should be reported. Keep in mind that pregnancy is still a possibility if you miss a period, even though fertility declines with the approach of menopause.

Q. How long should you wait before reaching out to your doctor? Is one abnormal cycle enough, or should you wait a few cycles?

A. It depends on how marked the change is. A single episode of very heavy premenopausal bleeding out of the blue should prompt a call to report the event. For a woman who is experiencing longer cycles or who skips a period (if there is no possibility of pregnancy), it’s reasonable to keep a menstrual diary for a few cycles and then check in with the doctor.

Q. What conditions may cause abnormal bleeding? Can any of these conditions be successfully treated?

A. Abnormal bleeding in perimenopause is often caused by the dramatic hormonal changes that take place during this phase of reproductive life.

Other common causes of bleeding include problems in the uterus, such as fibroids (benign growths of muscle or fibrous tissue that can develop inside or on the uterus), polyps (noncancerous areas of endometrial tissue overgrowth inside the uterus), and adenomyosis (a condition where tissue that normally lines the uterus migrates into the uterine wall). In adenomyosis, the tissue continues to respond to hormones, leading to thickening and bleeding with menstrual periods, which can cause discomfort or irregular periods.

Bleeding may also arise from problems with blood clotting or be triggered by certain medications. Less commonly, bleeding may be caused by cancer of the cervix or by precancerous changes (hyperplasia) or cancer of the uterine lining. All of these conditions can be treated.

Q. If you have abnormal bleeding, what type of tests should you anticipate?

A. Your doctor may want to order blood tests, such as a complete blood count, to check for anemia and to rule out pregnancy. She may also want you to undergo a pelvic ultrasound to look for a structural problem within the uterus (such as a fibroid or polyp), and to measure how thick the lining of the uterus is. Sometimes a biopsy of the uterine lining is necessary. Routine blood tests to check hormonal levels are often not helpful.

Q. Is bleeding a problem if you have already gone a year since your last menstrual period?

A. Any bleeding after menopause, even a tiny spot or brownish staining that looks like old blood, should never be ignored. Always report it to your doctor.

Although most cases of bleeding after menopause are not due to cancer, even a single episode can be a symptom of cancer of the endometrium (the uterine lining) and needs to be thoroughly evaluated.

Bible verses for today’s meditation and inspiration: Matthew E. McLaren

2 Corinthians 13:9 For we rejoice when we ourselves are weak but you are strong; this we also pray for, that you be made complete.

Colossians 1:28 We proclaim Him, admonishing every man and teaching every man with all wisdom, so that we may present every man complete in Christ.

Colossians 4:12 Epaphras, who is one of your number, a bondslave of Jesus Christ, sends you his greetings, always laboring earnestly for you in his prayers, that you may stand perfect and fully assured in all the will of God.

2 Corinthians 10:15-16 not boasting beyond our measure, that is, in other men’s labors, but with the hope that as your faith grows, we will be, within our sphere, enlarged even more by you, so as to preach the gospel even to the regions beyond you, and not to boast in what has been accomplished in the sphere of another.

2 Thessalonians 1:3 We ought always to give thanks to God for you, brethren, as is only fitting, because your faith is greatly enlarged, and the love of each one of you toward one another grows ever greater;

2 Peter 3:18 but grow in the grace and knowledge of our Lord and Savior Jesus Christ To Him be the glory, both now and to the day of eternity. Amen.

Ephesians 1:17-18 that the God of our Lord Jesus Christ, the Father of glory, may give to you a spirit of wisdom and of revelation in the knowledge of Him. I pray that the eyes of your heart may be enlightened so that you will know what is the hope of His calling, what are the riches of the glory of His inheritance in the saints,

Ephesians 3:16-19 that He would grant you, according to the riches of His glory, to be strengthened with power through His Spirit in the inner man, so that Christ may dwell in your hearts through faith; and that you, being rooted and grounded in love, may be able to comprehend with all the saints what is the breadth and length and height and depth, read more

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