Midlife & Menopause Moments

Join Dr. Bitner in a lively discussion about midlife changes and menopause.


My Changing Period—What Does It Mean?

by on December 6, 2013 6 Comments

BitnerChangingPeriodImageKatie* was a new patient to our office who came to see me because she was concerned that her period was changing. She was 46 years old and healthy overall. Katie had done her homework. She recorded her period for the last 12 months in a notebook, including the dates of her period, how long it lasted, and how heavy it was each time. Katie’s notes told us that her period ranged from two days of light spotting to eight days of heavy flow, followed by a day of dark spotting. Her period was never more than 60 days apart, and she had gone one month without a period. She also had occasional spotting in the middle of her cycle, only requiring a panty liner.

I asked Katie if she was experiencing other symptoms related to her period cycle. She told me she was especially hot at night around the time her period began each month, but she never really made the connection. She simply thought she was using too many blankets. She also noticed that she felt more edgy and irritable at different times of the month, but she felt she was able to hide it most of the time. Overall, her biggest complaint was her constantly changing period and never knowing what to expect each month.

My first goal as a specialist in perimenopause and menopause is to make sure nothing abnormal is happening. In other words, the abnormal bleeding is just a result of ovarian aging. We began talking about what was happening to her body. I used a diagram of the uterus, ovaries and brain to describe the hormone conversation that must occur to have a normal cycle each month. When a period happens, the brain tells the ovary to make another egg with the signal follicle-stimulating hormone, or FSH. A follicle, or premature egg, starts to develop. The cells around the egg first secrete estrogen and then, after ovulation, progesterone.

Here’s another way to look at it. The lining of your uterus is like a lawn, and estrogen is the equivalent of fertilizer for the lawn. Progesterone helps the lawn mature, not just grow longer. It’s the equivalent of weed killer. If just the right amount of hormones is secreted, the lawn is perfect and ready for a baby to be planted. If there’s not a pregnancy, then a message isn’t sent back to the cells to keep making estrogen and progesterone. Therefore, the cells die off and the lining of the uterus falls off, resulting in a period.

I continued to explain to Katie that when periods become closer together, farther apart, heavier or lighter, it means that the hormone balance is changing. As an ovary gets older, the estrogen levels become more erratic—some days higher, some days lower—and the progesterone levels are lower and fall more quickly. During some cycles, progesterone levels are almost nonexistent. As a result, the most common changes are a period that is closer together and heavier, followed by a normal cycle, followed by a period that is farther apart and lighter again.

After we discussed Katie’s symptoms, the next step was to check her blood work for thyroid and prolactin disorders, which could signal that other hormones might be disrupting the ovary-brain conversation. The blood work showed that Katie had normal thyroid and prolactin levels, so I ordered a pelvic ultrasound to confirm she had a normal uterus. She did, in fact, without fibroids or abnormal thickening of her uterus lining to indicate uterine polyps, or precancerous or cancerous growths.

After her tests were complete, Katie came back to see me. I performed a PAP smear (she was already due for one) and a biopsy of her uterus lining to confirm she didn’t have abnormal cells. She didn’t, so then we discussed her options.

Here are the options we looked at:

  1. Continue to observe her period and changes, but don’t make any adjustments. Simply knowing that the changes were normal and didn’t indicate something was seriously wrong can be very helpful and offer peace of mind. With time, many women cycle through these changes without much incident.
  2. Start taking birth control. Since Katie wasn’t a smoker, this was an option for her. The pill can turn off the ovary and allow for a light, regular period every month. It can also help decrease night sweats and regulate mood changes related to cycling hormones. Katie had been on birth control in the past and didn’t feel well while taking it, so she eliminated this option.
  3. Use an intrauterine device containing progesterone. An intrauterine device, or IUD, releases progesterone mainly inside the uterus. Many women who don’t tolerate the pill do very well with the Mirena® IUD without any side effects. For most women, an IUD will make their periods very light or even nonexistent for up to five years. This is an especially good option for women who smoke, are at risk of leg or lung blood clots and are not good candidates to take estrogen.
  4. Have a uterine ablation. An ablation is done by several methods—all with the goal of destroying the lining of the uterus to avoid bleeding. It has an approximately 80 percent success rate in a normal uterus. This is a potential option for Katie because her uterus is normal. If she had fibroids or other uterus abnormalities, the ablation would most likely not work.

Katie decided to choose the IUD with progesterone option, and she was very pleased with the results. After three months of almost daily spotting, her period stopped. She could rest assured that her system was normal and healthy, and she could finally get on with her life.

*Patient name has been changed.

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About the Author ()

Diana Bitner, MD, is board certified in obstetrics and gynecology. She received her medical degree from Wayne State University School of Medicine in Detroit and completed her residency in obstetrics and gynecology at Butterworth Hospital in Grand Rapids, Michigan. Dr. Bitner has special interests in women’s wellness and prevention of heart disease, menopause, perimenopause, laparoscopic and robotic pelvic surgery, and pelvic pain. She is also fluent in Portuguese.

Comments (6)

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  1. Wendy Scholten says:

    My 13 year old daughter has autism as well as several serious health problems…feeding tube, wear diapers, pro-longed qt interval to name a few. She has not started her period (I did not start until I was 17). We know our daughter will not handle periods well. With her heart problem deprovara has been taken off the table. An abaltion was suggested. I know a few woman who had problems with this and ended up in the ER with heavy bleeding.
    Any input you have would be most welcome. I remember you from Dr. Holt’ s office.

    ~Wendy S. Scholten

    • Diana Bitner, MD says:

      Hi, Wendy,

      I am glad you asked this question about ablation, and I’m sorry your daughter has to deal with these health problems. Hopefully she starts her period late. This can be a difficult situation to address, because everything we offer has risks. It sounds like systemic hormones are off the table, and an ablation at such a young age will not be effective because it tends not to last long. There is significant time for the lining of the uterus to grow back and/or pockets of blood to collect in her uterus and not be able to get out. This can cause acute pain and a possible need for surgery. A better option could be an IUD which contains progesterone; the systemic dose is minimal and should not affect her heart. Another option is very drastic: a hysterectomy. We do not offer this lightly, and it would have to be a thorough discussion between all of her doctors weighing the risks and benefits. I would not even consider a hysterectomy until she starts having periods to see how she is affected by them. As a result of her health status, her periods might be very light and infrequent, and there will be no more reason to worry. That is what I sincerely hope for you and your daughter!

      Dr. Diana Bitner

  2. Lisa O'Hare says:

    What are your thoughts on bio-identical hormone replacement in this situation? Why wasn’t it even an option given to the patient? I am also 46 and had similar symptoms. I am now taking progesterone 14 days of my 28 day cycle and also estradiol and testosterone since my blood work showed I was low in all 3. My thyroid also is low. I am working on boosting that through vitamin B5 and B6 and some other supplements. Is the progesterone in the IUD that Katie chose synthetic or natural, bio-Identical?? I feel natural replacement of hormones is the way to go. I have read so many good things about this option. I also feel most doctors fear using them due to lack of proper studies. The only bad results (stroke, heart attack, cancer) coming from studies were when synthetic hormone replacement had occurred, not bio-identical.

    • Diana Bitner, MD says:

      Hi, Lisa,

      Most of the hormones I prescribe are bioidentical, but they are FDA-approved bioidentical.

      Bioidentical hormones are identical to the hormones made in your body. There is a really good article about this in the women’s lifestyle magazine “MORE” that tested the medicines sold as bioidentical hormones in non-FDA-approved forms by doctors prescribing supplements—not approved drugs. You can read the article at more.com/health/perimenopause-menopause/are-natural-hormones-safer. The survey showed that the medicines were tested by an outside lab and contained between 0 percent and 1,000 percent of what was promised on the label.

      My first concern is, and always will be, safety. I agree that the Women’s Health Initiative study in the “MORE” magazine article showed more adverse events with the synthetic progesterone, and that is why I almost exclusively prescribe FDA-approved bioidenticals.

      The IUD contains synthetic progesterone, but it mostly stays in the uterus, and I do not worry about a systemic effect to the point where it could cause a bad side effect. The other key point from the article about the safety of hormones is that most bad events—heart attacks, strokes and blood clots—occurred in women older than age 65 who also had a high underlying risk for these events to happen anyway. Most of the women who experienced the events also had metabolic syndrome: central obesity, high blood pressure, high “bad” cholesterol and elevated blood sugar levels.

      Everything I prescribe has risks and benefits; my goal is to minimize the risk and promote good habits and good health. For many, for example, the risk of the IUD with progesterone is minimal, and it can save them from having a hysterectomy, prevent uterine cancer and be an alternative if they do not tolerate systemic progesterone.

      I hope this helps. Thank you.

      Dr. Diana Bitner

  3. tina says:

    I think I’m at the late stages on menopause. I expect TiVo be through menopause within the next year or so. When I do menstrate it’s very light now (yay). I’m only 34. Is it important to see a doctor for hormone replacement? Or, can I just go through this change without anything? I feel fine and am ok with most of the symptoms, I understand it’s all part of the change. But I hate what’s happening with my teeth and hair (especially at my age). Do calcium pills help or hurt?
    Thanks!

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