Katie* 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:
- 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.
- 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.
- 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.
- 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.