Since my early 40’s, I’ve noticed that my menstrual cycles are unpredictable and sometimes very heavy. Is this normal?

This is a very common question and concern! This is often (not always) a sign of hormonal transition. The female body produces three major hormones which regulate our cycles: estrogen, progesterone, and testosterone. During our peak reproductive years, these hormones work in balance with one another to produce (in most cases) cyclical and predictable menstrual cycles, with “normal” menstrual flow. During the “perimenopausal” years, or those transitional years leading up to menopause, the first change which occurs is typically a gradual drop in progesterone levels (with estrogen and testosterone levels remaining pretty constant). This has to do with the fact that during these later reproductive years, less of the egg follicles actually mature to the point of ovulation. Related to this, cycles become more irregular and heavy. With diminishing levels of progesterone, there is a relative excess of estrogen: More estrogen can cause our uterine lining (the endometrium) to become plumper than usual, leading to heavier flow with menses. This is a very common process that occurs in most women to some extent during the later reproductive years.

It is strongly advised that you seek consultation with your healthcare provider if you are experiencing significant changes in the pattern or flow of your menstrual cycles. In addition to hormonal changes, there are many other potential reasons for a woman to experience changes with menses in the perimenopausal years. An undiagnosed pregnancy, a thyroid condition, a blood disorder, an anatomical abnormality such as a uterine fibroid or endometrial polyp, or even uterine or cervical cancer are all examples of other possible causes for abnormal uterine bleeding. Based on your history and your clinical symptoms, your healthcare provider will help you to determine which types of evaluation and testing might be recommended in order to accurately determine the cause of your change in menstrual cycles.

Generally speaking, you are bleeding too much if you typically bleed for longer than one week, or if when you bleed you saturate a tampon or pad in less than one hour (in an ongoing way), OR if your bleeding interferes with your life either due to feeling depleted (some women will become anemic with heavy or frequent menses) or because of “flooding” which prevents you from being able to comfortably leave your home. When you are experiencing too much bleeding, there are many options in terms of treatment including, but not limited to, the use of NSAIDS, cauterization, hormones, surgery, and complementary therapies. Again, your healthcare provider can help you to determine which is the best method of treatment for you.

As for the interval between menses, we consider anything less than a 3-week interval (21 days from the start of one menses to the start of the next) to be abnormally short. If this type of pattern occurs in an ongoing way, it is advised that you seek care from a healthcare provider.

Concerning a long space between menstrual cycles (and not related to a pregnancy or any other underlying medical condition) we generally feel that an interval of 3 months between menses should prompt a call or visit to your provider. This has to do with the fact that during these perimenopausal years in which a woman still produces plentiful levels of estrogen, it is sometimes necessary to “induce” a menstrual bleed in order to be sure of effective shedding of the endometrium. If the uterine lining is not effectively shedding, it is possible, over time, for a condition to develop called hyperplasia. This means an overgrowth or thickening of the tissue, and which could become a precursor to the development of endometrial or uterine cancer. Your provider can help you decide how to most safely and effectively monitor your cycles, while minimizing risks and keeping you as satisfied and comfortable as possible along the way!

Please keep in mind that the above discussion is in no way meant to be inclusive of the many possible other factors which can affect and alter menstrual cycles. For further direction on this topic we highly recommend that you make an appointment with your healthcare provider to discuss any questions that you might have.