Understanding Irregular Periods and Their Causes

The menstrual cycle is an important vital sign beginning in early life. Irregular periods are a common concern for many individuals, causing anxiety and confusion. Understanding the underlying causes can help in managing and addressing this issue effectively. This article aims to shed light on irregular periods, their potential causes, and possible treatments.

What Are Irregular Periods?

The cycle length is notoriously variable, but the average figure is 28 days from the start of one menstrual period to the beginning of the next, but it can range from 21 to 35 days in adults and 21 to 45 days in teenagers. By common usage, the days of the cycle are identified by number starting with the first day of menstruation. (Thiyagarajan, D. K et al., 2022)

When the cycle length varies significantly, or if periods are missed altogether, it is considered irregular. Irregular periods can manifest as:

• Amenorrhea: Primary amenorrhea, defined as the lifelong absence of menses (periods), requires evaluation if menarche (the first menstrual period in a female adolescent) has not occurred by 15 years of age or three years post-thelarche. Secondary amenorrhea is characterized by cessation of previously regular menses for three months or previously irregular menses for six months and warrants evaluation. (Klein, D. A et al., 2019)
• Oligomenorrhea: Women with oligomenorrhea have menstruation intervals of more than 35 days and less than 90 days or a total of 5–7 cycles a year. The prevalence of oligomenorrhea has increased considerably in recent decades, ranging from 12% to 15.3% according to different studies worldwide, with 10%–20% occurring in infertile women. Therefore, diagnosis and treatment of menstrual disorders are of utmost importance. (He, Y et al., 2020)
• Menorrhagia: Menorrhagia (also known as heavy menstrual bleeding) limits normal activities, affects the quality of life, and causes anemia in two-thirds of women with objective menorrhagia (loss of 80 mL blood per cycle). Prostaglandin disorders may be associated with idiopathic menorrhagia and with heavy bleeding due to fibroids, adenomyosis, or the use of intrauterine devices (IUDs). (Duckitt, K. 2015)
• Metrorrhagia: Bleeding between the first week of life and menarche is considered abnormal, as is metrorrhagia. (Bohiltea, R. E et al., 2024)

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Common Causes of Irregular Periods

Irregular periods can result from a variety of factors, ranging from lifestyle changes to underlying medical conditions. Here are some of the most common causes:

Hormonal Imbalances:

Hormones play a crucial role in regulating the menstrual cycle. Any imbalance can lead to irregular periods. Common hormonal causes include:

• Polycystic Ovary Syndrome (PCOS): A condition characterized by the presence of small cysts on the ovaries, leading to hormonal imbalances. It is the most common endocrine disorder in women during their reproductive period, with a prevalence of 6–20%, depending on the criteria used. It is the most common cause of menstrual disorders and hirsutism. (Anagnostis, P et al., 2018)
• Thyroid Disorders: Thyroid dysfunction is an important causative etiology of menstrual abnormalities. (Ajmani, N. S et al., 2016) Alterations in production and activity of the thyroid hormones thyroxine (T4) and tri-iodothyronine (T3) may result in menstrual abnormality. Both hyperthyroidism (overactive thyroid) and hypothyroidism (underactive thyroid) may result in menstrual disturbances. (Deshmukh, P. Y et al., 2015)
• Hyperprolactinemia: Elevated levels of prolactin, a hormone responsible for milk production, can disrupt menstruation. Hyperprolactinaemia is a common endocrinological disorder; it could be physiological, pathological, or idiopathic in origin. The predominant physiological consequence of hyperprolactinemia is the suppression of pulsatile GnRH. The clinical manifestations of conditions vary significantly depending on the age and sex of the patient. In women, it frequently leads to gonadal dysfunction including ovulatory disorder, menstrual disturbances, galactorrhoea, and infertility. (Majumdar, A., & Mangal, N. S. 2015)

Stress and Lifestyle Factors:

Stress negatively impacts the menstrual cycle and can cause hormonal imbalance. Stress, whether physical or emotional, can significantly impact the menstrual cycle. Factors include: (Nagma, S et al., 2015)

• Emotional Stress: Anxiety, depression, and significant life changes can cause irregular periods.
• Physical Stress: Extreme weight loss, excessive exercise, and poor nutrition can disrupt normal hormonal function.
• Shift Work: Working irregular hours, especially night shifts, can affect the body’s natural circadian rhythms and menstrual cycle.

Medical Conditions

Several medical conditions can lead to irregular periods:

• Uterine Fibroids: Non-cancerous growths in the uterus that can cause heavy bleeding and irregular cycles. Fibroids can also cause abnormal uterine bleeding, pelvic pressure, bowel dysfunction, urinary frequency and urgency, urinary retention, low back pain, constipation, and dyspareunia. (De La Cruz, M. S. D., & Buchanan, E. M. 2017).
• Endometriosis: A condition where tissue similar to the lining inside the uterus grows outside it, leading to painful and irregular periods. (Vercellini, P et al., 2014)
• Pelvic Inflammatory Disease (PID): An infection of the reproductive organs that can cause irregular menstruation.  PID can be acute, chronic, or subclinical and is often underdiagnosed. Untreated PID can also lead to chronic pelvic pain, infertility, ectopic pregnancy, and intra-abdominal infections. (Curry, A., Williams, T., & Penny, M. L. 2019)

Diagnosis and Evaluation

If you experience irregular periods, it is important to consult a healthcare provider for a proper diagnosis. The evaluation may include:

• Medical History: Detailed information about menstrual cycles, lifestyle, and medical history.
• Physical Examination: A pelvic exam to check for abnormalities.
• Blood Tests: To check hormone levels, thyroid function, and other relevant markers.
• Imaging Tests: Ultrasound or MRI to detect structural issues like fibroids or cysts.
• Endometrial Biopsy: In some cases, a small sample of the uterine lining is taken for further analysis.

Treatment Options

• Balanced Diet: Healthy and a balanced diet is important for women throughout the cycle, getting enough iron, and fiber, and consuming adequate calories throughout the month is important. For example, people with heavy periods may become low in iron due to blood loss, which can lead to anemia. Foods like meat, poultry, fish, legumes, leafy greens, and fortified grains are rich in iron and can help increase iron intake. (Begum, M., Das, S., & Sharma, H. K. 2016).
• Manage Stress: Stress negatively impacts the menstrual cycle and can cause hormonal imbalance. Prescribed coping mechanisms can reduce stress and its negative impact on menstruation. Stress-reducing techniques like yoga, exercise, and meditation can be practiced to support hormonal balance. Yoga is beneficial for other risk factors as well such as high blood pressure, lipid level, oxidative stress, and immune status (Mahajan, A. 2014).
• Regular Exercise: Regular physical exercise can help reduce stress and can support hormonal balance. Regular exercise contributes to the protection of cardiovascular diseases both primary and secondary. Aim for exercise like cardiovascular, strength training, and meditation to support overall health and hormonal balance. (Begum, M., Das, S., & Sharma, H. K. 2016).
• Adequate Sleep: Sleep is connected to several hormonal and metabolic processes in the body and plays a crucial role in maintaining hormonal balance and energy homeostasis. The present study shows that leptin (a hormone that signals energy balance to the brain) is influenced by sleep. Sleep is also associated with other hormones like TSH, cortisol, glucose, insulin, etc. Different bedtime conditions affect our hormones which is why we should prioritize getting enough sleep. It can help support hormonal balance and our overall well-being. (Begum, M., Das, S., & Sharma, H. K. 2016).

Hormonal Treatments

If hormonal imbalances are the cause, treatments may include:

• Hormonal Contraceptives: Birth control pills or patches can help regulate the menstrual cycle. Moderate‐quality evidence suggests that the combined oral contraceptive pill over six months reduces HMB in women with unacceptable HMB from 12% to 77% (compared to 3% in women taking placebo). (Lethaby, A. et al., 2019)
• Hormone Therapy: For conditions like PCOS, hormone therapy can help restore balance. (Patel, S. 2018).
• Thyroid Medication: If thyroid disorders are identified, appropriate medication can regulate thyroid hormone levels. (Biondi, B., & Wartofsky, L. 2014).

Medications and Surgery

For specific conditions, other treatments may be necessary:

• Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): To manage pain and heavy bleeding. Non‐steroidal anti‐inflammatory drugs (NSAIDs) reduce prostaglandin levels, which are elevated in women with excessive menstrual bleeding, and also may have a beneficial effect on dysmenorrhoea. Additionally, NSAIDs reduce menstrual bleeding. Endometriosis-related pain may also be treated with paracetamol, or selected cases with weak opioids, and neuropathic pain with anti-epileptics and anti-depressants (Rodriguez, M. B. et al., 2019)
• Antibiotics: If an infection like PID is causing irregular periods, antibiotics can be used for the treatment. (Chen, Y et al., 2020)
• Surgical Intervention: In cases of fibroids or endometriosis, surgery may be required to remove abnormal tissue. Surgery is a treatment option for both endometriosis and UF. Endometriosis surgery aims to relieve pain and improve fertility by removing all visible lesions or signs of disease. (Uimari, O et al., 2021)

When to Seek Medical Attention

It’s essential to seek medical advice if you experience any of the following:

• Periods that suddenly become irregular after being regular.
• Absence of menstruation for three or more months without pregnancy.
• Excessive bleeding, requiring frequent changing of sanitary products.
• Severe pain during periods.
• Any signs of infection, such as fever, unusual discharge, or severe pelvic pain.

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Conclusion

Understanding the causes of irregular periods can empower individuals to seek appropriate medical care and make informed lifestyle choices. While occasional irregularities are common, persistent changes should not be ignored. By consulting healthcare providers and making positive lifestyle adjustments, many can achieve better menstrual health and overall well-being. If you have concerns about your menstrual cycle, don’t hesitate to reach out to a healthcare professional for guidance and support.

References

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Duckitt, K. (2015). Menorrhagia. BMJ clinical evidence, 2015.

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Majumdar, A., & Mangal, N. S. (2015). Hyperprolactinemia. Principles and practice of controlled ovarian stimulation in ART, 319-328.

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