Common Period Problems: top questions about irregular menstrual cycles answered

Missed periods, strange cycles, irregular bleeding … we tackle your most pressing ovulation and menstruation questions, using advice from our top docs.

The menstrual cycle is a truly elegant feedback system. In theory, and most often in practice, it runs like a well-oiled machine with very little intervention. The body produces hormones in a cycle, each one of which causes changes that automatically “flip the switch” to turn itself off and the next hormone in the cycle on. (Get the details in How Ovulation Happens.) Ovulation, of course, is key to getting pregnant, as an explanation of the mechanics of conception makes clear. But ovulation is only part of the continuous cycle.

Changes or abnormalities in your period might be the easiest aspect of your cycle to notice, as actual menstruation is a hard-to-ignore symptom. Irregular menstrual cycles—having cycles that are shorter than 21 days, longer than 35 days, or vary between extremes—are very common. You can actually be “regularly irregular.” And most women will have times when their periods get a little wacky due to illness, travel, or stress. Still, variations can be worrying. Other symptoms may be more subtle, but are worth noticing. For example, even if a woman has some periods, it doesn’t mean that she is ovulating. The body can still shed the uterine lining without ovulation occurring. Particularly if pregnancy is your goal, you should have your worries evaluated.

Over the years, readers have submitted questions to, which we asked women’s health specialists to answer. The following questions represent the most common period concerns and curiosities. If you have a persistent problem or anxiety, definitely check with your own gynecologist.

Changes in Your Period

I went off the pill about two months ago, and I have not had a menstrual cycle since then. For a couple of days I had a colored discharge. Could this be a menstrual cycle? Is it still possible to conceive if my regular menstrual cycle has not come back?

Yes, it’s possible to conceive before a real period, assuming you ovulate. Generally, menstrual bleeding happens only after you ovulate. If you fail to ovulate (it’s often delayed after being on the pill), you can have some dysfunctional bleeding, which could look like what you describe. Give it some time. If you’re not cycling normally in another month, check with your doctor: Doctors usually give such disorders a good three months to straighten out.

My periods have always been very regular, but the last three months they have changed. I have about three days of very light spotting, then the next 24 to 36 hours it is very heavy, with lots of cramping and clots. I have had some clots before, but not like this; they vary from the size of a dime to a quarter. Then it goes back to light spotting for another one to two days. Are clots normal or should I be concerned?

Your periods will change over the course of your premenopausal life. This may be a normal transition at whatever age you are, but any change should be reported to your doctor to rule out polyps, precancerous changes, fibroids, hormonal problems—things like that. It’s probably nothing, but let your doctor prove that.

I usually have a 26-day cycle with no abnormal bleeding. But now I’ve been experiencing spotting on and off for the last 13 days. What causes this? Can I conceive if I’m having such an abnormal cycle? What exactly is breakthrough bleeding and how do you tell it apart from menses?

Breakthrough bleeding (BTB) occurs when there’s not enough hormonal support for the lining of your uterus, so it disintegrates and sloughs away. This can happen if you’re on a birth control pill that isn’t strong enough or during occasional cycles where there’s a variation in your regular hormone levels. Be sure to report any irregular bleeding to your doctor.

My normal cycle length is from 27 days to 32 days. The past two months they have decreased seven to nine days each month from the last. How do I detect ovulation if my cycles are never the same, and now are only 19 days apart? Also, why are they happening more frequently?

Addressing this problem starts with determining whether you’re ovulating or not. You may not be ovulating at all, but instead experiencing dysfunctional bleeding. A progesterone test in the latter part of your cycle, even a short cycle, can tell whether you ovulated. If you’re not ovulating, then you might need hormonal manipulation each cycle to “jump start” a normal cycle. This is one thing that Clomid (an ovulation inducer) does. If you are ovulating, then perhaps the second half of your cycle is lackluster. This is called “inadequate corpus luteal phase,” and may need to be supplemented with progesterone, which your body normally makes in the second half of the cycle. With an inadequate corpus luteal phase, it is making too little for a healthy cycle (or pregnancy). (Read more in our article Irregular Menstrual Cycles and Fertility.)

Irregular or Abnormal Cycles

I had two periods last month—one at the beginning and at the end. Does the second one count for the next month?

It is a misconception that the “monthly” menses follow the calendar months. Every woman cycles according to her own body’s clock. Women can have cycles that repeat anywhere from every 21 days to every 40 days or so. Also, the menstrual cycle is influenced by many other factors, including stress, exercise, diet, weight, and illness. So even though most women have a period at about the same interval from month to month, every woman is entitled to a fluky one every now and then. For women who have the timing of their periods “all over the map,” once major gynecological concerns have been addressed, the irregular cycles can be manipulated into a normal rhythm using birth control pills.

My periods start early and then get heavier at the right time, and I’ve had two miscarriages. Are these two things related?

It’s possible you may have an “inadequate corpus luteal phase,” which can be explained this way: There are two phases of the menstrual cycle. The first, called the “proliferative” phase, is when the lining of the uterus proliferates (gets thicker). After you ovulate at midcycle, the area of the ovary from which you ovulated, called the corpus luteum, makes progesterone, a hormone that enables the second half of the cycle—the “secretory” part. In the first half of the cycle, the lining grows and is heaped up, and in the second, the lining is matured by the progesterone to prepare for the implantation of a fertilized egg. If implantation doesn’t happen, the progesterone production from the corpus luteum falls, the lining has no more hormonal support to keep it organized, and it falls apart—what you see as a period.

Now, if the corpus luteum is not a good one, and the production of progesterone is therefore less than adequate, then the lining will become fragile before the time you’d expect a well-timed period. This is your early spotting. But like the uterine lining, the plot thickens: Since progesterone is necessary to keep the lining of the uterus intact for the pregnancy, and if it’s too low, a miscarriage can occur. So an inadequate corpus luteum can be responsible for both spotting and recurrent pregnancy loss. But it’s very important to understand that, more than likely, the progesterone is low because the pregnancy is faulty, rather than the pregnancy being faulty because the progesterone is low. But it’s impossible to tell once trouble starts brewing, so most doctors will give a pregnant patient with low progesterone pills or suppositories that will increase the level of progesterone. If the baby’s in trouble because the progesterone is low, this may be pregnancy-saving. But you must be willing to accept that if the progesterone is low because the baby’s in trouble (the opposite), then giving a patient progesterone will only delay the inevitable miscarriage.

I tend to have brown spotting 3-4 days prior to my period. It does not happen every month. According to my temp charts and ovulation prediction kit tests, I am ovulating regularly at approximately cycle day 13-14 and my cycles are 27 to 28 days. What might be the reasons for this spotting? I was told I don’t have the signs for endometriosis.

It’s probably some lining of your uterus that requires a certain threshold to maintain, but sloughs before the rest of your period when the hormone levels begin to fall. Then the rest of the menstrual tissue follows like normal. It is possible this could represent a luteal phase defect, but the fact that you’re so cyclic speaks against that. A progesterone test on day 21-22 can tell you whether you ovulated well. An endometrial biopsy a week later can tell whether the rest of your endometrium (lining) is in sync with the ups and downs of your cyclic hormones. Endometriosis has nothing to do with this.

Late or Missing Periods

I am over two months late for a period, but the pregnancy tests are negative. Are the tests wrong?

Probably not. What you’re describing is a medical condition called secondary amenorrhea, meaning that you’ve developed a condition of having no periods after having had them regularly before. (Primary amenorrhea would mean never having ever had a period at all). Everyone’s entitled to an erratic cycle or two from time to time. Stress can cause this, but don’t be too quick to assume stress is always the cause. It is generally not worth pursuing an investigation with expensive testing until you’ve gone more than three months without a period.

If this happens, there are several things that should be investigated:

  • The first thing to do is undergo a physical exam to see if there are any ovarian cysts (possible) or tumors (very unlikely). This exam can (and should) be backed up with an ultrasound, preferably a vaginal ultrasound.
  • Blood work should be done, including the following: 1) thyroid stimulating hormone (TSH), to rule out thyroid problems; 2) follicle stimulating hormone (FSH), to rule out premature menopause (unlikely); 3) Prolactin, to rule out a pituitary tumor which can mimic a breast-feeding state that inhibits ovulation, and with it, menstruation. 4) Estrogen and progesterone levels, to see if you’re making the “right stuff” to cycle with periods.
  • You could be given a “progesterone challenge”: If you’re making estrogen, then a round of progesterone (given, then withdrawn) should yield a period. If not, you may not be making estrogen. This will indicate possibly premature menopause. However, this can also be ascertained by doing estrogen, progesterone, and FSH levels. Mechanical problems should be ruled out after all of the above.
  • Aschermann’s Syndrome, a condition involving scarring within the intrauterine cavity, can effectively seal the uterus or be so scarred that there’s no tissue remaining which builds up with each cycle, causing amenorrhea (no periods). Previous dilation and curettage (D&Cs;) and abortions can cause this. This can be ruled out with a hysteroscopy (looking into the cervix with a lighted scope) or with a hysterosonogram (a vaginal ultrasound in which saline is swished up the cervix to expand the intrauterine cavity to show any scarring or obliteration).

I am 18 years old, have stopped having periods and have gained weight. The pregnancy test is negative. What could be going on?

This also sounds like secondary amenorrhea. Pregnancy is the most common cause of secondary amenorrhea, but all of the other causes are not normal. A person can have a “post-pill” amenorrhea when discontinuing birth control pills until the pituitary gland resumes normal function after being blunted during the time on the pill, and this is fairly harmless. The same applies after depo-provera shots and other hormonal manipulations.

But there are other more suspicious reasons to experience secondary amenorrhea. An ovarian cyst (benign, pre-malignant, or malignant) can interrupt the cycle. A benign condition called polycystic ovarian syndrome (PCOS) puts your cycle on hold because you can’t ovulate. This interruption causes a build-up of testosterone and weight gain. Many doctors would recommend a serum testosterone level to see if it’s elevated, an ultrasound to check for cysts of the ovaries, and of course a thorough physical exam. If all of this turns up nothing, then it’s possible that becoming overweight has caused production of extra estrogen from your fat cells, which will muck up the works. And then there is the consideration of premature menopause, which at your age is extremely unlikely. A simple blood test of your FSH could be done at the same time as the serum testosterone. You should be evaluated by an OB/GYN.

I had a baby two months ago. It just dawned on me I’ll get my period again eventually! When should I expect it?

Most physicians say as early as two months, so it could be any day for you. If you are breast-feeding, it is likely to be longer. Some women don’t resume their menstrual cycle until they wean their baby. But (unhelpful as this is) not all of them. So the best advice is just to be prepared! Keep some pads or tampons on hand, and realize that postnatal lack of a period does not guarantee contraception! Your first ovulation may happen while you think you are still not cycling. (If you’re concerned about getting pregnant, check out Birth Control Options for New Moms.)

Could I Be Pregnant?

My period isn’t late yet, but I really feel like I’m pregnant. Am I crazy? How early can I do a home pregnancy test?

Early pregnancy often feels just like a period about to start, but some women notice the effects of the early rise in hCG levels, which can result in breast tenderness. A pregnancy test is the best way to determine if you are pregnant, and a blood test is the most accurate, particularly in early pregnancy. Home tests are accurate when used according to package instructions, usually not until the first day of your missed period. Some brands now offer results up to five days sooner, although with decreased accuracy. (Read more about the early signs of pregnancy.)

My periods are usually very regular, but the last one was late. Could that mean I was pregnant and miscarried?

It is possible. Ten to 25 percent of all pregnancies end in miscarriage, including many pregnancies that women aren’t even aware of because they occur very early. You would not experience more cramping with an early miscarriage, and the only way to know that you were pregnant and miscarried would be with a blood test. Having a late period one or two times a year is in fact normal and often due to stress, travel, exercise, or illness.

Is it possible to have a normal period after conception?

After conception, some people have a small amount of spotting around the time of their period called implantation bleeding, but it is not like a normal period. Spotting is very light bleeding (usually brown) and lasts only one to two days. This is different from a period which lasts four to five days and is heavier in flow. Women may spot during the first trimester, but you cannot be pregnant and get a true period.

Other Menstrual Problems

I have painful periods. I have heard about endometriosis, but what is it really?

In brief, endometriosis is the presence of viable endometrial cells in places other than the uterine cavity. Every month when a woman has a period, the cells that line the uterus, known as the endometrium, are shed in the menstrual flow. Some small portion of this combination of blood and endometrial cells may also pass out through the fallopian tubes into the abdominal cavity. Most of the time, the body’s natural defense systems attack and destroy these cells before they can begin to grow. However, this is not always the case. In some individuals, these endometrial cells actually implant on structures in the abdominal cavity and begin to grow. Then, each month when the normal hormonal changes bring on a menstrual period, much the same occurs in the endometriosis. A small amount of bleeding occurs from the endometriosis cells. This is very irritating to the body, and as a result of this, scarring occurs around the endometriosis. Most often this is a progressive process, with a small additional amount of bleeding and scarring occurring every month. It definitely has implications for future fertility, so check out the article Fertility and Endometriosis.

I’m only 39, but feel like my cycles—which have been regular all my life—are now going a little haywire. I seem to have PMS when I never did before, and huge variation in flow (sometimes nothing, sometimes I go through the “super” tampons in no time). I hope this isn’t the start of menopause already! What do you think?

Not to be confused with menopause, a distinct stage in a woman’s life where she has stopped producing estrogen and progesterone, and no longer menstruates, or even early menopause (defined by the cessation of a menstrual period for more than 12 consecutive months before age 45), perimenopause is a transitional phase—occurring up to a decade before menopause—defined by fluctuating hormone levels. With little or no progesterone (due to a non-ovulating cycle, or anovulation) to balance the effect, unopposed estrogen—up one day, down the next—causes many women to experience a myriad of symptoms from irregular menstrual cycles to changes in memory and mood. One big misconception about perimenopause is that what women are experiencing is all in their heads. It is not, and perimenopause may be one of today’s most misdiagnosed conditions. Physicians have begun to realize that there is a definable entity prior to the onset of menopause. Read more about perimenopause.

Six weeks ago I had a dilatation and curettage (D&C;) after a miscarriage at 10 weeks. Now my doctor has discovered via ultrasound that my ovaries are polycystic. Is this common after miscarriage or D & C? Is this the same as PCOS? And will this effect future attempts to conceive?

If the ultrasound was done soon after your miscarriage, it may just be the ovaries trying to start back up. Blood work can usually nail down the diagnosis of polycystic ovarian syndrome (PCOS), specifically, a measure of your glucose/insulin ratio, follicle stimulating hormone, luteinizing hormone, and serum testosterone. Your doctor may want to order these if a repeat ultrasound again demonstrates a multicystic picture. That you got pregnant already is a good sign against PCOS.

With PCOS, women suffer irregular—usually rare—periods, hair growth, and varying degrees of infertility. Its most general definition is a syndrome in which there is too much male-type hormone (androgen) produced by the ovaries (and sometimes the adrenal glands) with associated disruption of the normal cycle. Its exact cause is unknown, but it seems to be hereditary. Almost one in 20 women of reproductive age has it, and it is one of the most common causes of infertility. It is also one of the most underdiagnosed conditions in women. Now that other health consequences have been implicated in association with PCOS, a lot of attention has been given to making the diagnosis in women who otherwise would have been overlooked.

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