How does menopause affect periods?
During perimenopause, many women can find their periods change. They can be less predictable, heavier, lighter… as with all things menopause, it’s different for everyone. Consultant obstetrician and gynaecologist Dr Karen Morton is the founder and medical director of Dr Morton’s, The Medical Helpline.
She trained at Cambridge, Oxford, Queen Charlotte’s Maternity Hospital, Chelsea Hospital for Women and St Thomas’ Hospital, before becoming a consultant in Guildford in 1991. She believes in empowering women to make informed choices about their healthcare, starting Dr Morton’s in 2013 to help make that happen.
Dr Morton joined us for a Lunch and Learn webinar to explain more about how menopause can affect our periods, and what we can do about it.
Henpicked: First and foremost, why do periods change around menopause?
Dr Karen Morton: To answer this, we need to understand what a period is. Essentially, from when you were in your mother’s womb and less than a cm tall from head to toe, your body put into your ovaries all the eggs you’re ever going to have. There are millions of them to start with and they’re just microscopic dots.
From about seven years of age onwards, you start to make a bit of oestrogen. And from nine onwards your body starts to choose an egg to be brought to maturity – or sometimes two. The egg is brought to maturity within a follicle and when it’s mature the follicle will pop and the egg is released. The area on the ovary where the egg started will swell and make a hormone called progesterone.
The role of progesterone is to prepare your body for pregnancy. If the egg isn’t fertilised, the area making progesterone realises it’s not needed any more and stops.. The progesterone level falls and our womb lining falls away as a period.
So a period is a result of cyclical ovarian activity. All of that is under the guidance of the pituitary gland. This is our master gland, located behind the bridge of our nose, which tells our ovaries what to do.
In the same way as in early reproductive life, periods during perimenopause might not be regular. A 12 year old may have one period then not another for three months, as the rhythm of egg production has not yet got going. At the other end of reproductive life, eggs are becoming a bit rusty and there are not as many of them. The whole rhythm of production can be disturbed so periods can be affected. Menstrual irregularity usually means periods are more spaced out, but they can be chaotic.
However, it’s important for women not to ignore odd bleeding. If there’s a strange pattern or no pattern we do need to check there’s not a polyp or something worse going on in the womb.
Henpicked: How many eggs do we have?
Dr Karen Morton: We start with millions. Ovaries are not like testes, which are a factory that keep making sperm from puberty to death. Women are born with finite number of eggs. They go into our ovaries as immature things, and the majority fizzle away. We bring a certain number to maturity, and when we reach menopause all our eggs are gone.
Henpicked: One symptom many women tell us they find embarrassing is flooding…
Dr Karen Morton: This is a word used to illustrate blood pouring out like a nosebleed. People imagine there’s an amount of blood inside the uterus that’s going to come away, but that’s not true. Most of the blood of a period is coming from your whole body through raw blood vessels. These have been revealed on the inside of the womb because the endometrium (womb lining of the womb) has fallen away, just as if you’ve cut yourself.
If you cut your hand you probably press on it. But unless you’ve cut a major artery you wouldn’t bleed to death if you didn’t, because we have mechanisms for stopping bleeding. These are threefold. Blood vessels have a muscular coat and they constrict. We make little plugs in the blood vessel. And healing occurs. The healing that should be driven by hormonal rhythm may be lacking in perimenopausal woman, as the growth of new womb lining is impaired. The rhythm is lost and our natural mechanisms for reducing the heaviness of loss by curtailing bleeding are not working as well.
Henpicked: What other symptoms might we experience?
Dr Karen Morton: Quite a lot of women get a lead-in to their period. Their progesterone level should go up after ovulation and stay nice and high until they have not conceived and should then plummet down and they get a period. This all gets a bit more rusty during perimenopause. The progesterone level may go up and then start to fizzle a bit before it goes down. Quite a lot of women get dribs and drabs as a lead in to the period. That doesn’t usually mean anything worrying but it is a nuisance. There are simple ways of dealing with that, such as a progesterone supplement during the five days before their period.
Henpicked: Are there any other conditions that affect your period during perimenopause, such as endometriosis?
Dr Karen Morton: Endometriosis by and large occurs in women that have not borne children. It is progressive so won’t just come on at menopause. A woman may have had painful periods that have got progressively worse.
Henpicked: It’s often about knowing what’s right in our own body. Are there any red flags?
Dr Karen Morton: The most important two are bleeding randomly in between periods, and bleeding after sex. These should always be investigated. Also any bleeding that comes after menopause should be checked out. We do use the yardstick of a year without periods as defining menopause, but everyone is different and it’s not impossible for ovaries to have final burst of activity. But this should still be investigated
Henpicked: Many women use contraception. We’re often asked ‘If I’m on the pill how do I know I’ve had the 12 months period free?’ Or ‘I’ve had a Mirena coil fitted, should I have it taken out to see how I am?’
Dr Karen Morton: If you have coil the best thing to do is have a blood test to test if your follicle-stimulating hormone (FSH) level is still in the normal range. If it is, you can just have your Mirena changed as normal. On the pill you can’t have a blood test as it suppresses the pituitary hormone. You need to stop the pill and wait for six weeks. You may get a period, in which case the answer is clear. Or you could now have blood test to give a realistic reflection of your hormonal situation.
Henpicked: What can a woman do if periods are a problem during perimenopause?
Dr Karen Morton: Many women will go onto a cyclical HRT regime as means of menstrual regulation and moderation. In same way as pill periods are light and predictable, a woman can use an HRT regime to achieve these. The HRT is probably a pill but there are many varieties. Some may take this for six months and wonder if they’ve finished their periods and come off, others may choose to continue.
Henpicked: Many women think they can’t take HRT until their periods stop.
Dr Karen Morton: This isn’t the case. It can be used very safely and simply.
Henpicked: What about women who don’t want to take HRT but are having problems with their periods?
Dr Karen Morton: Once we’ve excluded disease by proper investigation there are probably two other options. The Mirena coil is a very clever device, releasing a tiny dose of progesterone into the womb over five years. Or you can have the lining of your womb ‘cooked’. We use an implement inside the uterus and apply a current to it. This cooks to just deeper than the growing layer, which will heal as an inactive scar. This means there is practically no womb lining. It’s incredibly simple, and only takes about three or four minutes. Some women think they should have a hysterectomy, but I’d never recommend this unless they absolutely have to.
Henpicked: So it’s important for women to understand what’s going on in their body, and if periods are getting in the way of life and work, speak to a medical expert or GP.
Dr Karen Morton: Yes. Don’t put up with it. Even if your periods haven’t been heavy enough to make you anaemic, your bone marrow which sits in your sternum and your hips is a factory, replacing the blood that you’ve lost. A factory needs energy. If it’s busy replacing blood you’ve lost it’s not available for you to be doing other things. Don’t be a putter upper.
Henpicked: Some women tell us their periods are becoming closer together and their cycles are shortening. Is this common?
Dr Karen Morton: The average cycle is 28 days. Some women will have 21-day cycle all their lives, others a 35-day cycle. Some cycles will change either with an event like having a baby or getting older. If they’re coming every 21 days your ovaries are trying very hard to make you reproduce again. In fact, twins are common as women get older, as a last evolutionary drive. Remember, your cycle includes the days of bleeding.
Henpicked: What about erratic periods, with pains but no blood?
Dr Karen Morton: Yes, this is very common, if the womb lining is not thick enough to bleed.
Henpicked: Is bloating also common?
Dr Karen Morton: it can be. The gut has smooth muscle in the middle, progesterone can make this rather floppy so you get pockets of wind in each direction. Some women get a lot of it, those with primary gut illnesses like IBS often notice that symptoms get worse premenstrually.
Watch the video of the webinar here: