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The Seesaw of Hormonal Production: Why Your Periods Are Wilder Than the Old- School Wild, Wild West!

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When the arrival of your period becomes more erratic than airplanes during the holiday travel season, you know something is up, especially if before they were like clockwork. Why this is happening and what this all means can be confusing. It can also make deciding if you should wear white jeans very difficult! Most fingers point towards the ovaries and their dwindling supply of eggs and specific hormones: think inhibin, estrogen, and AMH.

As the ovaries start to run on empty, they shoot mixed messages to the brain. The brain, which is used to orderly and steady hormone levels from the ovaries, is thrown into a tailspin. Without adequate ovarian hormone production, the brain overproduces certain hormones. Think FSH and LH. There goes the regularity of your menses. In medicine, we refer to this period of confusion and “crazy” period timing as perimenopause. And to put it bluntly, this period (no pun intended) can be a big pain.

In terms of the brain-ovary relationship, think of a seesaw. As the ovaries (egg production and select hormones) go down, the brain’s hormone production goes up—and in some cases, way up. FSH levels can reach the high double digits. Ovarian hormones and hormones in the brain, specifically the pituitary gland, work in a negative feedback loop—high ovarian hormones keep the brain’s reproductive hormones low. So when you are nearing menopause and the ovarian production lays low, lower, and then lowest, the seesaw will remain lopsided. And while on this seesaw, the person left high won’t get hurt, it will have a major impact on how frequently you see your periods—as well as other things like your internal temperature gauge.

For most of our reproductive lives, the ovaries and the brain work as a team to prepare an egg, ovulate an egg, and maintain the corpus luteum (a.k.a. the structure that makes progesterone and helps maintain a pregnancy). There are some conditions where this system doesn’t run so smoothly—cue PCOS, thyroid disease, or hypothalamic amenorrhea. But for most of us, it is pretty well-oiled machine, that is, until we hit our mid-40s or so. Then the pendulum starts to swing erratically. Periods come closer together (about 20 days) and then farther apart and then close together AND farther apart. Not a pleasant combo.

Consistency becomes a thing of the past. While your mind may view pregnancy as a thing of the past, your ovaries haven’t quite given up. They are still working to prepare and ovulate an egg each month. Because of the diminished supply, they start to prepare the egg in the second half of the menstrual cycle the month BEFORE that egg will be ovulated. Simply stated, they are letting the horse out of the gate (a.k.a. the egg) long before the race goes off (a.k.a. the next menstrual cycle starts). As a result, the menstrual cycles will get shorter and shorter.

Although irregular menstrual cycles are quite common when we hit our 40s and beyond, when bleeding becomes excessive or all of the time, you need to speak to your OB/GYN. While it likely means nothing more than the ovarian reserve fuel tank is running on empty, you want to make sure there is nothing structural (a polyp, a fibroid, or even a cancer) that needs to come out. Don’t brush it off as another joy of aging!

Just like any relationship, when one member of the team goes haywire, things can fall apart pretty quickly. If you are not in sync with your partner, the partnership falls apart. The brain and ovary alliance is no different. When one stops working, the other one tries to overwork or make up for the deficiencies, which leads to irregular and often frequent periods. Although there may be nothing you can do to mend or tame this wild relationship (once ovarian production goes down, it generally will remain down), just acknowledging it can bring you some peace.

And with that, you can go out and face the wild, wild west!

Post-Menopausal Bleeding: A Drop in the Bucket?

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Month after month, year after year, we are running for the bathroom searching for the tampon or pad that we keep buried in our purse for an emergency. After realizing that we used the emergency supply last month and never restocked, we seek out help from one of our bathroom mates who smiles and says, “Don’t worry; I’ve been there.” The truth is, we all have at some point; the monthly mess is just a part of a woman’s life. It can be so unpleasant—the cramps, the moods, the pimples, and of course, the endless bleeding—that it’s hard to imagine ever missing this. I mean, if your 20-year-old self could talk to your 50-year-old self, what a conversation that would be! When you are in the thick of those reproductive years, a little irregular bleeding here or there often goes unnoticed: what’s a little more bleeding? You probably don’t make much of it and maybe even forget to mention it to your doctor. It is, so to speak, just a drop in that much larger bucket. However, when bleeding arises post-menopause, it can be serious and should never be shrugged off, ignored, or go unnoticed.

Menopause is the end of a very, very, very long race; “miles” of menses ultimately come to an end. While this race is long, its end is gradual and is preceded by a major “spacing” out of rest stops. All regularity and predictability are lost, and irregularity and the unknown take the lead. Medically, this time of irregular periods is known as perimenopause; perimenopause and the haphazardness that it brings (both physical and often emotionally) can (oh joy) last for years.

It isn’t until a full year from the last period that you receive your official medal (a.k.a. menopause). From this point on, the flood gates are closed. No more bleeding should occur. Without the ebbs and flows of estrogen and progesterone made by the ovaries, the stimulus for a uterine lining to be produced and shed monthly is lost. The uterine lining becomes thin (no diet required!) and in most instances remains that way indefinitely. If it starts to receive mixed messages (um, no way, that’s not what she told me!), it can thicken and bleed. But let’s cut the game of telephone ASAP. This is not evidence that you are once again fertile. It can hint at a seriously serious situation, such as endometrial cancer, which requires immediate attention. Endometrial cancer is the most commonly diagnosed gynecologic cancer; about 55,000 women will be diagnosed in the US each year. Luckily, most endometrial cancers give you a heads up: a “get out of the way; the bus is about to hit you”-type of thing. For most women, bleeding, long after the days when there was bleeding, will happen.

Bleeding is an obvious and often early sign that something is off. Because it is so visible, endometrial (uterine) abnormalities are often picked up early in the game. In fact, in many cases, they are not even fully cancerous but rather precancerous (about 70% of endometrial cancers are stage I when diagnosed). The precancerous condition is called endometrial hyperplasia. Basically, the cells are becoming a little hyperactive and if untreated could be on their way to some serious Ritalin-requiring behavior. There are four types of endometrial hyperplasia, with some being more in line with cancer and others just slightly out of line with normal. As a common precursor to endometrial cancer, endometrial hyperplasia in a post-menopausal woman often leads to a hysterectomy.

Not all postmenopausal bleeding is bad. Some is just a reflection of a thin uterine lining or thin vaginal wall (medically termed atrophic). Think of dry hands or lips in the winter…they get dry, chapped, and cracked. This can lead to bleeding. There is no medical problem that caused the bleeding (it’s your lack of lotion and chapstick!). And while it can be unsightly, it usually doesn’t require medical treatment. The same goes for what we call endometrial atrophy. With years of low estrogen, things can sort of thin and shrivel. One such thing is your uterine lining. It can become so thin that it bleeds. Last, in certain cases the answer is C: neither of the above. Often, a benign structure like an endometrial polyp (an overgrowth of glandular tissue) can cause postmenopausal bleeding.

Our job is to sort out which type of bleeding you are having—the “I need some chapstick bleeding” or the “I need some surgery bleeding.” We don’t have eyes in the back of our head (even though our kids think we do), and we can’t diagnose endometrial pathology just by looking at your abdomen. In order to make a diagnosis, be it a cancer, hyperplasia, a polyp, or just a really thin lining, we need to perform an ultrasound and possibly even an in-office biopsy.

Sometimes, if more information is needed to make the appropriate diagnosis a D&C is required. The thickness of the uterine lining on ultrasound serves as sort of the gatekeeper for what should be done next. In this case, the line in the sand is 4mm. When the lining is less than or equal to 4mm, you pretty much have the all clear. No further testing is required unless the bleeding continues to occur because the risk of uterine cancer is so low. When the uterine lining is greater than 4mm, you have entered the no-fly zone, and further evaluation is required.

Luckily, the warning signs are fairly bright, so most endometrial cancers are diagnosed and treated early (making survival rates quite high). While most women with endometrial hyperplasia and cancer will require a surgical procedure (hysterectomy), it is a small price to pay to be cancer free. While seeing red again can be alarming, it is not always bad. However, you do need to sound the sirens (a.k.a. call your OB/GYN) and police the situation. Even the smallest drops in the bucket matter. When you are postmenopausal, every spot matters.