After last week’s endo post, I got an email from a beloved former client. The request was simple:
I would love more future musings about heavy periods, the possible root cause, and how to bring this up to a gynecologist so that they genuinely address it beyond just prescribing birth control. (Asking for a friend... :))
Yeah, I can do that.
It should be said from the start: I’ve never considered myself a menstrual health specialist or expert. But so many things I treat — endo, pelvic inflammatory conditions, fibroids, etc. — all center around this really cool AF cycle that a lot of people experience every freaking month.
Over the years, I’ve heard the same story: A sense of unease regarding changes in cycles. Bothersome symptoms. And gynecologists who shrug and say, “Birth control will help that!” without listening to the person’s health priorities.
So let’s get into it.
Here’s the tl;dr:
Bodies are different. With that said, there are norms that any menstruating person can expect.
A shift in cycles or new onset of symptoms can be a sign that something is up. It can also be your bod just doing the thing it does best, which is changing, always.
A normal period does not meaningfully disrupt your life due to physical or emotional symptoms. Normalizing AFAB people’s bodies suffering is not okay.
The deep dive:
I know you know, but I’m not your clinician. And, as mentioned up top, even if I were, we’re really here to talk about when to go to your GYN provider, and what to do if they are not supportive of your wishes. Cool cool?
Okay, so we know that bodies are different. But there are some general norms that we expect from a healthy menstruating person’s period. They are:
Cycle length of 21-35 days (average length is 28, and some scientific orgs suggest a tighter normal range of 23-32 days)
Period duration (i.e. length of menstruation, aka bleeding) of 2-7 days
Heavy bleeding is defined differently by different scientific agencies. The CDC defines it as filling a “tampon or pad more than every 2 hours or passing clots the size of a quarter or larger.” I have thoughts on this (see below).
No abnormal bleeding or “spotting”, i.e. no bleeding when you’re not on your period.
No pain or “mild” cramping in the days prior to and after your period begins. Similarly, “mild” changes in mood and affect in the days leading up to your period.
Sounds like a goddamned dream, right!?
It’s important to really hammer home that the best evidence is your own N of 1, which is to say, know thyself. If you know your own normal, you’ll be a better detective if things are veering off course, and to stay secure in what is healthy for your bod. Maybe that’s a 24 day cycle and a 7 day bleed, or a 31 day cycle and a 3 day bleed — it honestly doesn’t matter as long as it is working for you.
With that being said, I cannot count the amount of times I have heard about GYN providers normalizing pelvic pain, heavy periods, and PMS. Over and over again, one tool is used: oral contraceptives (OCs).
I am not against OCs. But they are a medication, and all medications have side effects — of which PMS, depression, lowered libido, and oh yeah, painful sex (vestibulodynia) are all included.
Once again, to be clear: OCs are not evil, and I’ve seen them work wonders, especially in folks with endometriosis. Know yourself and trust yourself when making these decisions.
Okay, so back to periods. Let’s say you’ve got a real rager of a cycle. It’s seven days long and you are busting through cups, tampons, pads, etc. You’ve got the period underwear. Your sheets are stained and you live by a black pants only rule. Oh, and you’re anxious AF and are constantly vibing on a heating pad.
It needs to be said: This is not normal. It’s normalized, and it’s frequently medicated (see OCs as an intervention). But you don’t need to accept these symptoms as your normal, especially if it’s really impeding on your ability to live life.
What OCs do is simply stop ovulation, halting the whole process. This can be a game changer for folks, and it’s not an inherently bad option. But it very frequently doesn’t treat what’s driving the dysfunction in the first place.
So what is the “root cause” of what’s going on?
How many times can I say this? Do not diagnose yourself over the internet. Bodies are highly bio-individual and it’s important to partner with providers you trust to help you sleuth this out!
Here are some conditions I regularly interface with in my practice that can cause heavy and/or painful bleeding, mental health symptoms, and pelvic pain:
Uterine fibroids (easily diagnosed via vaginal ultrasound)
Endometriosis (as discussed, not easily diagnosed — laparoscopic surgery is the gold standard)
Hormonal dysregulation. LOL! This can mean like a million different things and can be really tricky to effectively diagnose. This is why a team of skilled and trusted providers who actually give a fuck about you is crucial. (And yes, that’s a huge privilege that is not available to everyone.)
Perimenopause. If you’ve noticed that your period has gotten soooo much heavier past the age of 35 (yes, I said 35), you could be experiencing perimenopause, for which there is no precise testing mechanism. The endometrium — the lining of the uterus — can thicken during this process, which translates to heavier periods.
Scary stuff. Yes, I mean cancer. While it’s highly unlikely, this is why it’s great to ensure that you have regular screenings and GYN care. If you have any AFAB anatomy, you need a gynecologist! Preferably one that you like! A PCP who takes a PAP smear is not sufficient, IMO.
Let’s break down the basics of “hormonal dysregulation” for a hot minute. A quick visual review of the hormones in a “healthy” menstrual cycle:
We generally think of “PMS” symptoms to be due to the fall in both progesterone and estrogen, and specifically, progesterone. Lower than normal progesterone status is relatively common and throws the ratio of estrogen to progesterone off, therefore creating a state of “estrogen dominance”. The following symptoms are associated with lower progesterone/higher estrogen levels: heavy menstrual bleeding (lol!), more significant PMS symptoms/cyclic mood changes, undesired weight gain, and decreased sex drive. What a time!
The causes of these kinds of imbalances are broad and multifactorial, and “healing” them requires time, support, and individualized care. These are all massive privileges on like, a thousand fronts.
If you’re exploring a new provider or want to try different intervention strategies with an existing provider, try the following script: “I’m experiencing X, Y, and Z symptoms, and I don’t feel like my current plan of A, B, and C is really serving me.” If you are not open to OCs as an intervention, now is the time to simply say “I understand that OCs are a recommended intervention, but I am not interested in that option at this time for D and E reason.” Then: “Can we collaborate on strategizing some different options for my care?”
There’s no correct response. But hopefully your provider will be thoughtful and validating. If not, run.
Here’s the take-home:
There’s also no right way to work through these types of challenges, especially less cut and dry issues like hormonal dysfunction. One of my favorite resources on this topic is Dr. Aviva Romm’s Hormonal Intelligence, which is a sort of bible to me. I highly recommend it!
If you’re experiencing heavy periods and associated pelvic pain, I really highly recommend gentle movement to reduce the amount of fascial tension around the reproductive organs. I know, I know, no one feels like moving, and I am absolutely not suggesting you push for a PR. But I promise, a little twisting and breath work really, really help. Stay tuned later in the week for some of my favorite movement classes for painful periods!
As always, hang in there. You deserve a cycle without pain. You deserve amazing care providers. Remember that you deserve these things — they are your right, despite the health care system being in utter shambles.
I am always rooting for you.
Great letter, as always! I wonder how often you see people with adenomyosis and heavy bleeds?