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In July 2007, our guest expert in Le Club's Ask the Expert was Eileen McMahon, RN, BScN, MN.

Born, bred and trained in Toronto, Eileen is an Advanced Practice Nurse (APN) specializing in gynecology, and based at Women's College Hospital. An APN is a Masters-prepared nurse who is responsible for providing leadership and promoting excellence in care within a health-care setting.

Eileen has a special interest in "best practices" in all areas of gynecology. She also is the moderator for the popular Gynecological Health Discussion Group on womenshealthmatters.ca.

Here are Eileen’s answers to your questions on Menstruation:

Q: I am 45, have been having hot flashes and mild night sweats. My periods are still heavy and seem to becoming more painful as well as becoming more frequent. Sometimes it’s only 17 days between periods. I thought they would become milder and less frequent. But I seem to be going backwards and wonder, is this normal? Do they get worse before they get better and cease all together?  Thanks.

A: The symptoms you are having seem to indicate that you are in the menopause transition, or perimenopause. Perimenopause is a normal phase of a woman’s life, often beginning between the ages of 39 - 51 and lasting between 2 - 8 years. It is a gradual process that often begins with changes in the menstrual cycle and these changes can include lighter, heavier, or missed periods, as well as longer or shorter cycles. These changes are often due to decreased frequency of ovulation and erratic levels of ovarian-secreted hormones.

That being said, it would be worthwhile for you to let your doctor know that you are having bleeding at intervals less than 21 days (provided the 17 days between periods you speak of include the onset of one period and beginning of the next occurring within 17 days) so that potential concerns can be investigated. Once that is done, if you are healthy and non-smoking, you may benefit from low dose oral contraceptives during the perimenopause — not only for birth control, but to relieve the symptoms of menstrual cycle irregularity.


Q: I have tried so many types of birth control pills and I continue to have one persistent problem — I spot for about a week and a half before my period is due. It is enough to require tampon use. The only birth control method that got rid of this was the Nuva ring, however the side effects outweighed the benefits for me (very bad breakouts, yeast infections, bacteria vaginosis). As I said, I've tried so many different types of birth control pills (and each for at least three months), but I continue with this problem. What should I do?

A: Bleeding that requires a pad or tampon during the time active oral contraceptives are taken is known as breakthrough bleeding (BTB). BTB is most common with low-dose combination and progestin-only pills, and more common in overweight women.

Bleeding that starts after the tenth pill in the pack is taken is usually due to insufficient potency or dose of the progestin component. It sounds like you have tried a number of different pills and the ring, but have you also been examined for other conditions that may cause bleeding? If so, and if these investigations were negative, then your best option would be to use a pill with high progestational activity (for example Marvelon, Yasmin, or Linessa) and be sure to take the pill at the same time each day. Alternatively, you may want to inquire about the Mirena intrauterine system which may shorten, lighten or even eliminate your periods.


Q: I have been spotting before my period for the last two years - for five days, and then I have my period (at this point my period is only two days long).

I have had a D&C and a hysteroscopy and four transvaginal ultrasounds — these were all negative for anything abnormal. I have seen two gynecologists — no one seems worried. For the last 1 1/2 years I also have severe pain in my left ovary.

Advil helps, (there have only been three really bad months so far). In a good month it's 15 days and it’s only two to three days of pain). Again the gynecologist is not worried.  I have one more follow up appointment next week.  Any ideas? Mostly, I'm concerned about the pain in my left ovary and the amount of Advil I am taking.

A: Spotting before the full flow of a period starts is not uncommon and is almost always harmless. It is reassuring that your doctors have taken your concerns seriously and have investigated appropriately, and that these investigations are negative. It could be that the spotting you experience is actually the start of your period and is just light flow, especially if there are no days without spotting before your full period begins.

Although we cannot always explain why some women have spotting before a period, or very light flow to start a period, theories include low progesterone levels and short ovulation times. To help decrease the spotting, you may want to inquire about cyclic progesterone therapy.

With respect to your pain in your left ovary, left lower quadrant pain can be the result of a number of things, not just ovarian-related issues.

Keeping a pain diary may help your health care provider to determine the cause — keep track of the pain location, the type of pain (dull ache, stabbing pain, cramp etc.), what you were doing when the pain started or increased, what helped take the pain away, timing of the pain (for example where in your cycle), whether you had any other symptoms with this pain (nausea, headache, etc.), as well as how intense the pain was (scale of 0-10, 0=no pain, 10=worst possible pain).

Given your negative ultrasound results, you may want to consider other reasons for the pain; the foremost on my list would be constipation. See whether increasing your daily fibre intake, either by diet or supplement (such as Metamucil), decreases your pain. Even with regular bowel movements, women are often constipated and feel much better with a little fibre.


Q:  I am a 44-year-old woman. I still get my period regularly but in the last four years I find that I get my period for approximately four days, and then it stops for two days, and starts again just like it was the first day. It then lasts about another four days. Should I be concerned?

A: Like our very first question, your symptoms may indicate that you are in the menopause transition, or perimenopause. Considered the hallmark sign of perimenopause, menstrual changes related to flow and frequency are often due to decreased frequency of ovulation and erratic levels of ovarian-secreted hormones. To be safe, however, it is important that you have this investigated, especially if your bleeding is lasting more than seven days in total.


Q: I am 46-year-old woman and I have been bleeding for 14 days — going on 15.  It has been steady with no signs of letting up.  There has been some clotting and I do not know what to do. It is the first time that this has happened to me.  Can you give me some advice please?

A: As this is the first time this has happened to you, and because the bleeding is lasting longer than seven days and is associated with clots, it is important that you have this investigated. Unfortunately I am unable to assess you and therefore unable to determine the cause of your bleeding. Please see your health-care provider so that they can do so.


Q: Hello Ms. McMahon, I am really concerned about my monthly cycle. I have been getting two periods in one month, and both times they are flowing hard and lasting seven to nine days. I am 28 years old and weigh 274lbs. I'm currently on a diet (since March 5) and have lost 40lbs. Could that be a cause of having two periods in the same month?

A: First and foremost, congratulations for working at decreasing your weight! Your significant weight loss is quite rapid, however, so please be sure you are achieving this safely. Frequent periods can be caused by malnutrition so have a look at the diet you are on and be sure it follows Canada’s Food Guide to Healthy Eating. If you are confident that you are not malnourished, you should see your health care provider so that a thorough work-up (including a history, physical examination, and likely blood tests and an ultrasound) can be undertaken to determine the cause of your polymenorrhoea.


Q: I have a question about heavy periods for people with iron deficiency:  Is it possible to lose too much blood?  Or is it all 'waste' blood and not a concern? 

A: In North America, the most common cause of iron-deficiency anemia is menstrual blood loss, and women with heavy periods are at even higher risk for this condition. Because menstrual blood consists of a mixture of ordinary blood, the sloughed-off layer of the lining of the uterus (endometrium), and the virtually microscopic remains of an unfertilized human egg, it is possible to lose too much blood. In women with excessive or prolonged menstrual bleeding (menorrhagia), the health-care provider should investigate causes for the heavy bleeding. These include hormonal imbalances, uterine fibroids, polyps, lack of ovulation, side effects of certain medications or other medical conditions. If and when a cause is determined, a treatment plan would be recommended.


 I am not sure if I am in the menopausal stage, but in the last six months I have had my period — and when I do it is for 10 days then I go for about two weeks and have it again.  Then I don't have it for about two months and it starts again. My age is 54. This started when I was 53.  Thank you.

A: Like our very first question, your symptoms may indicate that you are in the menopause transition, or perimenopause. Considered the hallmark sign of perimenopause, menstrual changes related to flow and frequency are often due to decreased frequency of ovulation and erratic levels of ovarian-secreted hormones. To be safe, however, it is important that you have this investigated, especially since your bleeding is lasting more than seven days and is occurring at frequent intervals.


Q: I get my period for two weeks. First day light brown then it turns browner, then darker, then black and then finally after a week it turns red. I have two heavy days. I have a little discomfort but that's about it. I went for tests. I may have a little tiny polyp which may be causing this. My doctor says it nothing to worry about. He wanted to do an endometrial ablation, but I said no and that I would just leave it. I will go for my yearly checkups, especially to keep an eye on that tiny polyp. What do you think about my long periods? Is there anything I can do naturally to help this problem? I hear soy might help a little so I'm eating a little bit of soy nuts everyday.

A: Unfortunately natural remedies are not in my scope of expertise so I would hate to offer you inaccurate information! Your best bet would be to see a Naturopathic Doctor who can better inform you. In terms of the polyp, it certainly could be the cause of your bleeding and we always recommend removal of polyps that are causing symptoms. Besides the ablation, another treatment option to consider is a hysteroscopic polypectomy. Hysteroscopy is a procedure where a hysteroscope, a thin tube with a tiny camera, is used to look at the inside of your uterus. Once the polyp is seen, it can be removed and sent off to pathology for tissue diagnosis. Most centres offer this simple procedure in an out-patient manner under local anaesthetic (meaning you would not have to be put to sleep) so it’s certainly something to think about!


Q: I'm 46 and am in good health, plus I exercise regularly and try and eat healthy.

Ever since I've been menstruating, I usually get some cramps but can reduce the pain by taking some Advil. But, over the last several months, I've been experiencing a different kind of pain: very severe cramps localized in my lower left abdomen area (rather than generally throughout the abdomen). Sometimes this pain wakes me up at night and I find that taking even extra strength Advil doesn't get rid of the pain, and sometimes it's very acute. However, the pain only occurs during my period. I mentioned this to my doctor at my last annual checkup and she did a pelvic exam (she always does one of these) including an internal hand exam while pressing the lower abdomen, but found nothing unusual.

But, I'm wondering if this change in cramping is normal as women get older? Is it body or hormonal changes as we approach menopause? Is there anything else that could alleviate the pain?

Thanks very much. 

A: Good for you for exercising regularly and for trying to eat healthy! Considering your doctor assessed your pelvis for abnormalities and found none, the pain you are describing may very well be menstrual-related constipation. The colon is a very sensitive organ and can react to many different things including the body's hormones, so women often experience constipation problems around menstruation and menopause. Try increasing your daily fibre intake either by diet or supplement (such as Metamucil) just before and during your period, and see if your symptoms improve.


Q: I am spotting a week before my scheduled period.  Why is this happening??

A: Like I mentioned in one of the answers above, spotting before the full flow of a period starts is not uncommon and is almost always harmless. You may be experiencing these symptoms because of low progesterone levels and/or short ovulation times. You should, however, see your health-care provider so that together you can try to determine the cause of the spotting, and to discuss the possibility of cyclic progesterone therapy.


Q: Is it possible to get pregnant without getting your period?

A: This is a tricky question to answer as I do not have information such as whether you have had your first menstrual period yet, whether you have had regular periods but are now having an episode of amenorrhoea (absent periods), or whether you are breastfeeding. Generally speaking, it is possible for a woman to get pregnant without having periods because she normally releases an egg 12-16 days before the day she expects a period. If that egg is fertilized, the expected period will not occur! Women who have infrequent periods (possible causes include polycystic ovarian syndrome, low body weight, extreme exercise, breastfeeding or perimenopause) may ovulate at any point so contraception should always be used if pregnancy is not desired.


Q: My flow seems to change from month to month.  I am almost 40 and have never had children. Some months are "regular," some "heavy" and some very "light."  Some months the flow is over in three days, some it drags on for seven or eight days. Is this just part of the normal aging process, or could there be a problem?

A: Like our very first question, your symptoms may indicate that you are in the menopause transition, or perimenopause. Considered the hallmark sign of perimenopause, menstrual changes related to flow and frequency are often due to decreased frequency of ovulation and erratic levels of ovarian-secreted hormones. To be safe, however, it is important that you have this investigated, especially if your bleeding is lasting for more than seven days.


Q: I am 25 years old and have recently been having some trouble with my menstrual cycle.

For the past couple of cycles I have been late (I am usually pretty regular and have a period that lasts about five days). Now my period is usually late and lasts from two weeks to a month — mostly spotting after a regular period I don’t know what’s wrong with me. I will stop spotting for a day or so and then keep spotting again. Then I may not have another period until a month or two months later Please, is there anything I should be concerned about?

A: Changes in your menstrual period can result from physical or hormonal imbalances. Sometimes the amount or timing of hormones released by the thyroid, adrenal and pituitary glands, or hypothalmus may cause the ovary to delay or skip ovulation.

If ovulation doesn’t occur, regular periods are not possible. However, the same changes in hormones may trigger bleeding at abnormal times (like the spotting you are experiencing). A common cause of anovulation (lack of ovulation) is body weight; low body weight can cause a prolonged absence of periods whereas excessive body weight tends to cause abnormal bleeding.

Other things, such as sudden changes in how often or intensely you exercise, stress, certain medications and herbal preparations as well as physical changes in the uterus or ovaries, such as abnormal development of tissue in the uterine lining or muscle, or ovarian cysts, may also be the cause. It would be a good idea for you to see your health care provider so that these causes can be investigated and from there, a treatment plan can be recommended.


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