Managing difficult menses

This post was written by Wendy Walmsley, NP, PPG – OB/GYN.

During the reproductive years leading up to menopause, a woman will have approximately 450 menstrual cycles over her lifetime. Despite the frequency of this occurrence, it can be hard to discern "normal" from concerning. In this post, we discuss the most common signs of difficult periods and available treatment options.

Overview

Having difficult menstrual cycles can be disruptive to everyday life for many women. While occasional fluctuations in period flow or changes in how you feel are natural and expected, when menstrual experiences interfere with responsibilities or social interactions, it may signal an underlying issue.

Common symptoms that accompany difficult periods can include:

• Dysmenorrhea (severe cramping/pelvic pain): Painful menstrual cramps may occur from time to time. It's typical to experience cramping just before or during your period. The pain from primary dysmenorrhea (not caused by a medical condition) and secondary dysmenorrhea (related to a problem other than menstruation) can range from mild to severe. It can involve the lower belly, back or thighs. You may also have headaches, nausea, dizziness, fainting, diarrhea or constipation with your cramps.

• Menorrhagia (heavy bleeding): Most women lose between 20 and 80 milliliters (mL) of blood per period. With heavy menstrual periods, your bleeding may be heavier or last longer than usual. It may also include passing large blood clots (larger than a grape or quarter) and soaking through your pads or tampons often.
  
  Measuring exact blood loss can be challenging, but tracking menstrual product usage can provide a rough estimate.

  • Menstrual cups often include volume markings on their exterior and can typically hold between 25 and 30 mL of fluid.

  • Tampons may hold between 3 and 12 mL of liquid, depending on their size and absorbency.

  • Sanitary pads may hold between 5 and 15 mL of liquid, depending on their size and absorbency.

For a few months, keep a record of how frequently you change products each day of your cycle. If the total amount per cycle exceeds 80 ml, consider speaking with your gynecologist or primary care provider.

• Irregular bleeding: The average adult menstrual cycle is approximately 21 to 35 days long, while for a teenager, it can range from 21 to 45 days. Bleeding is considered irregular if it occurs more or less often than normal, lasts more than 7 days, is lighter or heavier than usual, or occurs unexpectedly, such as between cycles or after sex.

• Premenstrual dysphoric disorder (PMDD): Premenstrual syndrome (PMS) refers to a range of physical and emotional symptoms that occur in the lead-up to menstruation each month. While PMDD has similar symptoms to PMS, it is a more severe and debilitating form, marked by intense mood swings, depression and anxiety. These symptoms can significantly affect daily life.

Women can have one or more of these symptoms with their periods.
 

Causes and diagnosis

Before treating these problems, it's important to identify the cause, as this can help your providers recommend the most effective treatment options for your circumstances. To determine what's behind your symptoms, your provider will start with a detailed medical history and a conversation about your cycle patterns. From there, they may recommend additional testing, such as blood work, pelvic exams or an ultrasound. A range of factors can contribute to abnormal or painful cycles, including:

• Hormonal dysfunction such as thyroid disorders or polycystic ovary syndrome (PCOS)

• Structural conditions like endometriosis, uterine fibroids, adenomyosis, or polyps

• Clotting disorders

• Lifestyle factors, including high stress, poor sleep, diet, lack of exercise or obesity

• Medications and chronic conditions
   

Treatment

Management approaches depend on the specific symptoms you're experiencing. Here's how your provider might address each:

Menorrhagia (heavy bleeding)

• Hormonal treatments: Combined oral contraceptives, progestins, GnRH agonists or hormonal IUDs

• Non-hormonal treatments: Medications like tranexamic acid or NSAIDs (ibuprofen) to reduce blood loss

• Surgical options: Endometrial ablation, myomectomy or hysterectomy for severe cases
   

Dysmenorrhea (severe cramping/pelvic pain)

• OTC pain relief: NSAIDs to reduce prostaglandin levels

• Hormonal regulation: Birth control pills, patches or IUDs to suppress ovulation

• Alternative therapies: Acupuncture, magnesium supplements and heat therapy

• Surgical options: Endometrial ablation, endometrial resection or hysterectomy for severe cases
   

Irregular cycles

• PCOS-related: Weight management, metformin, hormonal therapy

• Thyroid or prolactin-induced: Correcting underlying endocrine dysfunction

• Cycle regulation: Combined hormonal contraceptives or cyclic progesterone
   

PMS/PMDD (severe mood and physical symptoms)

• Lifestyle changes: Regular exercise, balanced diet, stress reduction techniques, consistent sleep

• Medications: Selective serotonin reuptake inhibitors (e.g., fluoxetine, sertraline) for mood symptoms, hormonal therapy

• Supplements: Calcium, vitamin B6, magnesium
   

Lifestyle and holistic approaches

• Diet modifications

  • Anti-inflammatory foods: Berries, olive oil, turmeric, avocado, leafy greens, green tea, dark chocolate, tomatoes, nuts and oily fish (salmon, tuna)

  • Iron-rich foods: red meat (beef, lamb, pork), poultry, liver, eggs, seafood (oysters, mussels, clams), legumes (beans, lentils, chickpeas), dark leafy green vegetables (spinach, kale, collard greens), seeds (pumpkin seeds, sesame seeds, flax seeds), nuts (cashews, almonds, pistachios), dried fruits (raisins, apricots, prunes) and whole grains (iron-fortified cereals, bread, pasta)

• Regular moderate exercise to help regulate hormones

• Stress management techniques such as yoga, meditation, and therapy for stress-related cycle changes

 

Final thoughts

While many period issues are common, it doesn't mean they are normal. If something seems off, don't hesitate to speak with your provider. Parkview Physicians Group offers OB/GYN care in over 15 locations throughout the region. Visit the website here or call our Access Center at 877-774-8632 to establish care. To learn more about women's health services at Parkview, visit us here.