Why do periods go haywire?
It all comes down to “the sputtering ovaries,” said Dr. Malcolm Munro, an obstetrics and gynecology professor at the David Geffen School of Medicine at U.C.L.A. In a regular cycle, the ovaries make estrogen to nurture an egg for release and thicken the uterine lining for its arrival, Dr. Munro said. Once the egg is released, the ovary also emits progesterone, which stops the lining from growing and changes its structure to make it a soft landing place for a fertilized egg. If there is no fertilized egg, the ovary stops producing progesterone, which triggers menstrual bleeding. Progesterone is also responsible for stopping menstrual bleeding after a few days, he said.
Think of the uterine lining “like grass in your garden,” Dr. Munro said. Estrogen acts like water that helps the grass grow and progesterone is the equivalent of “cutting the grass every four weeks” and keeping it tidy, rather than letting it grow unchecked.
As a woman enters the menopause transition, the ovaries make less estrogen and have fewer eggs to release, which means there might be cycles where ovulation doesn’t occur at all, throwing off the delicate balance of hormones, Dr. Munro said. “It’s not an on and off circumstance,” he said, “it’s a spectrum.” In some women, it can lead to long gaps between each period because there is no progesterone. The absence of progesterone can also lead to a buildup of the lining, which can “randomly fall off” and trigger unusually heavy periods, he said. Or, for other women, there might be so little estrogen that the uterine lining hasn’t grown much, leading only to some light spotting. Dr. Harlow found in her study that smoking and a higher B.M.I. were associated with heavier bleeding in perimenopause, although it’s unclear why. Black women were more likely than white, Chinese or Japanese women to have heavier bleeding.
There are some risks linked to hormonal imbalances in perimenopausal women — key among them is endometrial cancer, said Dr. Ekta Kapoor, assistant director of the Mayo Clinic Center for Women’s Health. During the perimenopause phase and even after a woman has had her final period, the absence of progesterone means the uterine lining can continue to grow and become abnormally thick — a condition called endometrial hyperplasia, which can turn cancerous, she said. One of the telltale signs of endometrial hyperplasia, Dr. Kapoor said, is heavy periods.
In cases where women have immensely heavy periods, Dr. Munro said, they might also experience iron deficiency and anemia, which in turn can be connected to other common menopause symptoms, including fatigue and brain fog.
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