By: @drmelissa.co

A woman’s period is a vital sign. Just like your blood pressure, heart rate, temperature, and breath rate, a woman’s cycle is indicative of her health overall. An imbalanced period indicates suboptimal health. 

The menstrual cycle is incredibly complex and requires a constellation of factors to align for it to occur at regular intervals. Factors that can delay a period or cause it to happen unpredictably vary from diet and lifestyle to emotional stressors and deeper underlying health concerns. 

Before delving into the potential causes for a missed or irregular period, it is important first to note what a healthy period looks like. A healthy period typically occurs every 25-35 days (with day one being the start of menstrual bleeding). The key is that a period occurs at around the same interval for a woman. In other words, it can be healthy and normal for a woman to have her period every 28 days, as long as this is the pattern she is seeing most of the time. For another woman, each cycle may be closer to 32 days; as long this is consistent, there is no cause for concern. When the period starts to occur at varying intervals — for example, 25 days one cycle, 34 days the next cycle, 29 days the next cycle — it is a signal from the body that an underlying factor may be out of alignment and needs to be addressed to bring the period into a tighter, more predictable range. Another scenario warranting investigation is when a woman’s cycle is shorter than 25 days or longer 35 days.

A healthy period not only arrives at regular intervals, it should be relatively symptom-free. Increased appetite a few days before along with mild fatigue when the menses starts can be normal. Other symptoms like premenstrual symptoms (aka PMS — breast swelling and/or tenderness, breakouts, mood swings, night sweats, etc.), symptoms that begin at the onset of bleeding (cramping, nausea, headaches, etc.), and the quality of the period itself (clotting, colour of flow, how long the bleeding lasts, how heavy it is) all provide additional information along with cycle length that help a clinician like myself understand what the body may need in order to have a more symptom-free, regular cycle. 

When a period is late, the first condition a doctor will assess for is pregnancy. If pregnancy is not the cause, the following should be assessed for, especially if a woman’s period has been irregular for three or more cycles: 

• Activity level: for some women, over-exercise, endurance training, and/or competitive athletics can decrease fat stores and modify hormonal balance such that a period may come irregularly or sometimes not at all. This is especially true if the woman is not consuming enough calories and nutrients to meet her metabolic needs - particularly fats and proteins. 

• Birth control: using certain birth control methods (oral contraceptive pill, hormonal IUD) will cause a woman not to have a true period or bleed at all. Furthermore, when coming off of these birth control methods, women may not resume normal periods for some time after cessation and may require support.

• Breakouts: acne breakouts that occur around a woman’s period or even those that happen throughout the cycle can be indicative of hormonal imbalance, especially when paired with irregular cycles. Acne that tends to be more connected with hormones occurs along the jawline, on the chin and cheeks, and on the neck, and typically can be more cystic in nature.

• Breast symptoms: discharge from the nipples along with irregularly timed periods can be indicative of a prolactinoma — a benign tumour of the pituitary gland in the brain which causes imbalance in sex hormone levels like estrogen and testosterone. This must be addressed before a period can become normal. 

• Diet: poor nutrition can cause imbalanced hormones and a lack of nutrition necessary for healthy, regular cycles. Eating three balanced meals daily with protein, healthy fats and a variety of fruits and vegetables, ideally eaten at regular intervals can help with menstrual regularity. Breakfast is a particularly important meal when it comes to a healthy cycle; aim to eat within 90 minutes of rising, ensuring the breakfast contains both proteins and healthy fats. 

• Family history: some women note that other women in their families have suffered from irregularly timed or missed periods. While this does not necessarily mean this is a normal symptom to be experiencing, it can provide a clinician with insight into which family members a patient shares similar characteristics with, and what conditions these family members may also have (i.e. polycystic ovarian syndrome, thyroid imbalance, etc.) 

• History of eating disorder: active or past eating disorders can have an impact on hormone levels, causing irregular or elongated menstrual cycles. Typically consistent and long-term dietary intervention, support with supplements, and counselling is required for recovery.

• Medications: certain medications may interfere with a woman’s menstrual cycle. These include chemotherapeutics, medications for epilepsy, certain antidepressants, thyroid medications, blood thinners like aspirin, and anti-inflammatories.

• Post-partum and/or breastfeeding: after pregnancy, it may take time for a woman’s cycle to resume and regulate, particularly if she is breastfeeding. 

• Thyroid dysfunction: an over- or under-active thyroid gland can cause changes to a woman’s cycle. 

• Weight: being over- or under-weight can cause menstrual irregularities, including a delayed or missed period. Underweight individuals may be missing the calories and  nutrients required to produce the hormones needed to produce a period. Individuals who are overweight may be at risk for conditions like polycystic ovarian syndrome and/or insulin resistance which can cause an interference with ovulation, and therefore cause irregular cycles. 

• Other medical concerns: scarring of the uterus (Asherman’s syndrome), issues with the adrenal glands (Cushing’s syndrome or congenital adrenal hyperplasia) can also be underlying causes of irregular periods.

If you suffer from irregularly timed or missed periods, it is important to speak with your doctor. A detailed history, physical examination, blood work and possibly further imaging can provide valuable information and allow the clinician to understand why this is happening and provide the necessary treatment. 

It is important to note that, in many cases, the oral contraceptive pill is prescribed to initiate a “regular" period; however, this is not what this medication does. This medication will cause a monthly withdrawal bleed that is not a true period, often misleading a woman into thinking she has a regular cycle. This is not the case, and only masks the problem; when a woman is on the pill, we do not know what her period looks like naturally. The pill (along with other birth control methods) are best used for birth control only, not to manage menstrual symptoms. Instead, I guide patients in understanding the root cause of the cycle irregularities. When we discover why they are happening, we can provide the body with what it needs to heal and have regularly timed, healthy cycles.