Menstrual cycle: What's normal, what's not, and when to see the doctor

Many women have experienced varying menstrual cycles that have left them wondering whether their menses are normal or abnormal. Here’s how to tell whether your cycle is normal.

What is a normal menstrual period? 

Normal menstruation is defined using a number of parameters including: Frequency, (the first day of one cycle to the first day of the next should be between 24 to 38 days), duration, (number of days of bleeding should be up to eight days), regularity (variation in cycle length from month to month shouldn’t vary by more than seven to nine days), and, volume of blood lost during menses should not interfere with one’s physical, social, emotional well-being and quality of life. 

The common misconception is that some women think regular menses are the ones that come on the same date every month. This is not true. As long as menses fall within the criteria described above, they are normal. 

What is considered abnormal menstrual bleeding? 

Abnormal menstruation is any pattern that falls outside the criteria outlined above. That is, frequent menstrual bleeding (these are menses that occur in less than 24 days between the first day of one cycle to the next), infrequent menstrual bleeding (menstrual cycles that occur after more than 38 days between the first day of one cycle to the next, and, there are people who go for several months without seeing their periods), prolonged menstrual bleeding ( the bleeding period goes on for more than eight days), intermenstrual bleeding (this occurs when one bleeds in between well-defined menstrual cycles), heavy menstrual bleeding (bleeding that is heavy enough to impact the woman’s quality of life, physical, mental and emotional well-being). It is usually subjective. But generally if someone reports symptoms of anaemia such as headaches, dizziness and easy fatigability, it may give a clue on this. Also, if one changes a pad in under three hours, experiences big blood clots during menstruation or they have to  wake up at night to change a pad. 

Other signs of abnormal periods are; postmenopausal bleeding (any form of bleeding, whether spotting or heavy, that occurs after menopause) and postcoital bleeding, which occurs during or after sex.

Are there any instances of abnormal menstrual bleeding that may be considered normal?

Yes. For example, in adolescents, the years following the first period may be marked with irregular periods, heavy or light periods or even prolonged or no menses. All these occur due to the premature system that regulates menstrual bleeding, matures over the years and a regular pattern sets in. However, this can still be dangerous to young girls especially when it is very heavy or prolonged bleeding due to risk of anaemia, poor quality of life, among others.

The other situation where abnormal menses are not uncommon are the year preceding menopause - perimenopause or transitional period. These years are also marked with erratic menstrual bleeding of different patterns as the female hormones are shutting down. Just like in adolescents, if heavy or prolonged, it can be dangerous due to anaemia and poor quality of life. 

What are the causes of abnormal menstrual bleeding? 

Abnormal menstrual bleeding can be caused by several things. It is therefore advisable that medical help is sought to establish the cause and start treatment if need be. They include:

Polyps: These are small growths that occur in the inner lining of the uterus (endometrium) or cervix. They are mostly associated with intermenstrual, heavy or postcoital bleeding.

Adenomyosis: This is a condition that occurs when the cells in the inner uterine lining go to the muscle of the uterus, causing it to be enlarged and lead to pain and heavy or prolonged menstrual bleeding. 

Fibroids: These are growths that occur in the uterus. They are very common and can cause the uterus to enlarge; resembling a pregnancy. They lead to heavy and prolonged menses. 

Cancers: Cancers of the birth canal can cause intermenstrual and postcoital bleeding. This can be cancer of the cervix, uterus, vagina or vulva or even some cancers of the ovary. 

Blood clotting: Some people have problems with blood clotting either due to some medications such as blood thinners or poor functioning of blood components that control bleeding.

Medications: Medications such as blood thinners for blood clotting or some family planning methods can lead to abnormal menstrual bleeding. 

Infections: Infection in the birth canal such as pelvic inflammatory disease or yeast infection can lead to irregular menstrual bleeding and postcoital bleeding. 

How do I know if my menses are abnormal or normal? 

If you notice that your menstrual bleeding comes more often than 24 days (count from first day of period to the next first day); is longer than 38 days, or you bleed for more than eight days, or you change your pads in under three hours/have to use a pad and a tampon at the same time, or you wake up at night to change pads, or you skip work due to heavy menstrual bleeding, seek medical attention. A girl who hasn’t seen her first period by the age of 15 years should also seek medical attention.

How is abnormal menstrual bleeding managed? 

Management of abnormal menstrual bleeding varies depending on the cause. Once you get seen at the hospital, you will be checked to assess the impact such as anaemia, and possible causes of the abnormal bleeding after which an appropriate treatment will be instituted. Once the cause is identified, your doctor will hold a discussion with you on the various available treatment options. Some menstrual bleeding problems may need medication while others require surgery. It is important especially for postmenopausal women to see a doctor because postmenopausal bleeding can be a sign of a more serious medical condition such as uterine, cervical or ovarian cancer.

Young girls whose first period has delayed also need to be seen to check for some possible causes that may have occurred during their intrauterine life.

Dr Okemo is Consultant Obstetrician Gynaecologist at Aga Khan University Hospital, Nairobi