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Irregular menstruation

Irregular menstruation is a problem that affects many women of all ages, raising concerns and questions about their health. While occasional fluctuations in the cycle may be normal, persistent irregularities often signal the need for deeper diagnosis and possible treatment. Understanding what a regular cycle is, what are the potential causes of its disorders, and what steps can be taken to restore balance is crucial to any woman’s health and wellbeing.

What is regular menstruation? Definition and standards of the cycle

A regular menstrual cycle is one of the primary indicators of a woman’s reproductive health, and its irregularity can lead to more than 35 days of menstrual breaks. To understand when we talk about irregularities, it is first necessary to define what a correct cycle is.

How to calculate the menstrual cycle?

The menstrual cycle is counted from the first day of menstrual bleeding to the day before the next bleeding. The first day of menstruation is therefore the beginning of a new cycle. Keeping a menstrual calendar, whether in a traditional form or using mobile applications, is a simple and extremely helpful method of monitoring the regularity of the cycle, as well as predicting fertile days and ovulation. Regular cycle tracking is not just a matter of knowing your fertility, but a fundamental tool for early detection of potential health issues, allowing you to spot patterns and possible deviations from the norm.

When do we talk about irregular periods? (Polymenorrhoea, Oligomenorrhoea, Amenorrhoea)

A normal menstrual cycle should last between 21 and 35 days, with an average length of about 28 days. Irregularities can be said to occur when the time between menstruation is shorter than 21 days (which is referred to as frequent menstruation – polymenorrhoea) or longer than 35 days (infrequent menstruation – oligomenorrhoea). Also, a situation where the differences in the length of individual cycles exceed 8 days is considered irregularity.

A special case is amenorrhoea. Secondary amenorrhea is diagnosed when bleeding does not occur for more than 3 months in a woman who has previously menstruated regularly or, according to some sources, for more than 6 months. Primary amenorrhea refers to a situation when a girl did not get her first menstrual period until the age of 16.

However, the irregularity of the cycle is not only a matter of its length. It also applies to the duration of bleeding itself (the norm is 3-7 days) and its abundance. Both too little and too heavy bleeding, the appearance of intermenstrual spotting, or the presence of large blood clots (with a diameter of more than 2.5 cm) may indicate cycle disorders. Understanding that irregularity is a spectrum of problems, not just a “late period,” is important because different types of abnormalities can indicate different underlying causes.

Irregular period – is it always a cause for concern?

Not every deviation from the ideal 28-day cycle has to mean illness right away. There are situations in which irregular menstruation is a physiological phenomenon.

Physiological irregularities: puberty and perimenopause

Irregular menstruation is very common in young women during puberty. This is due to the fact that the first menstrual cycles are usually anovulatory, and the endocrine system responsible for regulating the cycle is still maturing. Cycle stabilization can last up to two years from the first menstrual period (menarche), and the entire hormonal system of a young woman can be formed even up to the age of 17.

Similarly, in the perimenopausal period (also known as menopause or menopause), which usually begins between the ages of 40 and 45, and the menopause proper (the last menstrual period) occurs on average around the age of 50-55, menstruation becomes more and more irregular, scanty, and finally disappears completely. This is a natural process associated with the slow extinction of ovarian function.

Physiologically, menstruation also does not occur during childhood (before menarche), during pregnancy and during breastfeeding (lactation), especially in the first months after childbirth, when high prolactin levels inhibit ovulation.

The distinction between physiological, i.e. expected, and pathological irregularities is extremely important. This allows you to calm women during the natural transitional periods of their lives, while also emphasizing when to be vigilant and consult a doctor.

Causes of irregular periods: From stress to serious medical conditions

The range of causes of irregular menstruation is very wide and includes lifestyle factors as well as serious hormonal disorders or organic diseases.

Lifestyle and cycle regularity

Daily habits, stress levels, diet and physical activity have a significant impact on the delicate hormonal balance of the female body, and thus on the regularity of her menstrual cycle.

Stress: the silent enemy of regularity

Severe or chronic stress is one of the most common causes of irregular periods. The mechanism of this phenomenon is well understood: stress affects the functioning of the hypothalamic-pituitary-ovarian (HPG) axis, which controls the menstrual cycle and can block ovulation and menstruation. In response to stress, the hypothalamic-pituitary-adrenal (HPA) axis is activated, which leads to increased secretion of cortisol, known as the stress hormone. Elevated cortisol levels can inhibit the secretion of gonadotropin-releasing hormone (GnRH) by the hypothalamus, which in turn lowers the levels of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) secreted by the pituitary gland. The latter are necessary for the proper course of ovulation. Additionally, stress can lead to increased levels of prolactin, a hormone that can also inhibit ovulation. The result of these hormonal changes may be a delay in menstruation (from a few days to even a few weeks), its complete disappearance (the so-called secondary amenorrhea), shortening of the cycle or changes in the amount of bleeding. This shows that stress is not just a “nerve” problem, but has direct, measurable biochemical effects affecting hormone production and cycle physiology.

Diet and body weight: from deficiencies to obesity

Both deficiency and excess weight can negatively affect the regularity of the cycle. Restrictive diets, rapid weight loss and eating disorders such as anorexia or bulimia often lead to irregular menstruation or its disappearance. The body of an underweight or rapidly losing weight woman produces smaller amounts of GnRH. Too low a level of body fat (below 17-22%) disturbs the production of estrogens, which are necessary for the proper course of the cycle.

On the other hand, significant obesity is also a common cause of menstrual disorders. In the cells of adipose tissue, androgens (male sex hormones) are converted into estrogens. Excess estrogen, unbalanced with an adequate amount of progesterone (which occurs in the absence of ovulation), leads to excessive growth of the endometrium and, consequently, to irregular, often heavy bleeding.

A deficient diet, poor in key nutrients and rich in highly processed products, can also lead to hormonal disorders and ovulation problems. For proper hormonal balance, it is important to provide the body with adequate amounts of zinc, iron, selenium, B vitamins, iodine, magnesium and omega-3 essential fatty acids.

Physical activity: when does sport harm the cycle?

Physical activity is generally very beneficial to health, but too much of it can become a stressor for the body and negatively affect the reproductive system. Intense physical exertion, competitive sports or hard physical work can disrupt the regularity of the cycle. Excessive activity, especially when combined with an insufficient supply of calories, can completely block ovulation and menstruation. The body treats such a state as a signal of danger, raising cortisol levels, which in turn reduces the secretion of GnRH and LH, crucial for ovulation. On the other hand, regular, moderate exercise can help regulate the cycle, relieve symptoms of premenstrual syndrome (PMS), and reduce stress. Therefore, it is crucial to find a balance and adjust the activity to the individual capabilities of the body.

Other factors: travel, stimulants

Even seemingly insignificant factors can affect the regularity of the cycle. Frequent travel associated with changes in climate and time zones can disrupt a woman’s internal biological clock, affecting the secretion of hormones. Similarly, alcohol and other substance abuse negatively affects hormonal balance and can be the cause of irregular menstrual periods that become scanty and irregular.

Hormonal disorders as the main culprit

Disorders in the delicate hormonal play of the female body are one of the most common causes of problems with the regularity of the cycle.

Polycystic ovary syndrome (PCOS) – the leading cause

Polycystic ovary syndrome (PCOS) is a complex endocrine disorder that, according to various estimates, affects from 5% to even 15% of women of childbearing age and is one of the most common causes of irregular menstruation. It is characterised by the presence of at least two of the three Rotterdam criteria:

1. Infrequent ovulation or complete absence, which manifests itself as infrequent periods (oligomenorrhoea) or lack of them (amenorrhoea).
2. Clinical and/or biochemical features of hyperandrogenism, i.e. excess of male sex hormones (e.g. acne, hirsutism, androgenetic alopecia).
3. Characteristic, polycystic image of the ovaries on ultrasound (presence of numerous small follicles, typically more than 12-20 with a diameter of 2-9 mm and/or increased ovarian volume of more than 10 cm3).

At the root of PCOS is a complex network of hormonal disorders. The ovaries produce excessive amounts of androgens, and the situation is often aggravated by concomitant insulin resistance (reduced sensitivity of tissues to insulin) and increased levels of luteinizing hormone (LH). Excess androgens interfere with the normal growth and maturation of ovarian follicles, resulting in many follicles starting to grow, but none reaching maturity sufficient to release an egg, leading to anovulation and irregular cycles. Insulin resistance, in turn, stimulates the ovaries to produce even more androgens, creating a vicious cycle. PCOS is not just a gynecological problem, but a complex metabolic disorder that can have wide-ranging health implications, including an increased risk of developing type 2 diabetes and cardiovascular disease.

Thyroid diseases: hypothyroidism and hyperthyroidism

The thyroid gland, a small gland located in the neck, plays a key role in regulating the metabolism of the entire body, including the functioning of the reproductive system. Both hypothyroidism (e.g. in the course of Hashimoto’s disease) and hyperthyroidism can cause menstrual cycle disorders. Thyroid hormones affect the metabolism of sex hormones and the proper functioning of the hypothalamic-pituitary-ovarian axis.

• Hyperthyroidism (overproduction of thyroid hormones) can lead to infrequent and scanty periods, irregular cycles, and even complete disappearance of bleeding (amenorrhoea).
• Hypothyroidism (thyroid hormone deficiency) often manifests itself as heavy and prolonged menstrual bleeding and prolonged cycle lengthening. It can also lead to increased prolactin levels, which further interferes with ovulation. This shows that both excess and deficiency of thyroid hormones are detrimental to cycle regularity, highlighting the importance of maintaining normal thyroid hormone function (euthyroidism) and diagnosing and treating the symptoms of irregular menstruation.

Hyperprolactinemia: when there is too much prolactin

Prolactin is a hormone produced by the pituitary gland, whose main role is to stimulate milk production after childbirth. However, its excess (hyperprolactinemia) in non-breastfeeding women can lead to ovulation disorders and irregular menstruation, or even their disappearance. The cause of hyperprolactinemia may be diseases of the pituitary gland (e.g. prolactin-secreting adenoma – prolactinoma), certain medications (e.g. neuroleptics, some hypertension drugs), hypothyroidism, excessive physical exertion, chronic stress, and physiologically – breastfeeding. The mechanism of action is that high levels of prolactin inhibit the secretion of FSH and LH by the pituitary gland, which blocks the maturation of ovarian follicles and ovulation. It is important to distinguish whether hyperprolactinemia has a physiological or pathological basis, as further management depends on it.

Disorders of the hypothalamic-pituitary-ovarian axis

The correct, harmonized functioning of the hypothalamic-pituitary-ovarian (HPG) axis is absolutely crucial for maintaining a regular menstrual cycle. The hypothalamus secretes GnRH, which stimulates the pituitary gland to produce FSH and LH, which in turn affect the ovaries, regulating follicular maturation, ovulation, and the production of estrogen and progesterone. Disorders at any of these levels – the hypothalamus, pituitary or ovaries – can lead to irregular periods. The causes may include organic damage to the hypothalamus or pituitary gland (e.g. as a result of injury, surgery, radiation, or Sheehan syndrome – postpartum pituitary necrosis), tumors of these structures, as well as functional factors such as severe stress, malnutrition, or extreme physical exertion, which affect the secretion of GnRH. The awareness that cycle problems may have their source “centrally” in the brain, and not only in the ovaries, is important for comprehensive diagnostics.

Premature ovarian failure (POI)

Primary Ovarian Insufficiency (POI), also known as ‘premature menopause’, is a condition in which the ovaries stop functioning properly before the age of 40. This manifests itself in irregular menstruation (oligomenorrhoea or amenorrhoea type), as well as other symptoms characteristic of estrogen deficiency, such as hot flashes, vaginal dryness, mood disorders. Hormonal tests show elevated levels of FSH and LH with low estrogen levels. POI is a significant cause of infertility and requires specialist care. Realizing that menopause-typical symptoms can appear much earlier is important for seeing a doctor early.

Gynaecological and other diseases

In addition to hormonal disorders, various diseases affecting the reproductive organs or systemic diseases can also be the cause of irregular menstruation.

Uterine fibroids and endometrial polyps

Uterine fibroids are benign (benign) tumors that originate from the muscle tissue of the uterus. They are very common, especially in women over 30 years of age. Depending on their location and size, they can cause a variety of symptoms, including heavy, prolonged menstruation and intermenstrual bleeding. Submucosal fibroids (growing inside the uterine cavity) and intramural fibroids (located in the uterine wall) are particularly problematic in this respect. Submucosal fibroids can interfere with the proper healing of the endometrium after it is shedding during menstruation, leading to excessive bleeding. They can also distort the uterine cavity, affect its contractility and vascularization of the mucous membrane.

Endometrial polyps are also benign lesions, which are local hyperplasia of the endometrium, which can cause menstruation to become scanty and irregular. They can cause irregular intermenstrual bleeding, spotting (e.g. after intercourse) and heavy menstruation. It is believed that their formation is related to hormonal disorders (mainly excess estrogen) and chronic inflammation within the endometrium. Fragile blood vessels within polyps, local inflammation and the influence of hormones contribute to abnormal bleeding. Both fibroids and polyps are structural causes of bleeding and require different diagnostics (mainly ultrasound) and treatment (often surgical) than purely hormonal disorders.

Endometriosis: a painful problem with irregular bleeding

Endometriosis is a disease characterized by the presence of tissue similar to the lining of the uterus (endometrium) outside the uterine cavity, such as the ovaries, fallopian tubes, peritoneum, intestines, or bladder. This ectopic tissue responds to cyclical hormonal changes in the same way as the endometrium in the uterus – it grows and then bleeds during menstruation. Since this blood has no outlet to the outside, it accumulates at the implantation site, leading to chronic inflammation, pain and the formation of adhesions and cysts (e.g. endometrial ovarian cysts, the so-called chocolate cysts). Typical symptoms of endometriosis are very painful menstruation, pelvic pain (not only during periods), pain during sexual intercourse, as well as fertility problems. Endometriosis can also cause irregular cycles, heavy bleeding (often with clots) and spotting before your period. Chronic inflammation, which can cause menstrual disorders, plays a key role in the pathogenesis of symptoms, including cycle disorders.

Inflammation of the reproductive organs

Infections and inflammation of the genital organs, such as endometritis or inflammation of the appendages (involving the ovaries and fallopian tubes – adnexitis), can cause irregular and often prolonged menstrual bleeding and spotting. Infections can disrupt the proper functioning of the endometrium and ovaries, affecting the regularity of the cycle.

Neoplasms of the reproductive organs

Although rarer, cancers of the reproductive organs can also manifest themselves as irregular bleeding. These include endometrial cancer (endometrial cancer), cervical cancer and ovarian cancer. Any bleeding or spotting from the genital tract occurring in a postmenopausal woman is particularly alarming – it always requires urgent diagnostics to rule out the neoplastic process. Irregular bleeding can be one of the first, and sometimes the only, symptoms of these serious conditions.

Diabetes and other metabolic diseases

Systemic diseases, such as poorly controlled diabetes, can affect the hormonal balance and lead to irregular menstruation. The endocrine system is very sensitive to metabolic disorders, so maintaining normal overall health is important for cycle regularity.

Effects of drugs on the menstrual cycle

Some medications taken for other conditions can cause menstrual cycle disorders as a side effect.

Hormonal contraception (during and after discontinuation)

The use of hormonal contraceptives (pills, patches, vaginal rings, implants, injections, hormonal IUDs) is often associated with changes in the bleeding profile. In the first months of use, there may be irregular spotting or bleeding between menstrual periods, and sometimes withdrawal bleeding may be very light or non-existent. Similar irregularities can persist for several months (usually up to 6 months) after discontinuation of hormonal contraception, as the body adapts to the return of its own hormonal activity. Also, intrauterine devices, both hormonal (releasing progestogen) and copper (non-hormonal), can affect the nature of bleeding – hormonal often reduce the volume and pain of menstruation, and copper ones can intensify them. These changes are usually temporary, but if they are bothersome or persist for a long time, they require consultation with a doctor.

Other drugs: steroids, antidepressants, neuroleptics, chemotherapy

A number of other medications can affect the menstrual cycle. These include:

• Glucocorticoids (steroids): used to treat many inflammatory and autoimmune diseases.
• Certain antidepressants: for example, there are reports (although often hypothesis-based) of the effect of sertraline on the cycle.
• Sleeping pills and sedatives.
• Certain medications used to treat high blood pressure.
• Antipsychotic medications (neuroleptics): can increase prolactin levels, leading to menstrual disorders, including anovulation and cessation of menstruation.
• Chemotherapy: Drugs used to treat cancer often damage eggs and interfere with ovarian function, which can lead to irregular cycles or permanent cessation of menstruation (premature menopause). Awareness that the treatment of other conditions may have an unintended impact on the menstrual cycle (so-called iatrogenic causes) is important for both patients and the doctors conducting the therapy.

The main causes of irregular menstruation and their characteristics.

Categories Causes	Specific cause	Brief description of the mechanism	Common Cycle Symptoms	Other possible symptoms of irregular periods include changes in hormone secretion and abdominal pain.
Lifestyle	Stress (chronic/severe)	Effects on the Hypothalamic-Pituitary-Ovarian (HPG) Axis via Cortisol and Prolactin, Ovulation Disorder	Delayed menstruation, amenorrhea, shortened cycle, changes in bleeding volume	Tension, fatigue, sleep problems
	Diet (deficiencies/restrictions), weight changes	Deficiency/excess of adipose tissue affects the production of estrogens and GnRH, insulin resistance in obesity	Irregular cycles, amenorrhea, scanty or heavy menstrual bleeding can be symptoms of more serious health problems.	Fatigue, skin problems, mood changes
	Excessive physical exertion	Treated by the body as a stressor, it increases cortisol, lowers GnRH and LH, blocks ovulation	Infrequent menstruation, amenorrhea	Fatigue, injuries, low body weight
Hormonal Disorders	Polycystic Ovary Syndrome (PCOS)	Excess androgens, insulin resistance, ovulation disorders	Infrequent menstruation (oligomenorrhoea), amenorrhea (amenorrhoea), anovulatory cycles	Hirsutism, acne, androgenetic alopecia, obesity, fertility problems
	Thyroid disease (hypothyroidism/hyperthyroidism)	Effect of thyroid hormones on sex hormone metabolism and the HPG axis	Hypothyroidism: heavy, long bleeding, prolonged cycles. Hyperthyroidism: scanty, infrequent periods, amenorrhea	Weight changes, tiredness/agitation, palpitations, skin problems, goiter
	Hyperprolactinemia	Excess prolactin inhibits the secretion of FSH and LH, blocking ovulation	Infrequent periods, amenorrhea, anovulatory cycles	Galactorrhea, headaches, visual disturbances (with a pituitary tumor) may be symptoms of irregular menstruation and require medical consultation.
	Premature ovarian failure (POI)	Loss of ovarian function before the age of 40, estrogen deficiency	Infrequent menstruation, amenorrhea	Menopausal symptoms (hot flashes, vaginal dryness), infertility
Gynaecological diseases	Uterine fibroids	Benign uterine tumors, disrupt the structure and function of the endometrium, uterine contractility	Heavy, prolonged menstruation, intermenstrual bleeding	Lower abdominal pain, feeling of fullness, frequent urination, anaemia
	Endometrial polyps	Benign endometrial hyperplasia, fragile vessels, inflammation, hormones	Irregular intermenstrual bleeding, spotting, heavy menstruation	Rarely lower abdominal pain, fertility problems
	Endometriosis	Presence of endometrial tissue outside the uterus, chronic inflammation, adhesions	Painful, heavy menstruation, spotting before period, irregular cycles	Chronic pelvic pain, pain during intercourse, fertility problems, intestinal/bullous complaints
	Inflammation of the reproductive organs (e.g. endometritis, PID)	Bacterial or other infections that impair endometrial and ovarian function	Prolonged bleeding, irregular cycles, spotting	Lower abdominal pain, fever, vaginal discharge
Neoplasms of the reproductive organs	Endometrial, cervical, ovarian cancer	Neoplastic lesions that infiltrate and destroy tissues, affecting hormones or organ structure	Unusual bleeding, intermenstrual bleeding, postmenopausal bleeding	Pelvic pain, weight loss, fatigue (in advanced stages)
Effects of drugs	Hormonal contraception	Influence of exogenous hormones on the HPG and endometrium axis, adaptation of the body	Spotting, no withdrawal bleeding, irregular bleeding (especially at the beginning or after withdrawal)	Mood changes, headaches, breast tenderness (depending on the preparation)
	Other drugs (steroids, neuroleptics, chemotherapy)	Various mechanisms: effects on prolactin (neuroleptics), ovarian damage (chemotherapy), effects on the HPG axis	Irregular cycles, amenorrhea	Dependent on the specific drug and its basic effect

Irregular menstruation: When to see a doctor and what tests to perform?

Although occasional deviations from the ideal cycle can happen to any woman, certain symptoms should prompt a visit to the gynaecologist for a thorough diagnosis.

Alarm symptoms: do not ignore these signals!

There are a number of symptoms that accompany irregular menstruation, they should be treated as “red flags” and a signal for urgent medical consultation to determine the causes and treatments. These include:

• Persistent irregularities: Cycles that are shorter than 21 days or longer than 35 days, or when the length of the cycle is significantly different each month, especially if this condition persists for several cycles.
• Amenorrhoea: Any amenorrhea lasting 3 months or more in a woman who previously menstruated regularly requires diagnosis. Similarly, a delay in bleeding of 8 days or more should be clarified.
• Very heavy bleeding (menorrhagia): If a woman needs to change a sanitary pad or tampon every hour for several hours, if blood regularly seeps onto underwear or bedding, or if large clots (more than 2.5 cm in diameter) appear in the menstrual blood, this is an alarm signal. A haemorrhagic period, i.e. very intense bleeding, is always a threat and requires immediate intervention.
• Unusual length of bleeding: Menstrual periods lasting less than 2-3 days or more than 7-8 days.
• Severe menstrual pain (dysmenorrhoea): Pain that prevents normal functioning does not go away with standard painkillers and recurs in subsequent cycles.
• Bleeding or spotting between menstrual periods: Any bleeding that occurs between regular menstrual periods (except for a possible slight periovulatory spotting, which in some women is physiological) requires attention.
• Postmenopausal bleeding: Any bleeding or spotting from the genital tract after confirmed menopause (i.e. 12 months after the last menstrual period) is an abnormal symptom and requires urgent gynecological consultation to rule out m.in endometrial cancer.
• Irregular menstruation with other symptoms: If irregular cycles are accompanied by other disturbing symptoms, such as sudden weight gain, excessive fatigue, the appearance of male pattern hair (hirsutism), increased acne, galactorrhea (leakage of milk from the breast in a non-breastfeeding woman), or problems with getting pregnant.
• Systemic symptoms: Fever, severe pain in the abdomen or pelvis, dizziness, fainting, especially if accompanied by abnormal bleeding.
• Suspected pregnancy: If your period is late and you are sexually active, you should always consider the possibility of pregnancy and take a pregnancy test.

Understanding which symptoms are particularly distressing and require a quick response is crucial for protecting your health. Not every irregularity is a cause for panic, but ignoring the “red flags” can lead to a delay in the diagnosis and treatment of potentially serious conditions.

Diagnosis of irregular menstruation: how does the doctor look for the cause?

Diagnosis of irregular menstruation is a multi-stage process that allows you to determine the possible causes of the problem. A gynaecologist has a number of tools at his disposal to make an accurate diagnosis.

Medical history and menstrual calendar

The first and very important step is a detailed medical history. Your doctor will ask you about the date of your last menstrual period, the regularity and length of your cycles (how long they last and how many days they occur), the amount and duration of bleeding, the presence of clots, menstrual cramps and any other accompanying symptoms. Information on past diseases (general and gynaecological), surgeries, medications taken (including contraception), lifestyle (diet, physical activity, stress level), family history of diseases (e.g. PCOS, thyroid disease, cancer) and procreation plans will also be important. Keeping a menstrual calendar by the patient is extremely helpful because it provides objective data on the nature of the cycle.

Gynaecological examination and vaginal ultrasound

The next stage is a gynecological examination, which includes an examination in specula (assessment of the cervix and vagina) and a two-hand examination (assessment of the size, shape and mobility of the uterus and appendages – ovaries and fallopian tubes). The key imaging test is vaginal ultrasonography (ultrasound). It allows for a thorough assessment of the structure of the reproductive organs – uterus (endometrial thickness, presence of fibroids, polyps, congenital defects) and ovaries (presence of cysts, follicles, features of polycystic ovary syndrome).

Hormonal tests from the blood (FSH, LH, estradiol, prolactin, TSH, testosterone, etc.)

If a hormonal basis of irregularities is suspected, the doctor will order appropriate blood tests. The test panel is selected individually, but most often includes the determination of concentrations:

• Hormones: FSH (follicle stimulating hormone), LH (luteinizing hormone), estradiol (main estrogen), progesterone (determined in the second phase of the cycle, around day 21, to confirm ovulation), prolactin, total and free testosterone, DHEA-S (dehydroepiandrosterone sulfate), androstenedione. The ratio of LH to FSH may be helpful in the diagnosis of PCOS.
• Thyroid hormones: TSH (thyroid-stimulating hormone – basic screening), and if necessary, also fT3 (free triiodothyronine) and fT4 (free thyroxine) and antithyroid antibodies (anti-TPO, anti-TG). Sometimes the so-called progesterone test is performed, which involves administering progesterone for several days and observing whether bleeding occurs after its discontinuation. A lack of bleeding may indicate low estrogen levels or problems with blood outflow from the uterus. If insulin resistance, often associated with PCOS, is suspected, the doctor may order an oral glucose tolerance test (OGTT, the so-called sugar curve) along with the determination of fasting and glucose insulin concentration (insulin curve).

Additional tests: cytology, tests for infection

As part of a comprehensive gynaecological health assessment, especially if a long time has passed since the last examination, cervical cytology – a screening test for cervical cancer – may be taken. If your symptoms (e.g., vaginal discharge, pain, itching) or history indicate a possible infection, your doctor may order tests for sexually transmitted infections (STIs) or other genitourinary tract infections. A complete blood count is often performed to assess possible anemia, especially in heavy or frequent bleeding. Fasting glucose level determination is also a basic test.

The diagnostic process is often gradual – it starts with basic tests and, if necessary, is deepened by more specialized tests, tailored to the individual clinical situation of the patient. The goal is not only to identify the irregularity, but above all to find its cause.

Questions to ask your gynaecologist

A visit to the doctor is not only a time to answer questions, but also to ask them. Preparing a list of questions will help the patient better understand her health condition, available diagnostic and treatment options, and actively participate in decision-making. Here are some examples of questions to ask your gynaecologist in case of irregular periods:

• What are some potential causes of my irregular periods, given my age, symptoms, and health history?
• What specific diagnostic tests are recommended to me and why? What are they intended to exclude or confirm?
• What treatment options are available if the cause is diagnosed? What are the benefits and potential risks or side effects of each?
• Can lifestyle changes (e.g. diet, physical activity levels, stress management techniques) help me? What specific lifestyle changes would be most beneficial in the diagnosis and treatment of irregular menstruation?
• Are there any natural treatments or dietary supplements that could be helpful and safe for my situation?
• What are the possible long-term health consequences if my irregular periods are not treated or their cause is not found (e.g. effects on fertility, risk of osteoporosis, heart disease)?
• How can irregular periods affect my fertility? What can I do if I am planning to get pregnant in the future?
• When should I come for a follow-up visit? What symptoms should prompt me to contact a doctor beforehand?
• Could my symptoms be indicative of a specific medical condition, such as polycystic ovary syndrome (PCOS), thyroid problems, endometriosis, or others?
• What is the prognosis in my case and what can I expect in terms of treatment and future functioning of the cycle?

Preparing such a list of questions will not only help to obtain comprehensive information, but also show the doctor the patient’s involvement in the process of treatment and taking care of her own health.

Diagnostic methods for irregular menstruation.

Diagnostic method	Aim of the study	How does it work?	When recommended?
Medical history + menstrual calendar	Gathering information about the nature of the cycle, symptoms, health history, lifestyle, medications, risk factors	Conversation with the doctor, analysis of the patient’s notes on menstrual cycles	Always, as the first step in diagnostics
Gynecological examination	Assessment of the condition of the reproductive organs (vagina, cervix, uterine body, appendages)	Viewing the external genitals, examination in speculums, two-handed palpation	Usually during each gynaecological visit, especially when abnormalities are reported
Vaginal (transvaginal) ultrasound is one of the tests that may be ordered in the diagnosis of irregular menstruation.	Imaging assessment of uterus (endometrium, fibroids, polyps), ovaries (follicles, cysts, PCOS features), fallopian tubes (e.g. hydroceles)	Insertion of a special ultrasound probe into the vagina, which allows for accurate images of the pelvic organs	Very often as a basic imaging test in the case of irregular menstruation, suspected organic lesions, PCOS
Hormonal blood tests	Assessment of the hormonal function of the hypothalamic-pituitary-ovarian axis, thyroid function, androgen levels, prolactin, etc.	Taking a blood sample (often on specific days of the cycle, e.g. progesterone on day 21) and determining the concentration of selected hormones	If hormonal disorders are suspected as the cause of irregularities (PCOS, thyroid disease, hyperprolactinemia, POI, etc.)
Cervical cytology	Screening for precancerous conditions and cervical cancer	Collecting cells from the cervical disc and canal with a special brush and then microscopic evaluation	In accordance with preventive recommendations (every 1-3 years), sometimes more often with abnormalities or risk factors
Additional tests
* Sugar and insulin curve (OGTT)	Diagnosis of insulin resistance and carbohydrate metabolism disorders	Fasting glucose and insulin measurement and at specified intervals after oral glucose solution	With suspected PCOS, obesity, symptoms suggestive of insulin resistance
* Testing for Infection (STI)	Detection of possible genitourinary tract infections	Taking swabs from the vagina, cervix, urethra, or urine test to identify pathogens	With symptoms suggestive of infection (vaginal discharge, itching, pain), risky sexual behavior
* Blood counts and laboratory tests may be important in diagnosis.	Assessment of general health, detection of anemia	Taking a blood sample and analyzing its components (red blood cells, white blood cells, platelets, hemoglobin, etc.)	With heavy, prolonged bleeding, general weakness
* Hysteroscopy is one of the tests that may be ordered in the case of irregular periods.	Direct visualization of the uterine cavity, the possibility of taking samples or removing small lesions (e.g. polyps)	Insertion of a thin endoscope (hysteroscope) with a camera through the cervix into the uterine cavity	When polyps, adhesions, uterine defects, abnormal bleeding are suspected, when the ultrasound is ambiguous

How to deal with irregular periods? Effective methods of treatment and symptom relief

The procedure for irregular menstruation depends primarily on the established cause. Treatment may include lifestyle changes, pharmacotherapy, natural supportive methods, and in some cases, surgical intervention.

Lifestyle change – the first step to regularity

Often, even modifying daily habits can bring a significant improvement in the regularity of the cycle, especially if the problem is caused by factors such as stress, improper diet or excessive exercise.

Diet to support hormonal balance (e.g. anti-inflammatory, low GI for PCOS)

A properly balanced diet is often the basis for the treatment of irregular menstruation. In overweight or obese women, weight reduction often leads to the restoration of regular, ovulatory cycles. The diet should be rich in key nutrients such as zinc, iron, selenium, B vitamins, iodine, magnesium and omega-3 fatty acids, which support proper hormonal balance. Highly processed foods high in simple sugars and unhealthy fats should be avoided, as they can negatively affect hormones and promote inflammation.

It may be beneficial to introduce an anti-inflammatory diet, based on a large amount of vegetables and fruits (especially those with intense colors), wholegrain cereal products, legumes, nuts, seeds (e.g. flaxseed, chia) and oily sea fish (salmon, mackerel, sardines), which are a source of omega-3 acids. Such a diet can help not only to regulate the cycle, but also to relieve menstrual cramps and PMS symptoms.

For women with polycystic ovary syndrome (PCOS), who often have insulin resistance, a low glycemic index (GI) diet is recommended. Limiting foods that rapidly raise blood sugar levels helps to improve insulin sensitivity, which can benefit androgen levels and ovulation regularity, although direct references to a low GI diet were not included in the materials provided, this is a logical consequence of the information about the role of insulin resistance in PCOS. Diet is the foundation of hormonal health, providing not only calories but also building blocks for hormones and modulating inflammation and insulin sensitivity.

Adequate physical activity

Regular, moderate physical activity is recommended as part of a healthy lifestyle and can support cycle regularity. However, you should avoid excessive, strenuous exercise, which, as previously mentioned, can act as a stressor and disrupt the cycle. Physical activity helps maintain a healthy body weight, can reduce menstrual pain, improve sleep quality and reduce stress levels. It is important to find the “golden mean” and adjust the type and intensity of exercise to the individual needs and capabilities of the body to reap the benefits without overloading it.

Stress Reduction Techniques and Sleep Care

Stress management is a key element in restoring cycle regularity, given its strong effect on the endocrine system. Various relaxation techniques such as meditation, yoga, breathing exercises (e.g. deep breathing) or mindfulness training can be effective. Moderate physical activity and, in the case of chronic or severe stress, psychological support from a therapist or psychologist can also be helpful. The right amount and quality of sleep is also extremely important. 7-8 hours of sleep per night is recommended, which is crucial for the body’s regeneration, lowering cortisol levels and restoring hormonal balance. Active stress management and attention to sleep hygiene are not “soft” recommendations, but specific actions that affect the physiology of the cycle.

Pharmacological treatment under the supervision of a specialist

In many cases, especially when the cause of irregular menstruation is hormonal disorders or other diseases, it is necessary to implement pharmacological treatment. The decision on the type of therapy is always made by a doctor after a thorough diagnosis.

Hormone therapy (birth control pills, progesterone)

Hormone therapy is often used to regulate menstrual cycles, especially when hormonal disorders such as PCOS or luteal insufficiency are at the root of it.

• Oral contraceptive pills (DTA), containing a combination of estrogen and progestogen or progestogen alone, can help stabilize the cycle, reduce the volume and soreness of bleeding. In women with PCOS who are not planning pregnancy, DTAs are often the method of choice to regulate menstruation and protect the endometrium from excessive growth.
• Progesterone preparations (e.g. dydrogesterone, medroxyprogesterone, micronized progesterone – e.g. in the form of Lutein) are used in cases of deficiency of this hormone, e.g. in corpus luteum insufficiency (luteal insufficiency), which may manifest itself in shortening of the second phase of the cycle and premenstrual spotting, as well as to induce bleeding in secondary amenorrhea. The use of hormone therapy, like any treatment, can be associated with potential side effects. The most common ones include intermenstrual spotting, headaches, nausea, breast tenderness, mood changes, weight fluctuations or decreased libido. A rarer, but more serious risk is, m.in, thromboembolism, especially in women with risk factors (smoking, obesity, age >35, genetic predisposition). Therefore, the decision to start hormone therapy is always made individually by a doctor after evaluating the benefits and risks. Hormone therapy is a tool that can effectively regulate the cycle, but it requires the right selection of preparation and dose as well as regular medical supervision.

Causal treatment (e.g. thyroid drugs, metformin in PCOS)

The most effective treatment is the one that addresses the root cause of irregular menstruation, not just its symptoms.

• If the cause is thyroid disease, the basis is the treatment of the stem condition, e.g. levothyroxine supplementation in case of hypothyroidism or antithyroid drugs/radioactive iodine/surgery in hyperthyroidism. Balancing the thyroid function often leads to a normalization of the cycle.
• In women with PCOS, especially if it is accompanied by insulin resistance and/or overweight/obesity, metformin is often used. It is an antidiabetic drug that improves tissue sensitivity to insulin, reduces glucose production in the liver, and in patients with PCOS can further reduce androgen levels, which promotes the restoration of ovulation and regular menstruation.
• In the case of hyperprolactinemia caused by, for example, pituitary adenoma, drugs that lower prolactin levels, such as dopamine agonists, are used, which is important in the diagnosis and treatment of irregular menstruation. bromocriptine – e.g. Bromocorn, cabergoline).

Natural methods to support cycle regularity

Many women are looking for natural ways to support the regularity of the cycle and alleviate the discomfort. Some herbs and supplements can be helpful, but always remember that they should not replace medical consultation and conventional treatment, especially if the cause of the irregularity is serious.

Herbal medicine: chaste, yarrow, white nettle, and others

• Chasteberry pepper (monks) (Vitex agnus-castus): It is one of the best-studied herbs used in menstrual cycle disorders and premenstrual syndrome (PMS). It is believed to affect endocrine balance by acting on dopaminergic receptors in the pituitary gland, which can lead to a decrease in prolactin levels (if elevated) and modulation of FSH and LH secretion. This may contribute to the regulation of the cycle and improve the secretion of progesterone in the second phase of the cycle, which is important in the context of the diagnosis and treatment of irregular menstruation. The effectiveness of chasteberry is usually observed after prolonged, regular use (minimum 3 months).
• Yarrow (Achillea millefolium): Traditionally used to stimulate menstruation when it stops (e.g. due to stress, exhaustion), as well as in painful and irregular bleeding.
• White nettle flower (Lamium album): It can be helpful in excessive and heavy menstrual bleeding, has anti-inflammatory and coating properties.
• Other herbs: Other herbs are also mentioned in folk medicine and some studies, such as maca root (affects hormone regulation), ginger (pain relief, potential reduction in menstrual blood), cinnamon (can help regulate the cycle, especially in women with PCOS), raspberry leaves, mint, parsley, calendula, St. John’s wort or black mallow flower. It is important to emphasize that the effectiveness of herbs can vary from person to person, and some of them may interact with medications. Therefore, it is always a good idea to consult a doctor or pharmacist before starting herbal therapy. Herbs can be a valuable support, but they should not be considered a substitute for professional medical care.

Supplementation: magnesium, B vitamins, myo-inositol, evening primrose oil, vitamin D

Certain vitamins and minerals play an important role in maintaining hormonal balance and can be helpful in regulating the cycle.

• Magnesium: This element is involved in hundreds of biochemical processes in the body. It affects the proper functioning of the pituitary gland, the production of progesterone, estrogen metabolism in the liver and the body’s response to stress. Magnesium supplementation can help relieve PMS symptoms, reduce menstrual cramps and support cycle regularity. For better absorption, it is often recommended to combine magnesium with vitamin B6.
• B vitamins (especially B6, B9 – folic acid, B12): They are essential for proper energy metabolism, the functioning of the nervous system, and the synthesis and metabolism of sex hormones. Vitamin B6 contributes directly to the regulation of hormonal activity. Folic acid and vitamin B12 are crucial for proper cell division and homocysteine metabolism; Their deficiencies can affect the menstrual cycle and fertility. Vitamin B3 (niacin) is involved in the synthesis of estrogen and progesterone.
• Myo-inositol (often in combination with D-chiro-inositol): It is a vitamin-like substance that has gained particular recognition in adjunctive therapy in women with PCOS [ (Ovarin supplement), ]. Myo-inositol improves tissue sensitivity to insulin, which leads to a decrease in insulin levels in the blood, a reduction in hyperandrogenization (excess male hormones), and consequently to an increase in ovulation frequency and the restoration of more regular menstruation.
• Evening primrose oil: It is a rich source of gamma-linolenic acid (GLA), an unsaturated fatty acid from the omega-6 group. GLA is a precursor to prostaglandins, which regulate many physiological processes, including inflammation and uterine contractions. Evening primrose oil can help regulate hormone levels (FSH, estrogen, progesterone), have anti-inflammatory effects and relieve PMS symptoms.
• Vitamin C: Some sources suggest that vitamin C may support hormone regulation and stress reduction, which may indirectly affect the cycle.
• Vitamin d: Studies have linked low vitamin D levels to irregular periods, especially in women with PCOS. Vitamin D supplementation can help regulate the cycle in this group of patients.
• Apple cider vinegar: A single study with a small group of participants with PCOS suggested that daily consumption of apple cider vinegar may help restore ovulation. However, this requires further research. Supplementation should always be thoughtful and, if possible, based on identified deficiencies or specific needs (e.g., inositol in PCOS). These are not universal solutions “for everything” and it is best to consult their use with a doctor or clinical dietician.

Surgical treatment – when is it necessary?

In some cases, when the cause of irregular menstruation is organic changes within the reproductive organ, surgical treatment may be necessary to block ovulation and menstruation. It is less often used than conservative methods, but it can be necessary. Indications for surgical treatment may include:

• Large or symptomatic uterine fibroids, especially submucosal or intramural fibroids, causing heavy bleeding or fertility problems, may lead to ordering a myomectomy – enucleation of fibroids.
• Endometrial polyps causing abnormal bleeding or problems with getting pregnant (they are removed during hysteroscopy – polypectomy).
• Advanced endometriosis with the presence of large endometrial cysts or extensive adhesions (laparoscopic removal of endometriosis foci and adhesions).
• Some ovarian cysts, especially if they are large, suspicious, or cause symptoms.
• Anatomical defects of the reproductive organ.
• Some tumors (tumors) of the reproductive organ. Surgical intervention is usually considered when other treatments are ineffective or inadequate, or when structural changes directly threaten health, cause significant discomfort, or prevent pregnancy.

Comparison of methods of coping with irregular periods.

Method	Description	Potential benefits	Possible defects/remarks	When to consider?
Lifestyle changes	They include diet modification, regular moderate physical activity, stress reduction techniques, attention to sleep	Improvement of overall health, natural regulation of hormones, reduction of accompanying symptoms (e.g. PMS, pain)	It requires commitment and time, the effects may not be immediate, it may not be sufficient for serious reasons	Always as a basis and first step, especially when the influence of environmental factors and habits is suspected
Hormone therapy may be recommended if irregular menstruation is due to hormonal disorders.	Use of hormonal drugs (e.g. birth control pills, progesterone preparations) to regulate the cycle	Effective cycle regulation, reduction of bleeding, pain relief, endometrial protection (in PCOS)	Possible side effects (spotting, headaches, mood changes, risk of thrombosis), requires medical supervision, does not treat the primary cause (if non-hormonal)	Diagnosed with hormonal disorders (PCOS, luteal insufficiency), when lifestyle changes are insufficient, after excluding contraindications
Causal treatment	Therapy that targets the root cause of the irregularity (e.g., treatment of thyroid disease, metformin in PCOS with insulin resistance, treatment of hyperprolactinemia)	Removal or control of the underlying disease, leading to normalization of the cycle, long-term health benefits	It requires a precise diagnosis, treatment of the underlying disease can be long-term and have its own side effects	Whenever a specific disease or disorder is identified as the cause of irregular periods
Herbal medicine	The use of herbal preparations (e.g. chasteberry, yarrow) that have traditionally been used to support the regularity of the cycle	Natural support for the body, alleviation of some symptoms (e.g. PMS)	Variable efficacy, possible drug interactions, requires caution and often long-term use, and does not replace conventional treatment	As an adjunctive therapy, after consultation with a doctor, for mild irregularities or to relieve PMS symptoms when there are no serious organic causes
Supplementation	Supplementing the diet with specific vitamins and minerals (e.g. magnesium, B vitamins, myo-inositol, vitamin D, evening primrose oil)	Supplementing deficiencies, supporting hormonal metabolism, improving insulin sensitivity (inositol in PCOS), anti-inflammatory effect	Effectiveness depends on the cause and individual needs, an excess of some supplements can be harmful, requires conscious selection	In the case of diagnosed deficiencies, in specific clinical situations (e.g. inositol in PCOS), as a support for diet and lifestyle, after consultation with a doctor or dietician
Surgical treatment	Surgical intervention to remove organic lesions (e.g. fibroids, polyps, cysts, endometriosis foci)	Removing the immediate cause of bleeding or other symptoms, improving fertility in some cases	The risks associated with surgery and anesthesia, the possibility of recurrence of some lesions, are not always necessary	When organic lesions are large, symptomatic, cause significant problems (e.g. anemia, infertility) or when other treatments are ineffective/inadequate

Long-term consequences of irregular periods: Why not to underestimate them?

Untreated, chronic irregular periods, especially those resulting from anovulation or serious hormonal disorders, can lead to a number of long-term health consequences.

Fertility problems

This is one of the most common and noticeable consequences. Irregular menstruation is very often a signal of infrequent ovulation (oligoovulation) or its complete absence (anovulation). Without regular egg release, getting pregnant naturally becomes much more difficult or impossible. Conditions such as polycystic ovary syndrome (PCOS), premature ovarian failure (POI) or advanced endometriosis are common causes of both irregular cycles and fertility problems. The regularity of the cycle is therefore often a reflection of the regularity of ovulation, which is crucial for procreative capabilities.

Risk of anemia

Heavy, frequent or prolonged menstrual bleeding, which can accompany certain types of irregularities (e.g. uterine fibroids, coagulation disorders, certain hormonal disorders), can lead to chronic iron loss and the development of iron deficiency anaemia. Anemia manifests itself as fatigue, weakness, pale skin, headaches, palpitations and a general deterioration in the quality of life.

Increased risk of osteoporosis

Estrogens, female sex hormones, play a key role not only in regulating the menstrual cycle, but also in maintaining bone health – they inhibit bone resorption (breakdown) and stimulate bone formation. Chronic anovulation, often associated with irregular menstruation, leads to a state of estrogen deficiency (hypoestrogenism). Long-term low estrogen levels, such as premature ovarian failure (POI), long-term functional amenorrhea (e.g. in energy-deficient athletes) or postmenopause, significantly increase the risk of bone loss and the development of osteoporosis. Osteoporosis leads to weakened bones and increased susceptibility to fractures.

Potential Risk of Endometrial Cancer

In a normal ovulation cycle, after ovulation, the level of progesterone increases, which prepares the uterine lining (endometrium) for a possible pregnancy, and if it does not happen – it causes its exfoliation and menstrual bleeding. In states of chronic anovulation (e.g., often in PCOS), the endometrium is subjected to long-term stimulation by estrogens, without the balancing, cyclic action of progesterone. This condition can lead to excessive endometrial growth (endometrial hyperplasia) and, in some untreated cases, increase the risk of developing endometrial cancer (endometrial cancer) after many years. The lack of cyclic desquamation of the endometrium is therefore a significant risk factor for pathological changes within the endometrium.

Associations with cardiovascular diseases (especially with PCOS)

Women with polycystic ovary syndrome (PCOS) often struggle not only with irregular periods and fertility problems, but also with a number of metabolic disorders, such as insulin resistance, obesity (especially abdominal obesity), dyslipidemia (abnormal cholesterol and triglyceride levels) and hypertension. These factors, often occurring together as part of the so-called metabolic syndrome, significantly increase the risk of developing cardiovascular diseases, such as ischemic heart disease, heart attack or stroke at a later age. The mechanisms underlying this increased risk are complex and include, m.in others, the negative impact of insulin resistance and hyperinsulinemia on blood vessels, endothelial dysfunction (the inner lining of the vessels), as well as chronic low-grade inflammation that often accompanies PCOS (manifested, for example, by increased levels of C-reactive protein – CRP and certain cytokines). PCOS should therefore be treated not only as a gynecological or reproductive problem, but as a condition with potentially serious long-term implications for the cardiovascular system.

Take care of your cycle, take care of your health

Irregular menstruation is a signal that should not be ignored. Although they do not always indicate a serious illness, they can be the first symptom of various disorders that require attention and appropriate management.

Key findings and recommendations

To summarize the most important information about irregular menstruation:

• There are many causes of irregular bleeding – from relatively mild, lifestyle-related (stress, diet, exercise) to more serious hormonal disorders (PCOS, thyroid disease, hyperprolactinemia) and organic diseases (fibroids, polyps, endometriosis, cancer).
• Persistent irregularities should not be underestimated, especially if they are accompanied by other disturbing symptoms, such as very heavy or painful bleeding, intermenstrual bleeding, amenorrhea for several months, or systemic symptoms.
• Proper diagnostics carried out by a gynaecologist are crucial to determine the cause of the problem.
• Treatment of irregular menstruation depends on its cause and should always be individualized and carried out under the supervision of a specialist.
• A healthy lifestyle, including a balanced diet, regular moderate physical activity, stress management techniques, and getting enough sleep, is the foundation for maintaining cycle regularity and overall hormonal health.

The role of regular visits to the gynaecologist

Regular check-ups with a gynaecologist are essential for monitoring a woman’s reproductive health at every stage of her life and for early detection of possible abnormalities, including the causes of irregular menstruation. Even if the observed irregularities seem mild or occur occasionally, it is worth consulting a doctor to rule out more serious causes and get professional advice. A proactive approach to your health, including regular preventive check-ups and conscious observation of your cycle, is the best investment in well-being and prevention of potential health problems.